Clinic Staff Welcomes Patients

With the number of Americans aged 65 or older projected to reach 83.7 million by 2050, managing care coordination to achieve better outcomes and control costs has become a national priority. Great Plains QIN partners with healthcare systems and communities throughout our region to foster improved coordination to decrease medication errors, unnecessary or repetitive diagnostic tests, unnecessary emergency room visits, and preventable hospital admissions and readmissions.

NEW—A Readmissions Interview Tool was recently developed by Great Plains QIN as a result of care coordination and readmissions conversations with hospital staff. This tool gives the care team and patients/families/caregivers an opportunity to discuss perceptions of their recent hospitalization and post-discharge experience with an added goal of engaging patients as active partners on their care team. The tool is a sneak peek into a Readmissions Toolbox to be released soon that is a compilation of practices and tools to reduce readmissions and improve care coordination.

Improved care coordination increases the amount of time people are able to stay in their home, referred to as community tenure. The Great Plains QIN Care Coordination team utilized a quality improvement problem solving process to analyze community tenure data, investigate potential issues affecting community tenure and their root cause, and identify potential solutions. The team identified limited access to or underutilization of Long Term Support Services (LTSS) as a major barrier that leads to potentially decreased community tenure and overutilization of higher levels of care such as skilled nursing facility or swingbed unit as depicted in the “Current Condition” image.

Current Condition Image


Opportunities for improvement identified by the team include: improving awareness of LTSS, expanding existing models such as community health workers and chronic care management, addressing health literacy and disparities, and increasing the use of advance health directives. Part of the Great Plains QIN response to this was the provision of the following educational Learning and Action Network events.

Learning and Action Network Event Recordings



National Care Transitions Awareness Day; hosted by the Centers for Medicare & Medicaid Services (you can still register to attend virtually)
National Healthcare Decisions Day