Senior Female Patient in Wheelchair & Doctor in Hospital

Today the Centers for Medicare & Medicaid Services (CMS) hosted the first annual National Care Transitions Awareness Day to highlight how beneficiaries, families and caregivers and every member of the healthcare team (e.g., community partners, healthcare system and team, and payers and other business entities) benefit from improving care transitions and the importance of engagement at all levels.

Highlights included a video shown by CMS Administrator Seema Verma that described CMS initiatives to improve care transitions, including a recently proposed interoperability rule that would provide notifications of admissions/readmissions to a patient’s entire care team. CMS’s 2019 priorities were also shared, including the MyHealthEData initiative which aims to empower patients by ensuring they control their healthcare data and can decide how their data is going to be used as well as the Patients Over Paperwork initiative to improve the beneficiary experience.

Peggy Hamilton, RN, MSN, Director of Quality Management at Einstein Physicians Montgomery, shared the top 3 drivers for improved outcomes:

1) Reports to identify and prioritize patients;
2) Transitional care management as a starting point not as an end point; and
3) Engaging patients and caregivers early and meaningfully.

All event presentations and videos will be posted here after the event.

Great Plains QIN continues to engage healthcare and community service professionals in efforts to improve care transitions for patients across our region. Check out the resources listed below available on our website.



Today is also National Healthcare Decisions Day (NHDD). This day exists to inspire, educate and empower the public and providers about the importance of advance care planning and to encourage people of all ages to have a conversation about their wishes for end-of-life care. The Conversation Project is a comprehensive tool that helps make those difficult conversations easier.

Before-I-Die-BannerTo draw awareness to NHDD, Honoring Choices ND and Honoring Choices MN hosted a booth at West Acres Mall in Fargo, ND. The booth displayed a large banner that allowed individuals stopping by to complete the statement “Before I Die, I Want To…” This interactive tool provided booth hosts an opportunity to share educational materials that addressed the important of advance care planning.

Some of the comments on the banner included: Before I die, I want to…

  • Be free of diabetes for one year
  • Love life
  • Spend more time with my grandkids
  • Sleep in a hut over the ocean
  • Join the army
  • Finish college
  • Make a difference!
  • Get a job with life enrichment
  • Be at peace with death
  • Stay healthy
  • Marry my best friend
  • Travel the world with my kids
  • Have a 97th birthday party
  • Become a mother

Additional advance care planning tools are available on the Great Plains QIN Care Coordination page under the Advance Care Planning tab.