Coordination of CareBetter 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
|Commentary on unleashing the potential for collaboration||Care Coordination||Cross-Continuum Collaboration in Health Care||Population 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 Planning||Making 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 Aim||Care Coordination||The Triple Aim - A Community Overview||GPQIN|
|Paper copy of tool that scores a patient on four variables with a final score predictive of readmission within 30 days||Discharge Planning||LACE Index Scoring Tool||Ottawa Hospital Research Institute|
|Overview of tool that scores a patient on four variables with a final score predictive of readmission within 30 days||Discharge Planning||Use of Modified LACE Tool to Predict and Prevent Readmissions||Ottawa Hospital Research Institute|
|Guidance for individuals who must make medical decisions for someone else.||Advance Care Planning||Making 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 Kansas||Tool||Kansas Care Coordination Quarterly Report||GPQIN|
|Home Health Chartbook 2015:|
Prepared for the Alliance for Home Health
Quality and Innovation
|Home health||Home Health Chartbook 2015||Alliance 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/Mobility||Preventing Falls: Guide to Community-based Falls Prevention Programs||National Center for Injury Prevention and Control|
|Use this tool to determine number of ACP facilitators needed to meet our goal||Advance Care Planning||Advance Care Planning (ACP) Goal Setting and ACP Facilitator Need Determination||GPQIN|
|Care Coordination quarterly report for North Dakota||Tool||North Dakota Care Coordination Quarterly Report||GPQIN|
|Care Coordination quarterly report for South Dakota||Tool||South 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 discussions||Advance Care Planning||A Framework for Improving End-of-life Care: Five Conversation Ready Principles||GPQIN|
|ICD-9-CM Code Crosswalk for Hospital Readmissions Measures||Toolkit||ICD-9-CM Code Crosswalk for Hospital Readmissions Measures||GPQIN|
|Care Coordination quarterly report for Nebraska||Tool||Nebraska Care Coordination Quarterly Report||GPQIN|
|Care Coordination lessons learned, challenges and success report.||Care Coordination||Care Coordination Learning & Action Environmental Scan Overview||GPQIN|
|Fall Risk Assessment for Older Adults: The Hendrich II Fall Risk Model ™ By: Ann Hendrich, PhD, RN, FAAN Patient Safety Organization (PSO); Ascension Health||Falls/Mobility||The Hendrick II Fall Risk Model TM||Hartford Institute for Geriatric Nursing, New York University, College of Nursing|
|Paula Sitzman||RN, BSN||Quality Improvement Advisor||Nebraska||Paula.Sitzman@area-a.hcqis.org|
|Jayme Steig||PharmD, RPH||Pharmaceutical Care Specialist||North Dakota||Jayme.Steig@area-a.hcqis.org|
|Sally May||RN, BSN||Senior Quality Improvement Specialist||North Dakota||Sally.May@area-a.hcqis.org|
|Linda Penisten||RN, OTR/L||Project Manager||South Dakota||Linda.Penisten@area-a.hcqis.org|
|Vanessa Lamoreaux||Project Manager||Kansas||VLamoreaux@kfmc.org|
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Learning and Action Network
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.