Addressing the fourth goal of the National Priorities Partnership, the NQF report to HHS stated that in regard to care coordination:

“Healthcare should guide patients and families through their healthcare experience, while respecting patient choice, offering physical and psychological supports, and encouraging strong relationships among patients and the healthcare professionals accountable for their care… Focus in care coordination by NPP are the links between:

“Care Transitions— …continually strive to improve care by … considering feedback from all patients and their families… regarding coordination of their care during transitions between healthcare systems and services, and…communities. Preventable Readmissions— …work collaboratively with patients to reduce preventable 30-day readmission rates.”

SETMA’s pilgrimage to patient-centered medical home, care coordination, transitions of care and a sustainable effort to decrease preventable admissions to the hospital began 14 years ago. This slide deck chronicles that pilgrimage and describes the steps in the process. It is only a beginning, but it is a beginning. In our commitment a celebratory spirit, we celebrate what we have done while planning and anticipating what we shall do.