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

See All Care Coordination News Posts 

Training Events
Oct 25 @ 1:00 pm – 2:00 pm
Participation Instructions: Pre-registration is not required. Please join 15 minutes prior to start. https://qualitynet.webex.com/ec Locate the event, click “Join” Enter your name and email Enter the password: ABS(If a dialogue box appears, click run. Set-up takes a[...]
Oct 10 @ 2:00 pm – 3:30 pm WebEx
All healthcare providers, partners and beneficiaries are welcome to attend! This Medication Safety Learning and Action Network (LAN) Event will feature a speaker panel of patients living with pain, a pain management specialist and a[...]
Sep 27 @ 2:00 pm – 3:00 pm
  Register Now In June 2016, Rapid City Regional Hospital in Rapid City, SD, launched a new method of quality improvement that puts frontline staff in the driver’s seat for healthcare reform. Data collected since[...]
Sep 20 @ 12:00 pm – 1:00 pm
Presentation handout Register Now Learn how a large system practice and rural clinic practice are using Chronic Care Management Programs to better coordinate care, increase communication to providers, reduce unnecessary hospitalizations and ED visits, empower[...]
Aug 23 @ 8:00 am – 4:00 pm Ramkota Hotel & Conference Center
Click here to download the brochure Overview and Purpose: Health and quality of life rely on many community systems and factors, not simply on a well-functioning health and medical care system. Making changes can effectively[...]
Jul 25 @ 12:15 pm – 12:45 pm
Presentation Handout Improving care for people with multiple chronic conditions that are often complicated by patients’ limited ability to care for themselves independently and by their complex social needs will help improve the performance of[...]
Jul 19 @ 2:00 pm – 3:30 pm
Presentation Handout Advance Care Planning Resources This webinar will feature a review of the Institute for Healthcare Improvement’s (IHI) framework for improving end-of-life care which includes five “bite-sized” practical principles. Stories from several organizations and[...]
Jul 11 @ 12:00 pm – 1:00 pm
Presentation Slides Handout The CDC Guidelines for Prescribing Opioids for Chronic Pain recommend tapering opioids when benefits do not outweigh harms of continued therapy. Tapering opioids can be challenging and a difficult process for patients.[...]
Jun 27 @ 12:00 pm – 12:45 pm
Presentation Handout Improving care for people with multiple chronic conditions that are often complicated by patients’ limited ability to care for themselves independently and by their complex social needs will help improve the performance of[...]
May 24 @ 12:15 pm – 1:00 pm
Presentation/Slide Handout   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[...]
Apr 26 @ 2:00 pm – 4:00 pm
Presentation/Slides Handout Agency for Healthcare Research and Quality (AHRQ) and the Department of Defense (DoD) have developed TeamSTEPPS, a teamwork system that offers a powerful solution to improving collaboration and communication. Teamwork has been found[...]
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. https://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,[...]

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 Consultant
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.