1. Reducing Readmissions through Community Collaboration Jean Roland and Jayme Steig Quality Health Associates of North Dakota February 26, 2016

2. Community Collaboration Goals Decrease hospital readmissions throughout the community Improve care coordination Improve end of life care Reduce adverse drug events Avoid duplication Alignment of strategic priorities 2

3. QHA Readmission Reduction in ND 3

4. Shared Purpose Common themes throughout ND –End of life care planning –Care transitions –Medication safety –Rural areas Lack of hospice and home health Family support and community resources 4

5. Community 5  Minot  Bismarck  Grand Forks  Fargo

6. DATA REVIEW Readmission 6

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11. Discharge Locations 11

12. Readmission Rates by Discharge Locations 12

13. DIVIDE WILLIAMS McKENZIE BURKE MOUNTRAIL BILLINGS DUNN STARK SLOPE BOWMAN ADAMS HETTINGER RENVILLE WARD BOTTINEAU McHENRY ROLETTE TOWNER CAVALIER PEMBINA McLEAN MERCER OLIVER MORTON GRANT SIOUX BURLEIGH EMMONS McINTOSH LaMOURE DICKEY SARGENT LOGAN RICHLAND SHERIDAN KIDDER STUTSMAN BARNES CASS WELLS RANSOM FOSTER EDDY BENSON PIERCE RAMSEY WALSH GRAND FORKSNELSON GRIGGS STEELE TRAILL GOLDEN VALLEY *Crosby *Kenmare *Williston *Stanley *Minot *Bottineau *Velva *Belcourt *Dunseith *Rolette *Rolla *Cando *Rugby *Langdon *Cavalier *Grafton *Park River *Devils Lake *Grand Forks *Northwood *McVille *Mayville *Cooperstown *Fargo *Valley City *Jamestown *Steele *Bismarck *Mandan *McClusky *Harvey*New Rockford *Carrington *Turtle Lake *Underwood *Washburn *Hazen*Beulah *Watford City *Beach *Dickinson *Bowman *Hettinger *Elgin *Fort Yates *Linton *Strasburg *Napoleon *Wishek *Ashley *LaMoure *Oakes *Ellendale *Lisbon *Forman *Hankinson Wahpeton* *New Town *Mott *Wilton *Maddock *Gackle *Edgeley *Edmore *Osnabrock *Mountain *Walhalla *Arthur *Scranton *New England *Richardton *Glen Ullin *Killdeer *New Salem *Garrison *Tioga *Ray *Powers Lake *Lignite *Hillsboro *Enderlin *Milnor *Kulm *Zeeland *Hatton *Aneta *Lakota *Larimore *Mohall North Dakota Hospice Networks Altru Home Health & Hospice, Grand Forks Trinity Home Health & Hospice, Minot Heart of America Hospice, Rugby Jamestown RMC Hospice Sanford Hospice, Mandan Heartland Hospice, Dickinson Sakakawea Medical Center Hospice Hospice of the Red River Valley St. Alexius Home Care & Hospice Mercy Home Care & Hospice, Valley City Mercy Hospice, Williston

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16. REDUCING READMISSIONS THROUGH COMMUNITY COLLABORATION Panel discussion 16

17. Panel Members Dr. Tricia Langlois, Hospice of the Red River Valley Lois Ustanko, Sanford Health-Fargo, Director, Faith Community Nursing & Health Ministry Deb Knuth, American Cancer Society Cancer Action Network Nancy Joyner, Honoring Choices North Dakota Jason Eblin, F-M Ambulance Service Community Paramedic Mariann Doeling, Carrington Health Center 17

18. Discussion Please describe the services your organization provides and the value it brings to your community What opportunities exist for adoption or adaption of these services in rural communities? 18

19. Discussion What underutilized community resources are available to help support people at the end of life? –What are barriers that impede this process? How can the Community Paramedic model be adapted to meet the needs of CAHs and rural communities? 19

20. Discussion Audience Q&A 20

21. Recap Key discussion points Final remarks Leave in action: Name one action you will take in next 2 weeks to collaborate with community partners 21

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