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 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
Initiatives
- Cardiovascular Health
- Care Coordination
- Community Based Sepsis
- Diabetes Self-Management
- Drug Safety
- Immunization
- MAPPP
- Nursing Home Quality
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- Nursing Home Quality (NY)
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- QAPI Self-Assessment
- CASPER Data
- Eliminating Inappropriate Antipsychotic Medication Use
- Clinical Quality Measures (QM)
- Composite Measure Score
- NHQCC Collaborative I Kick-Off
- NHQCC Collaborative I Outcomes Congress
- QI/QAPI
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- 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
- Resources
- Consumers
- Nursing Home Quality (DC)
- Nursing Home Quality (SC)
- Outpatient Antibiotic Stewardship
- Quality Payment Program
- Transforming End of Life
Contact Us
South Carolina
Sarah Stein Banyai, Care Coordination Manager
803-212-7521
sbanyai@thecarolinascenter.org
Cheryl Anderson, Medication Safety Pharmacist
803-727-7017
canderson@thecarolinascenter.org