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.

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

Care Coordination News

News

09Apr

A Culture of Patient Safety

Originally published in the South Dakota Medicine Journal, April 2018 By: Stephan Schroeder, MD, CMD, CMQ Medical Director, South Dakota Foundation for Medical Care The potential for harm in medical care…read more →

See All Care Coordination News Posts 

Training Events
May 24 @ 12:15 pm – 1:00 pm
Register Now Naloxone is a safe medication that can prevent opioid deaths. This webinar will improve participants’ understanding of the role of naloxone in preventing opioid overdose related death, identification of individuals who may benefit[...]
Apr 11 @ 11:00 am – 12:00 pm
Presentation/Slide Handout Early Recognition and Management of Sepis for Post-acute Settings (MPRO) Sepsis is one of the top diagnoses involved with readmissions throughout the Great Plains and Lake Superior Quality Innovation Networks. This webinar is[...]
Apr 10 @ 12:15 pm – 1:00 pm
This webinar will review acute pain and chronic pain guidance and will discuss how to use a pain guidance document in practice. Differentiation of pain treatment recommendations as they relate to patient populations will be[...]
Mar 29 @ 12:00 pm – 1:00 pm
Presentation/Slide Handout   On January 1, Nebraska became the first state to require pharmacists and pharmacies to report all dispensed prescriptions daily to the state’s Prescription Drug Monitoring Program (PDMP), not just controlled substances. PDMPs are a[...]
Mar 21 @ 12:00 pm – 1:00 pm
Due to technical difficulties the video of this training event is unavailable.  You can listen to the audio and download the presentation below. http://greatplainsqin.org/wp-content/uploads/2018/02/NETO-3-21-18-1.mp3   Presentation/Slides Handout NETO 3-21-18 Transcript The Nebraska Emergency Treatment Orders[...]
Mar 13 @ 12:15 pm – 1:00 pm
This webinar highlighted the development of a Pain Guidance Task Force in Nebraska. Presenters discussed composition of the task force and utilization of CDC’s guidelines on opioid prescribing to compile the Nebraska Pain Guidance Document[...]
Feb 20 @ 12:00 pm – 12:30 pm
One of the multitude of contributing factors to the opioid epidemic is highly variable pain treatment practices between healthcare providers. Efforts are being made nationally and at organizational levels to provide more consistent treatment guidelines[...]
Feb 14 @ 11:00 am – 12:00 pm
  Presentation Handout Every two minutes someone dies from sepsis in the United States. Eighty percent of sepsis begins outside the hospital. The elderly, as well as patients with chronic conditions, are at significant risk[...]
Feb 6 @ 12:15 pm – 12:45 pm
One of the multitude of contributing factors to the opioid epidemic is highly variable pain treatment practices between healthcare providers. Efforts are being made nationally and at organizational levels to provide more consistent treatment guidelines[...]
Jan 29 @ 12:15 pm – 12:45 pm
Nonpharmacologic therapies have become a vital part of managing chronic pain. This webinar will focus on the non-pharmacologic options available including mindfulness and meditation, yoga and exercise, anti-inflammatory foods, emotional triggers, sleep and more. Target[...]
Jan 25 @ 12:00 pm – 1:00 pm
Join experts from the American Medical Association (AMA) to learn how AMA’s extensive, evidence-based resources can lead to better health, better care and lower costs. The AMA has put together 50 free online modules on[...]
Jan 9 @ 12:15 pm – 12:45 pm
  Presentation handout Nonpharmacologic therapies have become a vital part of managing chronic pain. This webinar will focus on the non-pharmacologic options available including mindfulness and meditation, yoga and exercise, anti-inflammatory foods, emotional triggers, sleep[...]
Dec 14 @ 1:00 pm – 2:00 pm
  Heart failure is one of the top diagnoses involved with readmissions throughout the Great Plains and Lake Superior Quality Innovation Networks. This webinar is the sixth in a series to assist communities in this[...]
Dec 14 @ 12:00 pm – 1:00 pm
  Presentation handout While colorectal cancer is preventable, one in three Americans has not been screened.  During this Learning and Action event, a patient and healthcare professional panel will share insights and tools to engage[...]
Dec 12 @ 12:15 pm – 12:45 pm
  Prescription drug monitoring programs (PDMPs) are a valuable tool to improve patient care and coordination and public safety by reducing drug diversion and inappropriate use. This follow-up coaching call provides participants the opportunity to[...]
Dec 5 @ 12:00 pm – 1:00 pm
  Presentation Handouts: Presentation Handout Leadership Team Diagnostic Checklist This event has been approved for 1.0 hour of Continuing Education (nursing) credit through the North Dakota Board of Nursing: Course #1573   During this WebEx,[...]
Nov 28 @ 12:15 pm – 12:45 pm
Prescription drug monitoring programs (PDMPs) are a valuable tool to improve patient care and coordination and public safety by reducing drug diversion and inappropriate use. This event includes PDMP staff from throughout the Great Plains[...]
Nov 14 @ 12:15 pm – 12:45 pm
Prescription drug monitoring programs (PDMPs) are a valuable tool to improve patient care and coordination and public safety by reducing drug diversion and inappropriate use. This event includes PDMP staff from throughout the Great Plains[...]
Oct 31 @ 1:00 pm – 2:00 pm
Heart failure is a top diagnoses linked to readmissions throughout the Great Plains and Lake Superior Quality Innovation Networks. This webinar is the fifth in a series of webinars to assist communities in this seven-state[...]
Oct 17 @ 12:15 pm – 12:45 pm
Medication Safety LAN Series An important pillar to reducing abuse of opioids is safe and proper disposal of unused medication.  This coaching call will allow participants to interact with take back experts to ask questions,[...]
Oct 13 @ 12:00 pm – 1:00 pm
The Triple Aim of healthcare improvement historically has not addressed the providers critical role in transforming healthcare. Therefore, there is a new call to emphasize the original three goals plus adding the goal of improving[...]
Oct 10 @ 12:15 pm – 12:45 pm
Medication Safety LAN Series An important pillar to reducing abuse of opioids is safe and proper disposal of unused medication.  This webinar reviews success approaches at the community and state level to improve access to[...]
Sep 26 @ 12:15 pm – 12:45 pm
Medication Safety LAN Series There is no single solution to the opioid epidemic.  It will require a collaborative approach with variety of community partners to address factors such as pain management, treatment, and societal impact.[...]
Sep 26 @ 11:00 am – 12:00 pm
Heart failure is one of the top diagnoses involved with readmissions throughout the Great Plains and Lake Superior Quality Innovation Networks. Providing targeted assistance to Congestive Heart Failure (CHF) patients in the home setting after[...]
Aug 23 @ 11:00 am – 12:00 pm
Heart failure is one of the top diagnoses involved with readmissions throughout the Great Plains and Lake Superior Quality Innovation Networks. This webinar is the third in a series of webinars to assist communities in[...]
Jul 27 @ 11:00 am – 12:00 pm
  Heart failure is one of the top diagnoses involved with readmissions throughout the Great Plains and Lake Superior Quality Innovation Networks. This webinar is the second in a series to assist communities in this[...]
Jul 25 @ 12:15 pm – 12:45 pm WebEx
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 Care webinar series.[...]
Jul 11 @ 12:15 pm – 12:45 pm WebEx
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[...]
Jun 28 @ 12:00 pm – 1:00 pm
Presentation Handout We will add the WebEx recording when available. This WebEx offers real world experience of success in the Million Hearts® Initiative. The Avera St. Benedict’s clinic staff from Parkston, SD provided insight into[...]
Jun 20 @ 1:30 pm – 2:30 pm
Presentation Handout Overview and Purpose: Heart failure is a top diagnosis linked to readmissions throughout the seven states that comprise the Great Plains and Lake Superior Quality Innovation Networks. This webinar is the first in a series [...]
Jun 20 @ 12:15 pm – 12:45 pm WebEx
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 Care webinar series.[...]
Jun 6 @ 12:15 pm – 12:45 pm WebEx
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 Care webinar series.[...]
May 23 @ 12:15 pm – 12:45 pm WebEx
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 Care webinar series.[...]
May 23 @ 12:00 pm – 1:00 pm
Care Coordination and Medication Safety Progress within the Great Plains QIN Region Join the Great Plains Quality Innovation Network Care Coordination Team for the fifth in this series of action-oriented learning events. This WebEx session will[...]
May 9 @ 12:15 pm – 12:45 pm WebEx
  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 Care webinar[...]
Apr 26 @ 12:00 pm – 1:00 pm
Teach-back is a communication method used to help patients understand and remember important information. Successful implementation of teach-back has demonstrated better recall and understanding of procedures by patients as well as improved patient satisfaction, medication[...]
Apr 25 @ 12:15 pm – 12:45 pm
  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 Care webinar[...]
Apr 25 @ 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[...]
Apr 11 @ 12:15 pm – 12:45 pm
  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 Care webinar[...]
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[...]
Feb 28 @ 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[...]
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. Medication Safety Presentation Handout Medication safety contributes to reducing[...]
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[...]
Sep 14 @ 11:30 am – 1:00 pm Rapid City Regional Hospital, Trautman Room
Please Note: This event is 11:30 a.m. Mountain Time or 12:30 Central Standard   To participate via phone:  877/662-7634, Passcode 6315499
Aug 11 @ 1:00 pm – 2:00 pm Avera St. Mary's Hospital, 4th Floor Lecture Room
Please Note:  All events are listed in Central Time. To participate via phone:  1-877-662-7634, passcode 6315499
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 21 @ 10:00 am – 11:30 am Lutheran Social Services
Please Note: All events are listed in Central Standard Time   To participate via phone:  877/662-7634, Passcode 6315499
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.[...]
Jul 9 @ 1:00 pm – 2:30 pm Smart Center
Please Note:  All events are listed in Central Time To participate via phone:  877-662-7634, Passcode 6315499        

Advanced Care Planning

External Resources 
Advance Care Planning: An Introduction for Public Health and Aging Services Professionals [Course]
Caring Connections  State-Specific Healthcare Directives
Dying in America: Improving Quality and Honoring Individual Preferences Near the End of Life Consensus Report 2014
INTERACT (Intervention to Reduce Acute Care Transfers)
Let's Talk About Dying - Peter Saul (YouTube)
Making Health Care Decisions in North Dakota: A Summary of North Dakota Law Regarding Health Care Directives
Making Medical Decisions for Someone Else: A North Dakota Handbook
National Healthcare Decisions Day
Palliative Care Fast Facts and Concepts Overview
POLST® Physician Orders for Life-sustaining Treatment
Respecting Choices®

Care Coordination

External Resources
AHRQ Chartbook on Care Coordination
AHRQ Community Care Coordination at a Glance
CDC Community Health Improvement Navigator
Community-Based Care Coordination Toolkit
Geri Pearls Reviews
Huddle for Care
IHI STARR Initiative (State Action on Avoidable Rehospitalizations)
INTERACT (Intervention to Reduce Acute Care Transfers)
Leadership Toolkit for Redefining the H: Engaging Trustees and Communities
National Transitions of Care Coalition (NTOCC)
Rural Care Coordination Guide
Rural Care Coordination Toolkit
The Care Transitions Program®

Discharge Planning

External Resources
AHRQ - Improving the ED Discharge Process 
Project RED (Re-Engineered Discharge)

Patient Activation
Person and Family Engagement
Reports

External Resources

Jayme Steig

Jayme Steig, PharmD, RPh

Pharmaceutical Care Specialist
North Dakota
701-989-6224
Email Jayme

Paula Sitzman

Paula Sitzman, RN, BSN

Quality Improvement Advisor
Nebraska
402-476-1399 x512
Email Paula

Sally May

Sally May, RN, BSN

Senior Quality Improvement Specialist
North Dakota
701-989-6228
Email Sally

Linda Penisten

Linda Penisten, RN, OTR/L

Program Manager
South Dakota
1-605-336-3505
Email Linda

Amanda Bridges

Beth Nech, MA

Quality Improvement Project Manager
Kansas
1-785-271-4120
Email Beth

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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.