Care Coordination

The Midwest QIN-QIO offers a multi-pronged approach to address key components to improve care coordination and decrease hospital admissions and readmissions, incorporating best practices for standardizing communication, integration of care, data-driven improvements, and partner collaboration. By fostering strong partnerships among healthcare providers, pharmacists, and community-based organizations, the Midwest QIN-QIO builds a more connected care ecosystem that supports both physical and behavioral health needs.

How the Midwest QIN-QIO Supports Care Coordination

Three medical doctors standing in a hallways, reviewing a clipboard

The Midwest QIN-QIO strengthens care coordination by helping providers and outpatient clinical practices implement innovative, technology-driven models that reduce avoidable emergency department visits and hospital readmissions. Recognizing that patients often navigate complex healthcare systems involving multiple providers and settings, we support organizations in improving communication, data sharing, and care transitions. Through evidence-based strategies and CMS-approved interventions, we equip providers with the tools and expertise to identify high-risk patients, streamline care across teams, and better integrate medical and social services. These coordinated efforts ensure that patients receive timely follow-up care, improved medication management, and access to the community resources they need to maintain stability and avoid preventable hospitalizations.

Whether your organization is working to reduce readmissions, improve communication between care settings, or strengthen community partnerships, the Midwest QIN-QIO can help design and implement effective care coordination solutions that lead to lasting improvement.

Care Coordination Sub-Aims

Hospital 30-Day Readmissions

Promote cross-setting collaboration to encourage data sharing and strengthen communication with the goal of improving outcomes and empowering patients to access and use health information.  

Hospital Readmissions from Skilled Nursing Facilities

Focus on best practices for identifying risk factors for post-hospitalization complications, communicating patient needs, and ensure discharge to appropriate settings to reduce unnecessary readmissions.

Community-Based Emergency Department Utilization

Improve discharge communication and readiness for care management and promote knowledge of alternatives to emergency department utilization in the community.

Featured Resource

Quality Improvement Workbook

This is Midwest QIN-QIO’s one-stop resource for interactive quality improvement activities and worksheets. In this workbook, you will find valuable resources to support your team’s quality improvement efforts. We have created a timeline to follow and ways to track…

Care Coordination Resources

COVID-19 Vaccine Toolkit for All Provider Types and Patients

This 6-page toolkit has been developed with the resources, mainly from the Centers for Disease Control and Prevention (CDC), along with a plethora of other sources to help build COVID-19 vaccine confidence among healthcare workers and people with Medicare. Access This…

Infection Prevention and Control (IPC) Risk Assessment

This resource is a tool to help focus improvement activities on essential tasks to reduce infection control risks. Completing an infection control risk assessment can help improve resident and staff safety, identify training opportunities and uncover prevention…

Age-Friendly Health Systems Resource Package

The tools and resources in this package have been thoughtfully curated to support healthcare professionals in addressing the most pressing patient safety issues and improvement opportunities that challenge our current healthcare industry. By identifying and addressing…

Influenza and Pneumonia: Infection Prevention and Control

Minimizing the impact of influenza and pneumonia through vaccination, early detection, and good infection prevention and control habits prevent additional strain on an already overburden US healthcare system. This toolkit provides links to resources to support the…

Root Cause Analysis Tool Selection Guide

This tool was designed to help with selecting which Root Cause Analysis tool to use: Affinity Group, 5 Whys or Fishbone. Root Cause Analysis is a structured team process that assists in identifying underlying factors or causes of an event, such as an adverse event or…

PDSA Worksheet

Use the Plan-Do-Study-Act Worksheet to guide you through the steps to conduct a Plan-Do-Study-Act process. Use this fillable resource to ensure quality improvement. Access This Resource

QAPI Plan How to Guide

This tool will guide your organization’s performance improvement efforts. The QAPI regulation requires a written plan. This plan is a framework for an effective, comprehensive, data-driven program that focuses on the indicators that reflect outcomes of care and…

Midwest QIN-QIO Continuity of Care Resource Package

The tools and resources in this resource package have been thoughtfully curated to support healthcare professionals in addressing the most pressing patient safety issues and improvement opportunities that challenge our current healthcare industry. By identifying and…

Quality Improvement Workbook

This is Midwest QIN-QIO’s one-stop resource for interactive quality improvement activities and worksheets. In this workbook, you will find valuable resources to support your team’s quality improvement efforts. We have created a timeline to follow and ways to track…