b'Improving Acute Transitions of CareNurses play a key role in providing safe transitions of care fromthe Hospital to home. A team consisting of Patient Relations,Quality Performance, Medical Home Navigation and Population DischargeHealth identified the top three opportunities to improve patient Timing & Planningsafety and experience at discharge. The Plan Do Study Act (PDSA)model is being used to implement and evaluate the impact of3 pilot initiatives:Patient Care Partner Program; Medication Prior Authorization;Pharmacy Discharge Medication Reconciliation.Ongoing After Transitions of Care work that has moved from pilot to support Discharge to preventProcessimplementation and expansion include: re-admission 30 Days Medical Home Navigation Transitions of Care Management; Readmission Risk Assessment and Interventions; Bedside Prescription Delivery.Supporting Health MaintenancePrimary care nursesare participating in a multidisciplinary project which leverages the CernerRecommendationstool that identifies when patients are due for important health screening and maintenance care like mammograms, colonoscopies and cervical cancer screening. Consistent utilization of Recommendations streamlines patient care and optimizes patient outcomes by forwarding talking points for the provider to review with patients during the office visit. An added benefit of using the tool is time savings for the clinical team by eliminating digging through the chart for the same information the following year. The launch followed a rolling timeline of one to two practices per week. Each practice was invited for a pre-work preparation and apost-live check in with the working team to bring questions, feedback or concerns about the application and workflow forward.The team actively worked to solve issues and answer questions as we went along. We continue to monitor the adoption andcompliance of the tool.For fiscal year 2023, the working team will be partnering with Laconia and Franklin Primary Care leadership to establish what is needed to roll the tool out for their locations.Providing Preventive CareConcord Hospital has committed to participate in the American Medical GroupAssociations (AMGA) Rise to Immunize campaign focusing onimprovingPneumococcal and Influenza vaccination rates.The campaigns national goal isto administer 25 million adult vaccinations by the year 2025. Collaboration amongstnursing, providers, practice leadership, pharmacy, informatics, patient relations,and public affairs ensures consistent education, infrastructure, documentation,marketing, billing/coding and education across the health system. We will utilize the recommended Healthcare Effectiveness Data and InformationSets (HEDIS) Value Set and Rise to Immunize (RIZE) reporting template to submithealth system data to the AMGA campaign. To date, we have seen slightly above average performance in comparison to the national participants. 44'