Care Coordination SC

    Improving Transitions of Care (SC)

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 working with 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 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)

 

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

Webinar #6:  The Imperative for Cross-Setting Coordination of Care
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

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

The following files are available for download:

AHRQ Hospital Guide to Reducing Medicaid Readmissions AHRQ Hospital Guide to Reducing Medicaid Readmissions

AHRQ Hospital Guide to Reducing Medicaid Readmissions - Toolbox AHRQ Hospital Guide to Reducing Medicaid Readmissions - Toolbox
Medicaid Readmissions Medicaid Readmissions

Report: Actions of the Spartanburg County Behavioral Health Taskforce Report: Actions of the Spartanburg County Behavioral Health Taskforce

Rethinking solutions in healthcare: Integrated Behavioral Health Care Rethinking solutions in healthcare: Integrated Behavioral Health Care