See below for tools and resources related to Care Coordination. <\/em><\/p>\n Community Coalition Participation Agreement <\/p>\n Data Sharing Agreement <\/p>\n Do you have a story where a community coalition made a positive impact? <\/strong>Share it here!<\/a><\/p>\n <\/p>\n How to Refer – Reference Partner Cards<\/strong> Blood Pressure Measurement<\/strong> COPD Booklet<\/strong> Transitions of Care Toolkit Reduce the Risk of Hospital Readmission Flyer COPD Zone Tool Skilled Nursing Facility Rehospitalization Risk Assessment Heart Disease Zone Tool<\/strong> Living with Heart Failure Booklet<\/strong> Resident Information Booklet<\/strong> Skilled Nursing Facility (SNF) Resident Pre-Admission Checklist SNF Transfer Checklist<\/strong> Northwest Montana Care Transitions Coalition Referral Checklist \u2013 Montana<\/strong> West Oahu Provider Capabilities Poster \u2013 Hawaii <\/strong> Windward Provider Capabilities Poster \u2013 Hawaii<\/strong> West Oahu Discharge\/Transfer Checklist<\/strong> <\/p>\n <\/p>\n<\/div><\/div>\n<\/div>\n Emergency Preparedness Guide Emergency Preparedness Plan Template Emergency Procedures Flipchart Emergency Preparedness Plan: After-Action Template Journey to Improved Kidney Care<\/strong><\/p>\n An educational presentation by Dr. Jared Sugihara and Anthone Jeon, DNP, from Malama Kidney Center. Dr. Sugihara and Anthone discuss the prevalence of chronic kidney disease in Hawaii, and how Malama Kidney Center works with their patients to improve outcomes.<\/p>\n Watch the recording<\/a> | See the slide deck<\/a><\/p>\n Mountain-Pacific Quality Health Montana Coalition Summit<\/strong><\/p>\n Coalition members, health care workers, family members, care givers and more were invited to attend the September 21, 2021 summit. Community feedback and local perspectives from community and coalition members were shared during the townhall discussion.<\/p>\n<\/div>\n Watch the recording<\/a> | See the key takeaways<\/a><\/p>\n Mountain-Pacific Quality Health Wyoming Coalition Summit Coalition members, health care workers, family members, care givers and more were invited to attend the September 9, 2021 summit. Community feedback and local perspectives from community and coalition members were shared during the townhall discussion.<\/p>\n<\/div>\n Watch the September 9, 2021 recording<\/a> | See the slide deck<\/a><\/p>\n Beneficiary and Family-Centered Care Quality Improvement Organization This webinar offers a basic overview of these services and is ideal for health care providers and advocacy organizations.<\/p>\n Watch the November 2020 recording<\/a> | See the slide deck<\/a><\/p>\n Data Comes in All Sizes \u2013 Webinar Series\u00a0<\/strong><\/p>\n Data comes in all sizes and Quality Assurance & Performance Improvement (QAPI) is applicable in many settings. Recorded for community coalitions, this webinar series focuses on the elements of QAPI.<\/p>\n Regional Community Coalition Quarterly Meetings Foundations of a Successful Coalition – Webinar Series Quality Improvement Collaborative Kickoff Event – Webinar Pain Management in the Elderly – Webinar<\/strong> See Presentation Slides<\/a><\/p>\n Top 10 Resources and Tools<\/strong><\/p>\n Explore these top 10 lists covering various topics, providing actionable insights for optimal care and well-being in nursing homes, community centers and health care environments.<\/em><\/p>\n Culturally and Linguistically Appropriate Services (CLAS) Checklist<\/strong> Medication Management and Safety: A Guidebook for Older Adults How to Use Your Medication List Addressing the Unique Care Needs of Older Adults<\/strong> | Access Tool Here<\/a><\/p>\n What Is an Age-Friendly Health System?<\/strong> | Access Tool Here<\/a><\/p>\n Pain Scale Card
\n<\/strong>It only makes sense pooling knowledge and resources between organizations can improve health care. As a result, the most effective way to impact health care is to align efforts with those who have common goals. If you with to partner with us to improve health care outcomes, please fill out the participation agreement below.<\/p>\n\n
\n<\/strong>The overall purpose of sharing the data specified in this agreement is to allow community providers to view admission and readmission data to identify patterns and construct patient population profiles for potentially avoidable readmissions. However, the data-sharing agreement must be signed first and can be accessed here: Data Sharing Agreement.<\/a><\/p>\n
\nAccess Cards<\/a><\/p>\n
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\nA practical guide to living with Chronic Obstructive Pulmonary Disease
\nSee Booklet<\/a><\/p>\n
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\nA Guide to Keeping a Strong and Steady Beat
\nSee Booklet<\/a><\/p>\n
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\nGo to the hospital or stay here?
\nSee Booklet<\/a><\/p>\n
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\nDeveloped by the Northwest Montana Care Transitions Coalition, this referral coversheet includes the phone and fax numbers for skilling nursing, long-term care and assisted living facilities in the Kalispell area along with a checklist of what should be transferred. Coalition members can submit updates to this referral checklist to Katie\/via the contact us form.<\/a><\/em>
\nAccess tool here<\/a><\/p>\n
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\nDeveloped by the West Oahu Community Partners Coalition. This poster shows what services each partner in the coalition offers, helping health care providers and patients identify what can be done with non-emergency health care providers. Coalition members can submit updates on the services for the next capabilities poster to Katie\/via the contact us form.<\/a><\/em>
\nAccess tool here<\/a><\/p>\n
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\nDeveloped by the Windward Community Partners Coalition. This poster shows what services each partner in the coalition offers, helping health care providers and patients identify what can be done with non-emergency health care providers. Coalition members can submit updates on the services for the next capabilities poster to Katie\/via the contact us form.<\/a> <\/em>
\nAccess tool here<\/a><\/p>\n
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\nThis tool can help ensure the right information is being transferred to the next care setting with every patient. Developed by the West Oahu Community Partners Coalition.<\/em>
\nAccess Tool Here<\/a>
\nCommunity Partner Cards<\/a><\/p>\n
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\n<\/strong>Use this guide to start and\/or evaluate your emergency planning. The guide contains information to help identify key emergency roles and responsibilities along with planning for safe building evacuations, effective emergency communications, strategies for resuming normal functions and developing a definition of essential personnel, mission-critical functions, staff release-time policies and internal emergency communications procedures.
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\n<\/strong>Use this template to help with your emergency planning.
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\n<\/strong>You can customize\u00a0this tool to help with your emergency preparedness.
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\n<\/strong>This tool can be used to evaluate the effectiveness and efficiency of an emergency preparedness plan.
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\n<\/strong>Kepro is the Beneficiary-and Family-Centered Care-Quality Improvement Organization (BFCC-QIO) for 29 states, offering free services to people with Medicare (and their families) that include quality of care complaints, hospital discharge and skilled service termination appeals and immediate advocacy<\/p>\n
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\n<\/strong>Each quarter regional community coalitions and coalition leads meet for quarterly regional community coalition meetings. During these meetings, attendees have the opportunity to learn best practices and share tips and tricks for creating a successful coalition.<\/p>\n\n
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\n<\/strong>During this webinar, participants learn how to build a strong foundation for a successful coalition. The presentation digs into the goals of coalitions, how to form a mission and vision, achieving SMART (specific, measurable, achievable, relevant, time-bound) goals and the process of collaborative decision making.<\/p>\n\n
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\n<\/strong>Mountain Pacific partners in communities across its region to support health care quality improvement. Watch this video to catch up on what’s new for coalition members, including the regional approach to group membership and the emphasis on engaging beneficiaries in their care.
\nPresentation by Mary Erickson, Mountain-Pacific Program Director<\/em>
\nSee May 7, 2020 Presentation<\/a>
\nSee May 14, 2020 Presentation<\/a><\/p>\n
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\nPresentation by Steven Atkinson PA-C, MS<\/em>
\nSee Webinar Presentation<\/a><\/p>\n
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\n<\/strong>Developed by the Billings Care Transitions Coalition. This guidebook gives older adults tips to stay safe while using medications, how to be an advocate for your health when talking with a pharmacist or doctor and a section of frequently asked questions.<\/em>
\nAccess tool here<\/a><\/p>\n
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\n<\/strong>This resource can help keep track of all current medications listed in one place.
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\n<\/strong>This tool was developed to provide a standardized way to evaluate pain. This print-out provides two, two-sided cards with a pain assessment on one side and a visual pain scale tool on the other.<\/em><\/p>\n