Geisinger Health Plan’s successful Transitions of Care program is the health plan’s response to rising rehospitalization rates among Medicare patients, a major concern of both CMS and private payors. Geisinger Health Plan’s Doreen Salek defines the transition teams’ key area of focus when providing a “clean and clear handoff” of a patient from one care site to another, with the goal of avoiding readmission to the hospital. The health plan’s director of business operations of health services also defines the plan’s ideal home health partner, its blueprint for a universal plan of care to improve care coordination and its expectations of patients and their families and caregivers. Salek, along with Janet Tomcavage, R.N., M.S.N., vice president of health services for Geisinger Health Plan, explained how a focus on transitions of care across the continuum can enhance care quality and reduce readmissions during an August 26, 2009 webinar, Constructing Care Transitions to Reduce Hospital Admissions. The 45-minute session is part of HIN’s continuing Medical Home Open House webinar series.