Improving Transitions of Care (SC)

Improving coordination of healthcare, communication and patient/caregiver knowledge by fostering community-based coalitions, teamwork and patient-centered care.

Efficient and effective care coordination means that necessary health care services are delivered in the right order, at the right time, and in the right setting. These efforts lead to lower costs, better outcomes, and increased patient satisfaction.

The Carolinas Center for Medical Excellence is a member of the Atlantic Quality Innovation Network (AQIN). The South Carolina AQIN team is recruiting Community Care Coalitions – hospitals, skilled nursing facilities, home health/hospice agencies, social service organizations, primary care providers, patients, caregivers, and other state and regional level stakeholders – to work together to identify and provide a quality improvement focus on special populations affected by poor care coordination. These special populations include Medicare fee-for-service (FFS) beneficiaries that fall within one of the following sub-groups

  • Eligible for both Medicare and Medicaid
  • Multiple chronic conditions
  • Behavioral health issues, such as depression
  • Alzheimer’s and dementia
  • Lower socioeconomic status and other social determinants of health risk

Community Care Coalition Goals

  • Reduce hospital readmission rates in the Medicare population by 20% by July 31. 2019.
  • Increase community tenure by 10 % (more nights spent at home for Medicare FFS beneficiaries)

Next Step for Interested Providers/Partners

If you are interested in participating in Community Care Coalitions or if you have any questions, please contact Heather Jones at Heather.Jones@area-I.hcqis.org or 803.212.7584.

Recorded Webinars

Care Transitions Best Practice Webinar Series

Webinar #1: Ride Assistance Program
Webex Recording
Presentation Slides

Webinar #2:  Pain Management and the QAPI Process
Webex Recording
Presentation Slides

Webinar #3: Huddling Around a Whiteboard
Webex Recording

Webinar #4: Reducing Pressure Ulcer Rates
Webex Recording

Webinar #5: Implementing INTERACT
Webex Recording

INTERACT Implementation: Learning in Action Collaborative

Kickoff Webinar #1: Readmission Tracker
Webex Recording
Presentation Slides

Webinar #2 INTERACT: Capabilities List
Webex Recording
Presentation Slides

Webinar #3 INTERACT: Transfers
Webex Recording
Presentation Slides

Webinar #4 INTERACT: SBAR
Webex Recording
Presentation Slides

Webinar #5 INTERACT: Stop and Watch
Webex Recording
Presentation Slides

Webinar #6 INTERACT: Next Steps
Webex Recording
Presentation Slides

Public Resources

AHRQ Medicaid Readmissions Webinar 3 – Enhanced Services to Reduce Readmissions
April 8, 2015
Webex Recording
View Transcript

AHRQ Medicaid Readmissions Webinar 2 - Identifying and Collaborating with Medicaid Partners Across the Continuum
March 25, 2015
Webex Recording
View Transcript (pdf)

AHRQ Medicaid Readmissions Webinar
March 11, 2015
Webex Recording
View Transcript (pdf)

The following files are available for download:

Initiatives

Care Coordination
Care Coordination DC
Resources
Care Coordination NY
Overview
Beneficiaries and Families
Healthcare Professionals
Other Website Resources
Tools and Resources
Past Success
Upcoming Events
Past Events
Blog
Contact Us
Care Coordination SC
Cardiovascular Health
Cardiovascular Health (DC)
Cardiovascular Health (NY)
Cardiovascular Health (SC)
Community Based Sepsis
Educational Events/Webinars
Sepsis in the News
Tools and Resources
Diabetes Self-Management
Diabetes Self-Management Education (DC)
Diabetes Self-Management Education (NY)
Diabetes Self-Management Education (SC)
Drug Safety
Anticoagulation Safety
Hypoglycemia Avoidance
Opioid Safety
Drug Safety (DC)
Drug Safety (NY)
Drug Safety (SC)
Hospital Safety
Hospital Safety (DC)
Hospital Safety (NY)
Hospital Safety (SC)
Immunization
Immunization (DC)
Immunization (SC)
SC Immunization Coalition Materials
Nursing Home Quality
Nursing Home Quality (DC)
Nursing Home Quality (NY)
Building Blocks for Quality
QAPI Self-Assessment
Casper Data
Eliminating Inappropriate Antipsychotic Medication Use
Clinical Quality Measures (QM)
Composite Measure Score
NHQCC Collaborative Kick-Off
NHQCC Collaborative Outcomes Congress
QI/QAPI
Using a System's Approach to Quality & Performance Improvement
Nursing Home Quality Care Collaborative (NHQCC) Learning
Engaging Staff in Individualized Care
QAPI Self-Assessment and Related Resources
QAPI In Action
Quality Improvement (QI) Resources
Quality Improvement Strategies
Steps to QAPI
Elements for Framing QAPI in Nursing Homes
Clinical Topics
Medication Use Tools & Resources
Pressure Ulcer Clinical Tools & Resources
Restraint Clinical Tools & Resources
Falls with Major Injuries
Health Care Acquired Conditions
Eliminating Long Term Care Re-Admissions Tools & Resources
Resources
Consumers
Nursing Home Quality (SC)
ACE e-Newsletter
Clinical Topics
Organizational Change
Presentations and Handouts
QI/QAPI
Upcoming Events
Outpatient Antibiotic Stewardship
Core Element One: Commitment
Core Element Two: Action for Policy and Practice
Core Element Three: Tracking and Reporting
Core Element Four: Education and Expertise
Technology-Enhanced Care
Meaningful Use of HIT (DC)
Meaningful Use of HIT (NY)
Meaningful Use of HIT (SC)
Transforming End of Life
Quality Payment Program

Contact Us

South Carolina

Heather Jones, Care Improvement Specialist
803-212-7584
hjones@thecarolinascenter.org

Cheryl Anderson, Medication Safety Pharmacist
803-727-7017
canderson@thecarolinascenter.org