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

Of those patients who are readmitted 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.

Hospitals, skilled nursing facilities, home health agencies, pharmacies, physician offices, dialysis centers as well as patients, families, payers and community stakeholders are all involved in improving care coordination, patient satisfaction and patient outcomes.

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)

Care Coordination News


See All Care Coordination News Posts 

Advanced Care Planning

External Resources 
Advance Care Planning: An Introduction for Public Health and Aging Services Professionals [Course]
Caring Connections  State-Specific Healthcare Directives
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
Nebraska Health Network - Emergency Treatment Orders (NETO)
Palliative Care Fast Facts and Concepts Overview
POLST® Physician Orders for Life-sustaining Treatment
Respecting Choices®
University of Kansas Health System: Advanced Care Planning

Discharge Planning

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

Patient Activation

External Resources
Insignia Health Patient Activation Measure Survey


External Resources

CMS Data Reports Blue Button
Medicare's Blue Button & Blue Button 2.0

Training Events

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Care Coordination

External Resources
Aunt Bertha
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 Age Friendly Health Systems
IHI STARR Initiative (State Action on Avoidable Rehospitalizations)
INTERACT (Intervention to Reduce Acute Care Transfers) 
Kansas Community Resources - Kansas Resource Guide
National Transitions of Care Coalition (NTOCC)
North Dakota Community Resources - CareChoice 
North Dakota Community Resources - My FirstLink
The Care Transitions Program®

Jayme Steig

Jayme Steig, PharmD, RPh

Pharmaceutical Care Specialist
North Dakota
Email Jayme

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Great Plains Quality Care Coalition

Our Vision: Through collaboration and partnership, we aspire to make healthcare in the Dakotas the best in the nation. We have partnered with committed nursing homes, community leaders and healthcare organizations to improve the care in our communities. Better together.