Care Coordination, Communities - atom Alliance

Communities

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Take part in dynamic community collaborations designed to reduce readmissions and improve the coordination of care for adults over 65. Communities nationwide have already contributed to significant gains made in reducing readmissions and admissions in hospitals.

atom Alliance is continuing to unite communities with the shared, measurable goal of improving care coordination in their area. The communities consist of

  • local providers across multiple settings,
  • patient advocacy organizations,
  • long-term services and support groups and
  • patients and families.

They meet frequently to address the needs of readmissions reduction and have first-hand access to the latest care coordination events, tools and resources. atom Alliance supports these communities by assisting with root cause analysis, engaging partners, implementing and tracking interventions and communicating successes.

Learn how one community in Kentucky is focused on reducing readmissions. Watch Video.

Find-A-Community
Contact Us to Join Today
Use the tabs to the right to search for specific tools and resources related to this page.

You can also search our comprehensive library of online resources, where you can sort by atom Alliance state, initiative, patient or provider focus or simply type in a keyword for quick access to the tools and resources you need.

Motivational Interviewing
Community Care of North Carolina webpage dedicated to motivational interviewing
CDC Toolkit for Long-Term Care Employers: Seasonal Flu
Provides resources to help long-term care facility, agency or corporation owners and administrators provide access to influenza vaccination for their workforce and to help any employer of workers in long-term care understand the importance of influenza vaccination for their employees
HHS/Healthy People 2020: Social Determinants of Health
Resource offers an overview of Healthy People 2020 objectives, as well as national and local resources and data on key determinants of health.
National Plan to Address Alzheimer’s Disease: 2014 Update
Activities outlined in the plan vary in scope and impact to include: (1) immediate actions that the Federal Government will take; (2) actions toward the goals that can be initiated by the Federal Government or its public and private partners in the near term; and (3) longer-range activities that will require numerous actions to achieve.
AHRQ Quality Indicators™ Toolkit for Hospitals
This toolkit is designed to help hospitals understand the Quality Indicators (QIs) from AHRQ and use them to successfully improve quality and patient safety.
Hospital Guide to Reducing Medicaid Readmissions
The Agency for Healthcare Research and Quality (AHRQ) commissioned this guide to identify ways evidence-based strategies to reduce readmissions can be adapted or expanded to better address the transitional care needs of the adult Medicaid population.
Next Step in Care
Provides easy to use guides to help caregivers and healthcare providers work closely to plan and implement smooth transitions for chronically or seriously ill patients
Medicaring
Aims to build a healthcare system that can find patients who are living with serious and complex illness, tailor services to their priorities, and plan and pay providers in a way that encourages quality care at a price that communities and families can bear
Eldercare Locator
A public service of the U.S. Administration on Aging connecting you to services for older adults and their families
Health Information in Multiple Languages: MedlinePlus
Offers access to high quality health information for patients in 40 languages; more than 2,500 links to nearly 250 health topics
Readmissions Penalties by State (Year 3)—Kaiser Health News
Kentucky Department for Aging and Independent Living
The National Consumer Voice
INTERACT 3.0
Renal Failure Zone Tool
Renal Failure Zone Tool

Preview: Renal Failure Zone Tool
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287.14 KB | Last Updated: June 20, 2017

Sepsis Zone Tool
Sepsis Zone Tool

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176.14 KB | Last Updated: June 20, 2017

Sepsis Zone Tool Spanish
Sepsis Zone Tool Spanish

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306.22 KB | Last Updated: June 20, 2017

Medication Safety Workgroup Starter Pack (Bundle)
Medication Safety Workgroup Starter Pack (Bundle)

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4.65 MB | Last Updated: February 9, 2016

ADE SMART Goals Worksheet (Interactive)
ADE SMART Goals Worksheet (Interactive)

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566.06 KB | Last Updated: August 20, 2015

PDSA Worksheet for Testing Change (Interactive)
PDSA Worksheet for Testing Change (Interactive)

Preview: PDSA Worksheet for Testing Change (Interactive)
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318.58 KB | Last Updated: August 21, 2015

ADE Fishbone Diagram (Interactive)
ADE Fishbone Diagram (Interactive)

Preview: ADE Fishbone Diagram (Interactive)
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345.67 KB | Last Updated: August 20, 2015

2016 Tennessee Care Coordination Communities Directory
2016 Tennessee Care Coordination Communities Directory

Preview: 2016 Tennessee Care Coordination Communities Directory
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1.61 MB | Last Updated: February 4, 2016

CPPACP County Resource Guide | 2015
CPPACP County Resource Guide | 2015

Preview: CPPACP County Resource Guide | 2015
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2.1 MB | Last Updated: August 21, 2015

TPACC Resource Guide
TPACC Resource Guide

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4.64 MB | Last Updated: August 20, 2015

Motivational Interviewing Guide
Motivational Interviewing Guide

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4.49 MB | Last Updated: February 5, 2015

National Quality Strategy Toolkit
National Quality Strategy Toolkit

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1.95 MB | Last Updated: February 5, 2015

National Quality Strategy Lever Fact Sheet
National Quality Strategy Lever Fact Sheet

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304.38 KB | Last Updated: August 21, 2015

National Quality Strategy Fact Sheet
National Quality Strategy Fact Sheet

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343.86 KB | Last Updated: February 5, 2015

Decreasing Readmissions, A Small Hospital
Decreasing Readmissions, A Small Hospital's Story - MS Success Story

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134.00 KB | Last Updated: February 6, 2015

Why Care Transitions Communities Matter in Tennessee
Why Care Transitions Communities Matter in Tennessee

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1.28 MB | Last Updated: August 21, 2015

Rapid Estimate of Adult Literacy in Medicine - Short Form (REALM-SF)
Rapid Estimate of Adult Literacy in Medicine - Short Form (REALM-SF)

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25.28 KB | Last Updated: February 6, 2015

Short Assessment of Health Literacy for Spanish Adults (SAHLSA-50)
Short Assessment of Health Literacy for Spanish Adults (SAHLSA-50)

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131.77 KB | Last Updated: February 6, 2015

Universities & Geriatric Education Centers in the South
Universities & Geriatric Education Centers in the South

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1.36 MB | Last Updated: February 6, 2015

Care Coordination Fact Sheet
Care Coordination Fact Sheet

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611.07 KB | Last Updated: February 6, 2015

West Tennessee Senior Resource Guide
West Tennessee Senior Resource Guide

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789.35 KB | Last Updated: February 6, 2015

Figaro: Donna, Nicki & Bill – Caregiver Assistance
AARP’s contest-winning video tells the story of family caregiving through a short film.
Faith Community Nurses Home Health Care
Shows the importance of health ministries in home health care
Wellborn Health Ministries
Demonstrates the value of parish nurses and health ministries in healthcare
KATS: Kentucky Appalachian Transition Services
See how one community of healthcare providers in Kentucky is focused on reducing hospital readmissions for patients with Medicare and is succeeding in improving patient care.
What Is Palliative Care?
atom Alliance Pinterest Board: Hospital Readmissions & Care Coordination
QIO Program Progress Infographic 2011-2014
QIO Program Progress Infographic 2011-2014

Preview: QIO Program Progress Infographic 2011-2014
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1.68 MB | Last Updated: February 5, 2015

atom Alliance Communities Map
atom Alliance Communities Map

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310.47 KB | Last Updated: October 13, 2014

Understanding the Path to Readmissions Infographic
Understanding the Path to Readmissions Infographic

Preview: Understanding the Path to Readmissions Infographic
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1.93 MB | Last Updated: February 6, 2015

WalterINFO100x100Infographic: Walter’s Story: A Readmission Timeline

 

 

 

 

 

TN_Interactive_Readmission_MapMap: Interactive Map Shows Tennessee Readmissions Savings Per County


CMS Equity Plan
CMS Equity Plan

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433.40 KB | Last Updated: January 26, 2016

Logic Models
The QIO Program helps you embrace data in your healthcare setting
Failure Modes & Effects Analysis (FMEA)
The QIO Program shares 5 steps in the Failure Modes and Effects Analysis (FMEA) to anticipate potential problems before they occur
Root Cause Analysis (RCA)
The QIO Program demonstrates how to identify the root cause of a problem using The 5 Whys
An Illustrated Look at QI in Healthcare
QIO Documentary
Learn about the history of the QIO Program, from 1966 through today.
IHI Whiteboard: Model for Improvement, Clip 1
IHI Whiteboard: Model for Improvement, Clip 2
IHI Whiteboard: PDSA Cycles, Part 1
IHI Whiteboard: PDSA Cycles, Part 2
IHI Whiteboard: Cause & Effect Diagrams

Communities Blog

  • Care Coordination Q&A with Christina Goatee

    Care Coordination Q&A with Christina Goatee

    Care Coordination Q&A with Christina Goatee Christina Goatee, MSN, RN is a nurse consultant and the Centers for Medicare & Medicaid Services’ (CMS) subject matter expert for care coordination under the Quality Improvement Organization (QIO) Program. Her primary responsibilities include serving as a subject matter expert and overseeing Quality Innovation Network-QIOs’ (QIN-QIOs) quality improvement efforts… Read More »
  • Quality of Care Review Changes – Updates from KEPRO

    Quality of Care Review Changes – Updates from KEPRO

    Beneficiary and Family Centered Care Quality Improvement Organizations (BFCC-QIOs) will no longer review a specific number of short-stay claims based on a hospital’s size of large vs. average. Now, CMS will sample the top 175 providers with a high or increasing number of Short Stay claims per Area with a request for 25 cases, and… Read More »
  • Nationwide Challenge Aims to Control Hypertension

    Nationwide Challenge Aims to Control Hypertension

    Health systems and professionals are equipped with the knowledge and technology to help patients manage high blood pressure more effectively than ever before. Still, high blood pressure contributes to more than 1,100 deaths in the United States each day and puts millions at risk for heart disease and stroke. Read More »

Blog Archive

Care Coordination, Readmissions - atom Alliance

Readmissions

The problem of avoidable readmissions involves multiple providers across multiple settings. See how you can help.

Learn More >>>
Care Coordination, Interventions - atom Alliance

Interventions

We work with providers within their communities to help them select evidence-based interventions associated with known causes of readmission. Put them to work in your facility.

Learn More >>>
Care Coordination, Adverse Drug Events - atom Alliance

Adverse Drug Events

Adverse drug events are a leading cause of preventable patient harm. Learn what you can do to prevent them.

Learn More >>>