The STate Action on Avoidable Rehospitalizations (STAAR) initiative aims to reduce rehospitalizations by working across organizational boundaries in three states, initially — Massachusetts, Michigan, and Washington — and by engaging payers, state and national stakeholders, patients and families, and caregivers at multiple care sites and clinical interfaces.

Delivering high-quality health care requires crucial contributions from many parts of the care continuum, and effective coordination and transitions 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.