GOAL 3: Promote Effective Communication and Coordination of Care Task C.3: Coordination of Care Section A. Overview and Background Improving communication and the coordination of clinical decisions is a cornerstone of both the National and CMS Quality Strategies, and the IOM provides concrete recommendations for fostering organizational and leadership cultures that strengthen community-clinical partnerships. QIN-QIOs are uniquely situated to engage cross-cutting communities of practitioners, long-term services and support providers, and other community stakeholders to improve the quality of care for a population of Medicare beneficiaries. Employing a framework for quality improvement that centers on community organizing tactics, QIN-QIOs shall support the development of community coalitions that: Define a shared, measureable, population goal for improving care coordination in a defined geographic community. Perform community specific root cause analyses to identify the drivers of ineffective care transitions such as a lack of timely and complete communication, poor patient activation, and other system level process deficiencies that can lead to poor health outcomes including ADEs that can lead to increased utilization of acute care services Identify and implement appropriate community-level interventions that improve the coordination of care for beneficiaries and their family members across provider settings. Increase medication safety in the community to prevent adverse drug events, reduce readmissions, and improve care coordination for beneficiaries across provider settings. Collect data and determine measures to monitor community-level interventions that demonstrate improved outcomes across various populations of Medicare beneficiaries. CMS and its federal partners have employed many strategies focused on improving the care coordination and transition of Medicare beneficiaries across settings. Programs and interventions that improve care transitions from hospital to post-acute care settings such as the Care Transitions Program and Partnership for Patients Initiatives under Center for Medicare and Medicaid Innovation (CMMI), the Administration for Community Aging Living’s and Disability Resource Center Project RED and the Integrated Care Grant Programs, AHRQ’s for Populations and Communities Aim under the QIO 10th SOW have contributed to national declines in readmission and admission rates in hospitals across the country. But while there have been significant gains in reducing readmissions and admissions in hospitals, care coordination does not begin or end with an in-patient hospital stay. Beneficiaries and family
GOAL 3: Promote Effective Communication and Coordination of Care Task C.3: Coordination of Care Section A. Overview and Background Improving communication and the coordination of clinical decisions is a cornerstone of both the National and CMS Quality Strategies, and the IOM provides concrete recommendations for fostering organizational and leadership cultures that strengthen community-clinical partnerships. QIN-QIOs are uniquely situated to engage cross-cutting communities of practitioners, long-term services and support providers, and other community stakeholders to improve the quality of care for a population of Medicare beneficiaries. Employing a framework for quality improvement that centers on community organizing tactics, QIN-QIOs shall support the development of community coalitions that: Define a shared, measureable, population goal for improving care coordination in a defined geographic community. Perform community specific root cause analyses to identify the drivers of ineffective care transitions such as a lack of timely and complete communication, poor patient activation, and other system level process deficiencies that can lead to poor health outcomes including ADEs that can lead to increased utilization of acute care services Identify and implement appropriate community-level interventions that improve the coordination of care for beneficiaries and their family members across provider settings. Increase medication safety in the community to prevent adverse drug events, reduce readmissions, and improve care coordination for beneficiaries across provider settings. Collect data and determine measures to monitor community-level interventions that demonstrate improved outcomes across various populations of Medicare beneficiaries. CMS and its federal partners have employed many strategies focused on improving the care coordination and transition of Medicare beneficiaries across settings. Programs and interventions that improve care transitions from hospital to post-acute care settings such as the Care Transitions Program and Partnership for Patients Initiatives under Center for Medicare and Medicaid Innovation (CMMI), the Administration for Community Living’s Aging and Disability Resource Center Grant Programs, AHRQ’s Project RED and the Integrated Care for Populations and Communities Aim under the QIO 10th SOW have contributed to national declines in readmission and admission rates in hospitals across the country. But while there have been significant gains in reducing readmissions and admissions in hospitals, care coordination does not begin or end with an in-patient hospital stay. Beneficiaries and family
QIN-QIO_Task_Order_001.docx