References & Tools
The ‘Change Starts Here.’ webinar series provides quick overviews (approximately 10 minutes each) for QIOs, providers, and partners on the following topics:
- The One with the Dancing Guy (starting a movement). (9 Minutes)
This recording illustrates the importance of determining whether you are leading the Care Transitions movement in your state, or whether you can be the first follower, joining a leader in your state to create a movement.
- The One about Convening Communities. (7 Minutes)
This recording includes four potential models for convening a community to start their own Care Transitions movement.
- The One about Root Cause Analysis & Intervention Selection. (6 Minutes)
This recording reviews the evidence-based interventions to improve Care Transitions and provide a map as to which drivers are addressed by each intervention.
- The One about Measuring Interventions. (11 Minutes)
This recording offers initial thoughts to consider regarding intervention measurement strategies.
- The One about Drivers & Why Readmissions are a Community Problem. (7 Minutes)
This recording reviews the main drivers of rehospitalization: Lack of Patient and Family Activation, Lack of Standard and Known Processes, Lack of Information Transfer and offers insight into why reducing readmissions requires a community approach.
- The One about the Logic Models. (33 Minutes)
This recording conveys information about suggested approaches and components of logic models.
- The One about the Outcomes and Indicators. (15 Minutes)
This recording reviews time series outcomes, intervention implementation and the suggested data collection methods.
- The One about Demonstrating Change. (21 Minutes)
This recording focuses on how to effectively report time series data.
SAS Code Overview for QIO Analytic Staff
- ICPC NCC SAS Code Changes and Updates (10 minutes)
• Admission/Readmission per 1000 Beneficiaries (ICPC_AdmReadmper1000Benes_20120406) (re-release)
• Hospital Readmission Rates (ICPC_HospitalReadmissions_20120406) (re-release)
• Zip Code Import (ICPC_ImportZIPS_20120406)
- ED Visits/Observation Stays per 1000 Beneficiaries (ICPC_EDObsper1000Benes_20120406) (11 minutes)
- Disease-Specific (ICPC_Diseases_20120423.sas) (formerly titled ICPC_DiagnosisSpecific_20120406)
- The NCC recently released an updated version of this code. Please ensure that you have the most current version of the code. While the filename has been updated, the content of this presentation remains unchanged and still accurately reflects the SAS program described.
- Post Acute Care (ICPC_PostAcute_20120406) (5 minutes)
- Handout (*Revised 5/24/12)
- ICPC Community Mortality Rates (ICPC_CommunityMorality_20120406) (4 minutes)
- ICPC Parties to Transitions Overview - 3/26/12
Sample Presentations & Resources (please adjust for your community’s needs)
- Community-Based Care Coordination: 339 Days in the Life of Mrs. B, a Medicare Beneficiary
- Sample presentation by Jane Brock, MD, MSPH
Community-based Care Transitions Program (CCTP) Resources
- CCTP Budget Worksheet 101 (14 minutes)
This recording offers an overview of a simple approach to completing a CCTP budget worksheet.
- CCTP Budget Worksheet 220 (18 minutes)
This recording features an example of estimating a budget for a more complex model which includes two levels of stratification of beneficiaries into groups who will be receiving three different intervention models.
- Community-Based Care Transitions Program: Planning for Results that Move the Big Dot on Readmissions: WA
- Let’s Get Started: Community-Based Care Transitions Program Funding Opportunity: WA
- Section 3026 Application Information: NY
- CCTP Community Checklist: WA
- CCTP Application Checklist: IN