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Coordination of Care

Organizations are being driven to take greater responsibility for patient outcomes through accountable care organizations and risk-based reimbursement methods. Coordination of care is key to reducing risk and fostering optimal outcomes. Models that integrate with health and social support services within a community—community-based care coordination—provide the strongest support for patients.

Stratis Health helps health care organizations systematically organize patient care activities and share information among everyone concerned with a patient’s care, to achieve safer and more effective care.

Organizational preparedness for care coordination

Many health care organizations would benefit from using a more systematic approach to for their care coordination processes.

Stratis Health works with organizations to assess care management and care coordination practices using a Community-based Care Coordination Maturity Assessment. Up to eight factors are assessed depending on organizational need:  

  • Leadership
  • Patient population/panel management
  • Care management
  • Transitions of care
  • Community resources
  • Data and processes
  • Quality management
  • Financial management

Community coalitions

Stratis Health facilitates health care organizations to develop care coordination processes and serves as a neutral conveyor, bringing care delivery partners together to develop mutually beneficial care transition processes.

  • Through Lake Superior QIN, Stratis Health brings together partners in nine communities, representing 324,176 Medicare Fee-For-Service beneficiaries, to collaborate, improve transitions of care in the community and reduce readmissions. Over 367 organizations and 940 individuals are participating across the communities.
  • Stratis Health works with Minnesota Department of Health (MDH) grantee communities to design and implement community-level, evidence-based strategies that reduce health disparities and expand preventive services based on Centers for Disease Control and Prevention (CDC) priorities.
  • Community Wellness Grant Stratis health provided practice facilitation/ quality improvement coaching to support primary care practices in building organizational capacity for continuous quality improvement. (2014-2017)
  • Community Transformation Grant goal to significantly advance progress in preventing chronic disease, addressing health disparities, and building the evidence for prevention programs. (2011-2014)
  • The 15 Accountable Communities for Health across Minnesota participated in Stratis Health led learning communities for technical support and peer learning opportunities as they proceed toward alternative payment models and care delivery redesign. Topics included: care coordination, quality improvement, culturally appropriate care, population health and behavioral health integration. (MDH 2014-2016)
  • RARE logo
  • The RARE Campaign was a statewide initiative to prevent 4,000 avoidable readmissions in Minnesota within 30 days of discharge. September 2011 to June 2014, over 80 hospitals participated to exceed goals. Minnesota collectively prevented 7,975 readmissions and helped patients spend 31,900 nights at home instead of in the hospital. Minnesota hospitals reached a collective reduction in readmissions of 19 percent. The RARE Campaign received the 2013 John M. Eisenberg Patient Safety and Quality Award for Innovation in Patient Safety and Quality. RARE was led by Stratis Health, the Institute for Clinical Systems Improvement, and the Minnesota Hospital Association.

Health information technology

Health IT has become instrumental in supporting care coordination. Electronic health records allow better tracking of patient conditions for follow up and gather data that allows for risk stratification and supportive care plans. Providers, communities, and patients need to be prepare to exchange health information electronically with each other.

Health IT beyond the hospital and clinic

Minnesota e-Health Roadmap. The roadmap provides recommendations and actions to support and accelerate adoption and use of e-health in behavioral health, local public health, long-term and post-acute care, and social services. (2016)

Community-Based Organization Health IT Information Needs. Survey results lay the groundwork for understanding how community-based organizations and home and community-based services can prepare to work with health care organizations in the new models of care. (2015)

Interoperable health information exchange

Our team of subject matter experts guide health care organizations to develop health information exchange (HIE) strategies.

Contact Stratis Health for assistance with your quality improvement and patient safety needs.