Transitions….Transitions….Transitions…. A lot has been in the press recently about transitional care. What does this mean and how does in home care fit in? On the 13th of February The Robert Wood Johnson Foundation and dozens of organizations convened for Care About Your Care, a national initiative that highlights what works to improve care transitions and reduce avoidable hospital readmissions. You can watch the archived webcast here. The webcast features; Risa Lavizzo-Mourey, MD – Robert Wood Johnson Foundation president and CEO Eric Coleman, MD – University of Colorado Anschutz Medical Campus Mary Naylor, PhD, RN – University of Pennsylvania School of Nursing Jonathan Blum, MA – Centers for Medicare & Medicaid Services Representatives from care teams from across the nation who are working on innovative ways to improve care transitions I'd like to suggest that we as in home care providers are such an important part of the "ecosystem of stakeholders" and one of the essential pieces of America's healthcare future. I have had the privilege to meet Dr. Coleman and hear him speak on the Care Transitions Intervention. Dr. Coleman will refer to the intervention as being the "whole enchilada". Well, I have seen Home Health be the beans of the enchilada. We are in the homes of our clients. Let's face it, most of the care isn't being provided in the hospitals…care is happening (or not happening) in the homes. I have been in homes of our seniors where 20 medications or more are being prescribed for our clients from 4 or more different physicians. There are duplicate medications and expired medications in the cabinet mixed in with medications prescribed for the family dog. 19% of Medicare discharges followed by an adverse event within 30 days; 2/3 of those were medication events. Houston we have a problem and the time has come to allow Home Health (including private duty) as important stakeholder in the "ecosystem" a seat at the table. I'm excited about the Care About Your Care initiative and the opportunities it presents for our care delivery system.