CIMRO of Nebraska was awarded one of 14 CMS contracts nationally to conduct a cutting-edge initiative to improve care transitions between healthcare settings. CareTrek, Nebraska's care transitions initiative, focuses on improving transitions of care across healthcare settings to reduce avoidable rehospitalizations. CareTrek is working to bring together the community of providers, beneficiaries and stakeholders in the Douglas and Sarpy counties to measurably improve the quality of care Medicare beneficiaries receive during the transition between care settings.

CareTrek focuses on improving the coordination of care between providers and across the continuum of care by promoting seamless transitions from the hospital to home, skilled nursing facility, home health care or any other care provider to prevent avoidable rehospitalization.

Using community mapping, gaps in known and standard processes have been identified. This knowledge has helped CareTrek assemble community learning groups to focus on interventions that result in process improvements. These interventions address issues in medication management, post-discharge follow-up, communication and coordination of care. CareTrek promotes increased self-management of chronic disease for patients and their caregivers through education, support and a patient healthcare record.

For more information about CareTrek or how you can participate, please contact CIMRO of Nebraska at 800-458-4262.