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.

References:
1. Centers for Medicare & Medicaid Services (CMS)

Care Coordination News

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

Reports

External Resources

CMS Data Reports
HealthIT.gov Blue Button
Medicare's Blue Button & Blue Button 2.0

Training Events
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        Share this:FacebookTwitterLinkedIn
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 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 6315499Share this:FacebookTwitterLinkedIn
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[...]
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 6315499Share this:FacebookTwitterLinkedIn
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 6315499Share this:FacebookTwitterLinkedIn
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[...]
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[...]
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[...]
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[...]
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[...]
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[...]
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[...]
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[...]
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[...]
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[...]
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[...]
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[...]
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 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 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[...]
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[...]
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 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.[...]
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.[...]
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 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 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[...]
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[...]
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 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[...]
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[...]
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[...]
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.[...]
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[...]
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 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[...]
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[...]
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[...]
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,[...]
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 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 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[...]
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[...]
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[...]
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[...]
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 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[...]
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[...]
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[...]
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[...]
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 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[...]
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[...]
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[...]
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.[...]
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 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[...]
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[...]
Sep 20 @ 12:00 pm – 1:00 pm
Presentation handout WebEx Q&A 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[...]
Sep 27 @ 2:00 pm – 3:00 pm
  Presentation Handout Discharge Timeout Checklist 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.[...]
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[...]
Oct 25 @ 1:00 pm – 2:00 pm
Presentation handout Overview and Purpose: This webinar will provide a brief explanation of antibiograms and will delve into their value in acute care, long-term care and outpatient settings. Using antibiograms to support improved antibiotic use[...]
Nov 14 @ 1:00 pm – 2:00 pm
Overview and Purpose: From storms to droughts, wildfires to floods or accidents to epidemics, disasters occur nearly every day in the United States, and the frequency is increasing. How many people are hurt or even[...]
Jan 15 @ 12:00 pm – 1:00 pm
Presentation Handouts: Beyond First Impressions: Determining Market Impact on Patient Engagement Patient Engagement Case Study Patient Experience: A Beginner’s Guide   Overview and Purpose: Marketing in the healthcare industry must reach beyond first impressions of[...]
Feb 6 @ 12:00 pm – 1:00 pm
Register Now Participation Instructions: Register for the WebEx event. Upon registration, you will receive a confirmation email with a registration ID from messenger@webex.com. The information on the email will be required to log into the[...]
Feb 12 @ 12:00 pm – 1:00 pm
  Patient Experience Beginner’s Guide Facility Branding: Identify and Impact Public Perception Improving the Patient Experience Learning and Action Network Series Healthcare is personal. Any individual in need of healthcare services becomes vulnerable. The level[...]
Mar 19 @ 12:00 pm – 1:00 pm
Improving the Patient Experience Learning and Action Network Series Healthcare is personal. Any individual in need of healthcare services becomes vulnerable. The level of comfort and confidence relayed by healthcare professionals at every stage of[...]
Mar 20 @ 12:00 pm – 1:00 pm
Presentation/Slides Handout Bedside medication delivery (Med-to-Bed) involves patients obtaining their discharge medications and education prior to leaving the hospital. It has been found to reduce readmissions and improve patient satisfaction scores. This presentation provided an[...]
Mar 22 @ 1:00 pm – 2:30 pm
Presentation Handout/Slides Overview and Purpose: The recently finalized Patient Driven Payment Model (PDPM) along with the Quality Reporting Program and Value-Based Purchasing Program will have significant impact on long-term care ratings for 2019 and beyond.[...]
Apr 16 @ 12:00 pm – 1:00 pm
      Presentation Handout Improving the Patient Experience Learning and Action Network Series Healthcare is personal. Any individual in need of healthcare services becomes vulnerable. The level of comfort and confidence relayed by healthcare[...]
Apr 16 @ 1:00 pm – 2:30 pm
Presentation/Slides Handout Webinar Q&A’s Overview and Purpose: With the implementation of Patient-Driven Payment Model (PDPM) slated for October 1, 2019, diagnosis coding will become even more important. Skilled nursing facility and hospital diagnoses will be[...]
May 7 @ 12:00 pm – 1:00 pm
Overview and Purpose: Vaccine hesitancy has been identified by the World Health Organization (WHO) as one of the ten threats to global health in 2019, potentially having broad implications reaching beyond the typical vulnerable populations.[...]
May 23 @ 1:00 pm – 5:00 pm Four Locations in North Dakota (Held Simultaneously)
    This year’s Quality Health Associates of North Dakota Annual Quality Forum—The Power of Progress—is an intentional celebration of successes from across the continuum of care throughout North Dakota represented by professionals who are[...]

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
701-989-6224
Email Jayme

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Quality Care Coalition

We are getting ready to launch the Great Plains Quality Care Coalition in a community near you. Join our mission to make healthcare in your organization and community better. We are looking for committed nursing homes, community leaders and healthcare organizations to partner with us. Don’t miss out on this exciting opportunity to be change makers. Sign up to receive more information. Recruitment materials will be sent soon.