Inputs Outputs Outcomes ActivitiesParticipantsShort TermIntermediateLong Term Georgia Hospital Association Disseminate information on best practices in health literacy, patient and family engagement and medication management Community service organizations Increase use of the tools: Teach Back, medication reconciliation and PFE Test universal transition of care plan Reduce 30-day, all cause (All payor) readmissions by 20% Quality Improvement Network Share best practices on transition of care Hospitals Change patients’ perceptions of health care Develop a process to fill in medication management gaps Share patient information in a timely manner AAA-Community Services Create a universal transition of care plan Home Health Agencies (HHAs) Understand the importance of shared information between providers and PCPs in coordinating care Physician use and implementation of a transitional care plan for all patients Adoption of the medication management processes by a rate of 5% Medical Association of Georgia Develop a medication management plan Hospital Case Managers Identify gaps in medication management Adoption of the transitioning of care protocols by a rate of 5% Outpatient Case Managers Improve communications among providers for a timely handover of patients Primary Care Physicians Have conversations to identify the gaps in transition of care planning Improve transfer of care communication amongst providers Palliative Care Share the continuum of care information that is needed to improve patient care Palliative Care Conduct post-discharge phone calls to ensure discharge plan is seamless Data transparency with providers Health Information Network Hold conversations on where the patient fits into the continuum of care and establish common ground with providers Health Information Network Create clear pathways of communication and education to expand access to patient information Empower communities Physicians, PAs/NPs, nurses, etc. Improve communication and interaction between transitions of care (all those involved in all episodes of care) Physicians, PAs/NPs, nurses, etc. Identify barriers and share best practices to improve patient care when they are discharged from the hospital Physicians, PAs/NPs, nurses, etc. implement and share formal transitions of care plans through provider-to- provider direct communication Sharing and adoption of best practices for transitions of care between all providers of care Community and hospital pharmacists Provide education on advanced illness management Mental & Behavioral Health providers Clinics (EQHC, RHC, free health clinics) Explore ideas to help individuals achieve their health goals Patient Advocates Faith-based organizations Community service organizations Business Coalition Clinic/Center Academic training CCTP Nursing homes Home health agencies Payers Area Health Education Center American College of Physicians Priorities to consider Patient/Person-centered care The individual is the primary focus Seamless continuum of care starts at any transition of care External factors High staff turnover and satisfaction Underserved populations in Georgia Payment systems Policy changes CMS Condition of participation Cultural competencies Non-Medicaid extended state Staff Resources and Funding needed to implement best practices Assumptions All providers may want to reduce readmissions Better Health, Better Outcomes, and Lower cost Patients/caregivers are able to self manage their own care Patients may adhere to mutually developed care plan It is important for physicians to know transition of care and chronic care management reimbursements