Skip to main content

Care Coordination Quickinar Series

Provider in Home with Senior Patients Medical Team Looking at Xray
Top

Care coordination is a key priority for the Centers for Medicare & Medicaid (CMS) to improve quality and achieve safer and more effective care. The recordings and slides for this quickinar series help address gaps in care with short, 30-minute presentations.

Care Coordination Quickinar Sessions

(January 2022–May 2024)

Care Coordination During a Pandemic

Tuesday, January 18, 2022

Event recording

PowerPoint presentation

This presentation provides an overview of the Quickinar format and reintroduces care coordination in the era of COVID-19.

Objectives:

  • Examine the journey of care coordination pre and post COVID-19.
  • Discuss the Hospital Readmission Reduction Program (HRRP) and SNF VBP.
  • Review the HSAG readmission website.
  • Map out care coordination process for 2022.
  • Introduce the HSAG care coordination assessment

Care Transitions Assessment Overview
 
Tuesday, February 1, 2022 

Event recording

PowerPoint presentation

This session introduces the HSAG Care Transitions Assessment for various healthcare settings.

Objectives:

  • Describe the main categories of the Care Transitions assessment.
  • Discuss experiences, challenges, and lessons learned using the assessment.

Gap/Root Cause Analysis (RCA)
 
Tuesday, February 15, 2022 

Event recording

PowerPoint presentation 

This presentation reviews evidence-based strategies and tactics for facilitating a root cause analysis for opportunities of improvement identified in the care transition assessment.

Objectives:

  • Discuss and identify the components of the Gap/Root Cause Analysis tool
  • Identify other resource audit tools (7-day audit tool, patient interview, 5 whys, HSAG data reports)

Strategy Tree Development and Implementation

Tuesday, March 1, 2022

Event Recording 

PowerPoint presentation

This presentation reviews evidence-based strategies and tactics for facilitating a strategy tree for opportunities of improvement identified in the care coordination assessment.

Objectives:

  • Introduce and review the elements of the strategy tree.
  • Discuss the tactics category as a key component of the strategy tree.
  • Discover how the strategy tree can be used at your facility.

Readmission Super-Utilizers Part 1

Tuesday, March 15, 2022 

Event Recording 

HSAG PowerPoint presentation

Montage PowerPoint presentation

This presentation discusses the unique challenge super-utilizers present in care coordination.

Objectives:

  • Define super-utilizer as is relates to care coordination and readmissions.
  • Describe the impact of super-utilizers in healthcare settings.
  • Discuss care management/care transition strategies to address super-utilizers.
  • Identify available resources in your community.

Hotspotting and Resources

Tuesday, April 5, 2022

Event Recording

HSAG PowerPoint Presentation

HonorHealth PowerPoint Presentation

This presentation discusses how hotspotting and other resources can assist to identify super-utilizer, dedicate resources, and implement targeted interventions.

Objectives:

  • Review data and other tools/mechanisms to identify super-utilizers.
  • Explain strategies to improve coordination of care and reduce utilization for super-utilizers.

Measuring Progress: QIIP Performance Dashboard
 
Tuesday, April 19, 2022 

Event Recording

PowerPoint Presentation

This presentation introduces the HSAG Quality Improvement Innovation Portal (QIIP) performance dashboard, an analytic tool, to provide an overview of how you can use the tool to leverage your care coordination efforts.

Objectives:

  • Discover how to access the performance dashboard in the HSAG QIIP.
  • Review the features and data available in the dashboard.
  • Identify how to use the dashboard to guide and measure your readmissions progress.

The Role of Health Equity in Care Coordination

Tuesday, May 3, 2022

Event recording

PowerPoint presentation

This presentation discusses how a facility can identify the contributing factors that impact health equity and readmissions.

Objectives:

  • Explain community characteristics that impact health equity.
  • Review the hospital required Community Health Needs Assessment (CHNA).
  • Introduce the HSAG health equity assessment.

The Impact of Health Literacy

Tuesday, June 7, 2022

Event Recording

PowerPoint Presentation 

This presentation discusses the role health literacy plays in care coordination.

Objectives:

  • Define health literacy as a tool for effective healthcare communication.
  • Discuss how to assess health literacy levels.
  • Identify tools and strategies to address health literacy.

Teach-Back: A Strategy to Impact Health Literacy

Tuesday, July 5, 2022

Event Recording

HSAG PowerPoint Presentation

AHRQ PowerPoint Presentation

This presentation discusses teach-back as a tool to address health literacy.

Objectives:

  • Discuss the role and value of teach-back to improve care coordination.
  • Discuss teach-back resources.
  • Identify strategies/steps for implementing teach-back in your facility.

Community Collaboration Meetings

Tuesday, August 2, 2022 

Event recording

Slide presentation

This presentation discusses how to form and run effective community and post-acute care meetings.

Objectives:

  • Illustrate the essential elements of a successful community collaborative.
  • Discuss ways to collaborate with preferred post-acute providers.
  • Identify metrics to measure community success in reducing readmissions.

Readmission Data to Drive Change

Tuesday, September 13, 2022

Event Recording

Presentation Slides

This presentation provides an overview of the quickinar format and discusses how to use readmission data to implement change at your facility.

Objectives:

  • Discover how to access your Medicare fee-for-service (FFS) readmissions data in the Quality Improvement Innovation Portal (QIIP).
  • Discuss how HSAG, the Quality Improvement Organization (QIO), can support you in your readmission efforts.
  • Review the tools available on the HSAG Care Coordination website.
  • Examine how to use the dashboard to guide and measure your readmissions progress.

Super-Utilizers, Part 2

Tuesday, October 4, 2022 

HSAG Intro Slides

Super-Utilizers Slides

Recording 

This presentation discusses the case management program one health system implemented to address the needs of their super-utilizers.

Objectives:

  • Describe case management strategies for super-utilizers.
  • Explore the strategy implemented by the hospital to address their super-utilizer population.
  • Discuss and share relevant resources.

Care Transitions Assessment and Toolkit

Tuesday, January 10, 2023

Event Recording

Presentation Slides

This session introduces the HSAG Care Coordination Assessment and Toolkits as resources you can use at your facility. 

Objectives:

  • Review the elements of the HSAG Care Transitions Assessments and Toolkits.
  • Discuss how to use the assessment as a tool to implement to drive change at your facility.
  • Explore the quality improvement tools available in the toolkits.

Strategies to Prevent Urinary Tract Infection (UTI) and Pneumonia-Related Hospitalizations

Tuesday, February 7, 2023

Event Recording

Presentation Slides

This session examines specific strategies to reduce hospitalizations related to UTIs and pneumonia.

Objectives:

  • Review the elements of the HSAG UTI and pneumonia assessments and toolkits.
  • Discuss how to use the assessment as a tool to implement and drive change at your facility.
  • Discover how to register and access the Quality Improvement and Innovation Portal (QIIP) data application.

Deeper Dive Into Readmission Data

Tuesday, March 7, 2023

Event Recording 

Presentation Slides

This session reviews the different readmission data elements in the Quality Improvement Innovation Portal (QIIP) and how they can be used to identify areas of opportunity at your facility.

Objectives:

  • Discover how to access the performance dashboard in the HSAG QIIP.
  • Examine the features and data elements available in the QIIP dashboard.
  • Review how to use the dashboard to guide and measure your readmissions progress.
  • Identify readmission data as the basis for implementing a quality improvement project/area of focus.

Health Equity/Disparties—Health Area Deprivation Index

Tuesday, April 4, 2023

Event Recording

Presentation Slides

This session introduces tools to address health disparities and social determinants of health (SDOH) that impact readmissions.

Objectives:

  • Use Area Deprivation Index (ADI) to visualize your community’s level of social need.
  • Examine the various social need screening tools available to collect patient-level SDOH data.
  • Discuss how to use Z codes to document SDOH in the medical record.
  • Review HSAG tools and resources for addressing health equity.

Health Literacy, Part 2

Tuesday, May 2, 2023

Event Recording 

Presentation Slides 

This presentation continues the discussion about the role health literacy plays in care coordination.

Objectives:

  • Define health literacy as a tool for effective healthcare communication.
  • Describe how to become a health literate organization.
  • Demonstrate utilization of tools and strategies to address health literacy.

Engaging Patients in Care Coordination Efforts

Tuesday, June 6, 2023

Event Recording

Presentation Slides

This session describes strategies to engage patients to improve care coordination and reduce readmissions.

Learning Objectives:

  • Define patient engagement as it relates to care coordination.
  • Describe how higher levels of patient involvement leads to better outcomes.
  • Discuss practical tips to improvement patient engagement.
  • Introduce patient engagement educational tools and resources.

Teach-Back: A Strategy to Improve Care Coordination

Tuesday, July 11, 2023

Event Recording

Presentation Slides

Objectives:

  • Discuss the role and value of teach-back to improve care coordination and reduce readmissions.
  • Discuss teach-back resources.
  • Identify strategies for implementing teach-back at your facility.

Skilled Nursing Facility (SNF) 2.0 Interventions to Reduce Acute Care Transfers (INTERACT), Using Stop-and-Watch, and Situation, Background, Assessment, Recommendation (SBAR)

Tuesday, August 1, 2023 

Event Recording

Slide Presentation HSAG

Slide Presentation CALTCM

Objectives:

  • Discuss SBAR and how to effectively use it in your facility.
  • Distinguish how SBAR is used in the hospital and the SNF.
  • Identify strategies for implementing Stop-and-Watch and SBAR at your facility.

Sepsis Readmission Prevention

Tuesday, September 5, 2023

Event Recording

Slide Presentation 

Objectives:

  • Define sepsis.
  • Recognize basic sepsis pathophysiology.
  • Describe the sepsis bundle.
  • Implement sepsis early recognition and treatment protocols.
  • Recognize post-sepsis syndrome (PSS).

Preventing Pneumonia Readmissions

Tuesday, October 3, 2023 

Event Recording

Slide Presentation

Objectives:

  • Review evidence-based clinical practices shown to prevent pneumonia.
  • Explore strategies to reduce pneumonia.
  • Discuss adherence monitoring and feedback.

Preventing Urinary Tract Infection (UTI) Readmissions

Tuesday, January 9, 2024

Event recording 

Slide presentation

Objectives:

  • Describe the risk of healthcareassociated UTIs in SNFs.
  • Review the evidence-based clinical practices shown to prevent UTIs and catheter-associated UTIs (CAUTIs).
  • Discuss strategies to reduce healthcareassociated UTIs and CAUTIs.
  • Discuss adherence monitoring and feedback.
  • Review the HSAG UTI Prevention Bundle and Change Package.

Readmissions and End of Life

Tuesday, February 6, 2024 | 11–11:30 a.m. PT

Event Recording

Featured slide Presentation 

Objectives:

  • Differentiate palliative care from hospice.
  • Compare Advance Health Care Directive and POLST as tools for advance care planning.
  • Place ACP conversations in continuum of care.
  • Implement effective approaches to advance care planning and POLST.

Improving Communication and Teamwork Around Antibiotic Decision Making

Tuesday, March 5, 2024

Event Recording

HSAG Slide Presentation 

Featured Slide Presentation 

Objectives:

  • Explain how to improve communication with other healthcare workers.
  • Examine how to improve communication with patients and families.
  • Explore how to work as a team to improve antibiotic prescribing using The Four Moments of Antibiotic Decision Making framework.

Readmission Incentive and Penalty Programs: Hospital Readmissions Reduction Program (HRRP), Value-Based Purchasing (VBP), and Workforce & Quality Incentive Program (WQIP)

Tuesday, April 2, 2024

Event Recording

Slide Presentation 

This session will review the Centers for Medicare & Medicaid Services (CMS) HRRP, the CMS Skilled Nursing Facility (SNF) Value-Based Purchasing Program (SNF VBP), and the new California WQIP claims-based measures. Areas of focus will be:

  • Outpatient Emergency Department Visits per 1,000 Long-Stay Resident Days
  • Healthcare-Associated Infections Requiring Hospitalization
  • Potentially Preventable 30-Day Post-Discharge Readmissions

Readmissions and Post-Discharge Follow-Up

Tuesday, May 7, 2024

Event Recording

Slide Presentation

Objectives:

  • Discuss how discharge planning relates to the readmission penalty and
    incentive programs.
  • Discuss how disparities impacts discharge planning.
  • Share evidence-based best practices for post-discharge follow-up.
  • Describe tools and strategies facilities can implement to strengthen discharge processes.