Delivering high-quality health care requires crucial contributions from many parts of the care continuum, and effective coordination between providers and between care settings. In the hospital setting, poor coordination of care often results in rehospitalizations, many of which are avoidable. At the core of this challenge is improving care in the “white spaces” between settings of care, promoting enhanced “system-ness” in a fragmented environment.

On May 1, 2009, IHI launched STate Action on Avoidable Rehospitalizations (STAAR) — a groundbreaking, multi-state, multi-stakeholder approach to dramatically improve the delivery of effective care at a regional scale.

Funded through a grant from The Commonwealth Fund, this initiative aims to reduce rehospitalizations by working across organizational boundaries in three states, initially — Massachusetts, Michigan, and Washington — by engaging payers, state and national stakeholders, patients and families, and caregivers at multiple care sites and clinical interfaces. As the work progresses, IHI will make programming and information available for other states, regions, or organizations across the continuum to learn from the initiative.

Reducing avoidable rehospitalizations in a state or region requires not only front-line process improvement, but also identification and mitigation of barriers to system-wide improvement, especially policy and payment reforms that will reduce fragmentation and encourage coordination across the continuum of care. Such reforms are necessary to address the shortcomings of the current volume-based incentives, and to place a premium on the quality of the patient’s experience across the continuum of care. Prioritizing longitudinal care will create new public and professional norms in which avoidable emergency department visits and avoidable rehospitalizations are seen as system defects.