Improving Care Coordination and Medication Safety

In March 2016, the Centers for Disease Control and Prevention (CDC) published Guideline for Prescribing Opioids for Chronic Pain, which helps providers improve communication with their patients and provide guidance on safe and effective treatments of chronic pain. CDC offers several provider resources including Recommendations for Prescribing Opioids for Chronic Pain and a Checklist for Prescribing Opioids for Chronic Pain. For more information, visit CDC's website

Coordinating the process by which patients move from hospitals to other care settings is paramount to improving the health of people with Medicare. Recent statistics show that up to 76 percent of hospital readmissions may be preventable by increasing and coordinating post-acute care between discharge and readmission. 

In addition, a few high-risk medications – anticoagulants, diabetes drugs and opioids - are implicated in adverse drug events (ADEs) that lead to emergency department visits and hospitalizations. Utilizing education, best practices and interventions can help us to use these drugs more safely. Check out this fact sheet on “The Big Three” high risk medications.

How We Can Help

Quality Insights’ Quality Innovation Network seeks to serve as a cornerstone of care coordination by forming innovative community coalitions that unite stakeholders with a shared vision of reduced hospital readmissions throughout our region. Our leadership in these communities includes:

  • Providing mentorship to grassroots leaders using community organizing tactics
  • Leading communities’ efforts to identify and target special and vulnerable populations affected by poor care coordination
  • Introducing Health Information Technology (HIT) tools to support secure communication between health care settings
  • Providing data and analytic support to communities to identify gaps in quality and develop strategies for improvement
  • Utilizing the My Quality Insights platform to support the use of “teach back” methodology to measure success of provider communication with families and beneficiaries and measure the effectiveness of outcomes
Our efforts and communities include acute and post-acute providers across all care settings and Long-Term Services and Supports (LTSS), which are under-utilized services that have the potential to improve care coordination and quality. We are working with community-based providers to implement medication safety practices targeted to the three high risk drug groups. Quality Insights is also placing special emphasis on recruiting and sustaining the involvement of Medicare beneficiaries and their families to participate in all care coordination activities and planning processes.

What We Can Achieve Together

These and other activities will ultimately contribute to meeting ambitious goals that include:

  • Reducing hospital admissions and readmission rates in the Medicare program by 20 percent by 2019
  • Increasing community tenure, as evidenced by increased number of nights spent at home, for Medicare beneficiaries by 10 percent by 2019
  • Reducing ADEs due to anticoagulants, diabetes drugs and opioids by providing healthcare practitioners with tools and resources designed to reduce ADEs and patient harm that may decrease emergency department visits, observation stays, hospital admissions or readmissions

Get Involved

Quality Insights’ Quality Innovation Network’s goal is to be at the forefront of improving care coordination throughout our region. To learn more or initiate a partnership, please visit the Get Local section of this website to connect with your local project coordinator and read The Big Three Fact Sheet to learn how to get involved.

Related Resources

Visit our online Resource Library and these links on the web: