AQAF, the Medicare Quality Improvement Organization (QIO) for the state of Alabama, is one of only 14 QIOs in the nation to be awarded a special project by the Centers for Medicare & Medicaid Services (CMS) to improve the quality of care for Medicare beneficiaries who transition among care settings─ hospital to nursing home; nursing home to home care, etc.

The name of the Alabama project is PATH (Post Acute Transitions in Healthcare) Alabama.
It will be based in the Tuscaloosa Hospital Referral Region (HRR) that includes Tuscaloosa, Bibb, Greene, Hale, Fayette, Lamar and Pickens counties.

In PATH Alabama, AQAF will promote seamless transitions from the hospital to home, skilled nursing care, or home health care. AQAF will work to reduce unnecessary readmissions to hospitals that may increase risk or harm to patients and cost to Medicare. CMS is looking to AQAF to implement projects that effect process improvements to address issues in medication management, post-discharge follow-up, and plans of care for patients who move across health care settings.

The process by which patients move from hospitals to other care settings is increasingly problematic as hospitals shorten lengths of stay and as care becomes more fragmented. Medicare patients report greater dissatisfaction related to discharges than to any other aspect of care that CMS measures. PATH Alabama is designed to change that.

Utilizing a comprehensive community effort, the PATH Alabama project provides a framework for integrating and coordinating care with participating health care providers, and empowers Medicare patients to advocate for their care needs and effectively self-manage their chronic conditions. PATH Alabama will focus on assisting the community in designing effective systems of care to achieve high value health care for sick and disabled Medicare beneficiaries.

PATH Alabama is a collaborative effort between AQAF, Tuscaloosa HRR health care providers, the Alabama Hospital Association, the Alabama Nursing Home Association, the Alabama Association of Home Health Agencies, the Alabama Department of Public Health,  the American Heart Association- Birmingham Chapter, and academic centers including the University of Alabama Tuscaloosa - School of Medicine College of Community Health Services, University of Alabama Capstone Graduate Nursing Program, University of Alabama at Birmingham - Division of Geriatrics and Palliative Care, Auburn University Motivational Interviewing Training Institute, and Medicare beneficiary advocacy organizations such as the Alabama Department of Senior Services, West Alabama Area Agency on Aging and the Tuscaloosa chapter of AARP. 

Specific aims of PATH Alabama are:

• To establish a multidisciplinary, multi provider work group that will lead to effective partnerships between the community at large, providers, academic institutions and patients 
• To promote capacity building in the targeted communities through increased knowledge and empowerment of community constituents
• To engage community providers in the development, application and dissemination of data driven strategies for reducing hospital readmissions