Coordination of Care

Better patient outcomes, overall satisfaction and reducing avoidable hospital admissions

Effective Communication and Care Coordination

Nearly one in five Medicare consumers discharged from the hospital – approximately 2.6 million seniors – is readmitted within 30 days, at a cost of over $26 million every year.¹

Avoidable readmissions and patient satisfaction with discharge care are growing problems nationwide.  Of those patients who are re-admitted to the hospital, the Medicare Payment Advisory Committee estimates that 64 percent received no post-acute care between discharge and readmission and project that 76 percent of readmissions may be preventable. Further, CMS research shows consumers report greater dissatisfaction in discharge-related care than any other aspect of care.

The problems associated with poor transitions of care and 30-day hospital readmissions are not solely the responsibility of community hospitals; they often result from a breakdown in communication and care coordination. Weaknesses include the transfer of information between providers and patients at the time of transition, a failure to assure patients and/or caregivers they can self-manage their condition during transition and a lack of standard processes to effectively manage the transition of the patient between settings.

To address these issues, we are focusing on processes of care at a community level to engage providers and stakeholders across the continuum of care; not just the hospital. This includes home health agencies, dialysis facilities, skilled nursing facilities, pharmacies, physician offices as well as patients, families, payers and community stakeholders. We are specifically working with communities that focus on Medicare consumers of greatest need, such as individuals with multiple chronic conditions taking multiple medications, consumers with behavior health issues, those dually-enrolled in Medicare and Medicaid, rural populations and individuals impacted by other social determinants of heath.

Improving care coordination leads to better patient outcomes, overall satisfaction and reduces avoidable hospital admissions. Great Plains QIN is partnering with communities throughout the region to unite stakeholders, consumers and healthcare providers to improve communication and care coordination – resulting in reduced hospital admissions, readmissions and medication harm.

For more information on how medication safety and medication management play an integral role in care coordination, visit the Medication Safety Initiative page of this site.

1. Centers for Medicare & Medicaid Services (CMS) – http://innovation.cms.gov/initiatives/CCTP/?itemID=CMS1239313

Initiative Documents
Commentary on unleashing the potential for collaborationCare CoordinationCross-Continuum Collaboration in Health CarePopulation Health Management
Booklet developed by the Aging Services Division of the North Dakota Department of Human Services to provide a written summary of North Dakota law regarding advance directives and health care decision-making authority.Advance Care PlanningMaking Health Care Decisions in North Dakota: A Summary of North Dakota Law Regarding Health Care Directives
North Dakota Department of Human Services Aging Services Division
Visual representation of how work of Great Plains QIN relates to Triple AimCare CoordinationThe Triple Aim - A Community OverviewGPQIN
Paper copy of tool that scores a patient on four variables with a final score predictive of readmission within 30 daysDischarge PlanningLACE Index Scoring ToolOttawa Hospital Research Institute
Overview of tool that scores a patient on four variables with a final score predictive of readmission within 30 daysDischarge PlanningUse of Modified LACE Tool to Predict and Prevent ReadmissionsOttawa Hospital Research Institute
Guidance for individuals who must make medical decisions for someone else.Advance Care PlanningMaking Medical Decisions for Someone Else: A North Dakota Handbook
American Bar Association Commission on Law and Aging in collaboration with North Dakota Department of Human Services Aging Services Division
Care Coordination quarterly report for KansasToolKansas Care Coordination Quarterly ReportGPQIN
Home Health Chartbook 2015:
Prepared for the Alliance for Home Health
Quality and Innovation
Home healthHome Health Chartbook 2015Alliance for Home Health Quality and Innovation
The purpose of this guide is to provide information to help
CBOs choose and implement evidence-based fall prevention programs based on their organization’s goals and clients’
Falls/MobilityPreventing Falls: Guide to Community-based Falls Prevention ProgramsNational Center for Injury Prevention and Control
Use this tool to determine number of ACP facilitators needed to meet our goalAdvance Care PlanningAdvance Care Planning (ACP) Goal Setting and ACP Facilitator Need Determination
Care Coordination quarterly report for North DakotaToolNorth Dakota Care Coordination Quarterly Report GPQIN
Care Coordination quarterly report for South DakotaToolSouth Dakota Care Coordination Quarterly Report GPQIN
Use this tool to establish a process to enable your staff to be “conversation ready” for end-of-life care discussionsAdvance Care PlanningA Framework for Improving End-of-life Care: Five Conversation Ready PrinciplesGPQIN
ICD-9-CM Code Crosswalk for Hospital Readmissions MeasuresToolkitICD-9-CM Code Crosswalk for Hospital Readmissions MeasuresGPQIN
Care Coordination quarterly report for NebraskaToolNebraska Care Coordination Quarterly Report GPQIN
Care Coordination lessons learned, challenges and success report.Care CoordinationCare Coordination Learning & Action Environmental Scan OverviewGPQIN
Fall Risk Assessment for Older Adults: The Hendrich II Fall Risk Model ™ By: Ann Hendrich, PhD, RN, FAAN Patient Safety Organization (PSO); Ascension HealthFalls/MobilityThe Hendrick II Fall Risk Model TMHartford Institute for Geriatric Nursing, New York University, College of Nursing
Initiative Links
Community OrganizingUniversity of Kansas Community Tool Box
Disease PreventionGood & Healthy South Dakota
Consumer ResourcesGreat Plains QIN Care Coordination Consumer Resources
Care Coordination: Consumer ResourcesGreat Plains QIN Consumer Resources
Care CoordinationHuddle for Care
Disease PreventionMillion Hearts Campaign
Community OrganizingCommunity Organizing & Community Building for Health & Welfare
FallsFall Prevention Center of Excellence
Community OrganizingNorthwestern University Asset-Based Community Development Institute
Care CoordinationLeadership Toolkit for Redefining the H: Engaging Trustees and Communities
Discharge PlanningAHRQ - Improving the ED Discharge Process
Care CoordinationAHRQ Chartbook on Care Coordination
Healthcare DisparitiesAHRQ National Healthcare Quality & Disparities Report Chartbooks
Consumer Centered CareAHRQ Chartbook on Person and Family-Centered Care
Discharge PlanningProject RED (Re-Engineered Discharge)
Care TransitionsThe Care Transitions Program®
Advance Care PlanningCaring Connections -State-specific Healthcare Directives
Advance Care Planning: ProfessionalsAdvance Care Planning: An Introduction for Public Health and Aging Services Professionals [Course]
Care CoordinationCDC Community Health Improvement Navigator
FallsSTEADI: Stopping Elderly Accidents, Deaths and Injuries
Community OrganizingCounty Health Rankings & Roadmaps Action Center for Community Members
Advance Care Planning: CommunityRespecting Choices®
Health LiteracyHealth.gov Health Literacy
Disease PreventionHome Health Quality Improvement (HHQI) National Campaign
Health LiteracyHRSA Health Literacy
Care CoordinationIHI STARR Initiative (State Action on Avoidable Rehospitalizations)
Patient ActivationInsignia Health Patient Activation Measure Survey
Advance Care Planning: ProfessionalsDying in America: Improving Quality and Honoring Individual Preferences Near the End of Life Consensus Report 2014
Advance Care Planning: ProfessionalsPalliative Care Fast Facts and Concepts Overview
Advance Care Planning: CommunityNational Healthcare Decisions Day
Health LiteracyNIH Health Literacy
Care TransitionsNational Transitions of Care Coalition (NTOCC)
Advance Care Planning: CommunityPOLST® physician orders for life-sustaining treatment
Care CoordinationRural Care Coordination Toolkit
Community OrganizingReThink Health
Community OrganizingRobert Wood Johnson Foundation
Care CoordinationCommunity-Based Care Coordination Toolkit
Care Coordination ToolsGeri Pearls Reviews
Care CoordinationAHRQ Community Care Coordination at a Glance
Care TransitionsINTERACT (Intervention to Reduce Acute Care Transfers)
Advance Care Planning: ProfessionalsINTERACT (Intervention to Reduce Acute Care Transfers)
Healthcare DisparitiesMapping Medicare Disparities
Care CoordinationRural Care Coordination Guide
Advance Care Planning: ProfessionalsLet’s Talk About Dying – Peter Saul
Mar 28 @ 12:00 pm – 1:00 pm
Join the Great Plains Quality Innovation Network Care Coordination Team for the fourth in this series of action-oriented learning events. This WebEx session will help your organization build capacity for better, safer care and healthier[...]
Mar 14 @ 12:15 pm – 12:45 pm
Webinar Playback   Overview and Purpose: Key patient-centered care topics will be presented in 15-20 minute webinar segments highlighting provider and clinician perspectives while introducing corresponding resources and tools during the Provider Perspectives on Patient-Centered[...]
Jan 24 @ 12:00 pm – 1:00 pm
The Great Plains QIN Care Coordination Team held this third in a series of action-oriented learning events to help organizations build capacity for better, safer care and healthier people and communities. Start WebEx Playback Medication Safety Presentation Handout Medication safety[...]
Dec 20 @ 12:00 pm – 1:00 pm
  This month, the Great Plains QIN is providing the opportunity to participate in a Coaching Call with peers and experts in the field regarding any one of the following three topics: reducing rehospitalizations, medication[...]
Oct 25 @ 12:00 pm – 1:00 pm
Rehospitalizations – Medication Safety – Chronic Disease Management Start WebEx Playback Presentation Handout Recording Transcript Join the Great Plains QIN Care Coordination Team for a series of action-oriented learning events over the next several months[...]
Oct 20 @ 12:00 pm – 1:00 pm WebEx
Presentation handout: Outpatient Antibiotic Prescribing  Start WebEx Playback In May, the Centers for Disease Control and Prevention (CDC), in collaboration with Pew Charitable Trusts and others, released new data showing that at least 30 percent[...]
Aug 11 @ 1:00 pm – 2:00 pm
Start WebEx Playback Presentation Handout Overview During this WebEx, the presenters shared the unique partnership Park Nicollet Methodist Hospital has created with their local firefighters to conduct home visits on high risk patients that would[...]
May 3 @ 2:00 pm – 3:00 pm
MARK YOUR CALENDARS for the next installment of the National Learning & Action Network (LAN) webinar learning series, “Sharing Knowledge, Improving Healthcare.” The session topic will align with the Centers for Medicare & Medicaid Services[...]
Apr 19 @ 12:00 pm – 1:00 pm
Presentation Handout Start WebEx Playback Electronic Health Records (EHRs) can improve population health outcomes by efficiently collecting data in a form that can be shared across multiple healthcare organizations and leveraged for quality improvement and[...]
Dec 1 @ 2:00 pm – 3:00 pm
All too often patients do not receive the care they wish for as they approach their last days or in medical emergencies. Having conversations about these situations is difficult, but it is critical that these[...]
Nov 19 @ 2:00 pm – 3:00 pm
  Start WebEx Playback   Webinar Objectives This webinar will be a discussion on strategies to engage community-based programs to support advance care planning. Learn about the Institute for Healthcare Improvement’s (IHI) The Conversation Project[...]
Sep 29 @ 2:00 pm – 3:00 pm WebEx
Start WebEx Playback Purpose: To review the Hospital Readmission Reduction Program. Learn how to read your Hospital Specific Reports and make sense of them for your facility. There will also be time for an open[...]
Jul 23 @ 2:00 pm – 3:00 pm
    Start WebEx Playback Presentation Handout WebEx Overview This event will provide an introduction to the care coordination and medication safety Learning and Action Network (LAN). Included will be the patient/family perspective, overview of[...]
Jul 16 @ 12:30 pm – 1:30 pm
Start WebEx Playback Presentation Handout AD8 Dementia Screening Interview Behavior Log This program explores key elements in addressing the needs of individuals with dementia who are experiencing behavioral and affective challenges across the care continuum.[...]
Coordination of Care Contacts
Paula SitzmanRN, BSNQuality Improvement AdvisorNebraskaPaula.Sitzman@area-a.hcqis.org
Jayme SteigPharmD, RPHPharmaceutical Care SpecialistNorth DakotaJayme.Steig@area-a.hcqis.org
Sally MayRN, BSNSenior Quality Improvement SpecialistNorth DakotaSally.May@area-a.hcqis.org
Linda PenistenRN, OTR/LProject ManagerSouth DakotaLinda.Penisten@area-a.hcqis.org
Vanessa LamoreauxProject ManagerKansasVLamoreaux@kfmc.org

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We invite you to join the Great Plains Learning and Action Network (LAN). All LAN partners will be invited to attend educational sessions on a variety of topics, have opportunities to learn from peers throughout the state and region and have access to an abundance of resources and tools. The LAN is a great opportunity to get connected and demonstrate your commitment to quality improvement.

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