Health Care Reform
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Better Care, Lower Costs
Accountability, patient safety, and reduction of unnecessary hospital readmissions are high priorities of the health care reform movement. Across the nation, communities are organizing to provide better health care for Medicaid and Medicare beneficiaries—and others—at significantly lower cost by coordinating care among providers and improving the management of the chronic conditions that often lead to hospitalization.
Area Agencies on Aging and their network of health and social service providers bring new opportunities for health reform savings and service delivery improvements.
Aging and Disability Services (ADS) is committed to reducing unnecessary readmissions at local hospitals. We collaborate with health care providers to enable more effective transitions from hospital to home. We coach patients and their caregivers to follow their physicians’ discharge orders and manage their health care more effectively. Following are a variety of resources for local hospitals:
ADS has collaborated with hospitals to determine chronic conditions prevalent in south King County and to develop patient education materials for those conditions, plus several others.
Following is a series of Self-Management Plan handouts that include warning flags (green flags to indicate health, yellow flags that indicate warnings, and red flags that indicate emergencies) and Personal Health Records that help patients track providers, medications, and questions for their health care team:
- Chronic Pain
- Congestive Heart Failure
- Digestive Health
- Eye Health
- Falls Prevention
- Heart Disease
- Kidney Health
- Oral Health (full literacy)
- Oral Health (low literacy)
- Skin Health
- Personal Health Record only (no flags)
Some translations are also available. Each of these Self-Management Plans can be printed on 11x17 paper. They are available for use by any organization by request and may be modified, adapted, or built upon for publication if credit is given to Aging and Disability Services. Feedback is appreciated. Special thanks to Highline Medical Center, Northwest Kidney Centers, Valley Medical Center, and Washington Dental Service Foundation for input.back to top
Our booklet “Aging Network Services for King County Residents” is a handy guide to programs and services discharged patients may need, including referral for Medicaid long-term services and supports.
- Enhance Fitness / Enhance Wellness
- Falls Prevention
- Home Stretch
- King County Care Partners
- King County Caregiver Support Network
- Living Well (Chronic Disease Self-Management Program)
- PEARLS and PEARLS for Veterans
Aging and Disability Services RNs, social workers, and care transitions coaches are trained to use specific strategies for patient engagement:
- Motivational Interviewing is a collaborative, patient-centered form of conversation that elicits and strengthens motivation for change.
- Teach Back: Developed by the American Medical Association as a part of its Health Literacy Toolkit, Teach Backis designed to verify that the patient understands what a clinician says. See Health literacy and patient safety: Help patients understand (a manual for clinicians).
Aging and Disability Services, Qualis Health, and Valley Medical Center co-sponsored a half-day conference focused on reducing unnecessary hospitalizations (especially re-hospitalizations) in south King County on May 30, 2013.
- Care Transitions: Whose Job Is It Anyway? (5/30/13 conference summary)
- A keynote address providing a national perspective on care transitions was given by Alicia Goroski, MPH, Associate Director at the Colorado Foundation for Medical Care.
- A South King County update by Selena Bolotin, LICSW, Director of Washington Care Transitions & Patient Safety at Qualis Health, the Quality Improvement Organization for Washington and Idaho. Selena also provided the Qualis Health 2012 Community Performance Report.
- Together We Care: Lessons learned in Pierce County, by Kathleen Moisio, BSN, RN, Comprehensive Gerontologic Education Partnership, Pacific Lutheran University
Discussion groups and participant feedback are summarized in the report.
Special thanks to UW Medicine/Valley Medical Center for hosting the 2013 conference in their Medical Arts Center auditorium and meeting rooms.
For more information, e-mail ADS planner Irene Stewart at firstname.lastname@example.org.
- South King County Care Transitions Listserv: A communication tool for individuals and organizations engaged in improving patient transitions between health care settings (e.g., hospital to home or skilled nursing facility) and eliminating unnecessary hospitalizations.
On April 17, 2012, Aging and Disability Services convened a South King County Community Meeting on Effective Care Transitions, which was attended by more than 130 hospital, nursing home,and human services administrators; health care and human service providers; fire/EMS first responders; senior housing and transportation advocates; caregivers; and others.
- Report: Coordination, Collaboration, Communication & Care Transitions (4/17/12 meeting summary)
- Charter: South King County Care Transitions 2012 Collaborative Charter
- Keynote Presentation: South King County Community Meeting on Effective Care Transitions, by Selena Bolotin, Qualis Health
- Audience Response Results: For results of an electronic survey of meeting participants, click here.
- Video: Going Home From the Hospital, Qualis Health 2012
- Pre-meeting reading materials (see also the links embedded in the invitation):
- Rehospitalizations among Patients in the Medicare Fee-for-Service Program (New England Journal of Medicine)
- Community-based Care Transition Programs (federal)
- Care transitions models
2011 Focus on the Future Forum
On April 6, 2011, Aging and Disability Services convened the Focus on the Future Forum: Innovations for Accountable Care (ADS, 4/6/11)
- Accountable Care Organizations, Explained (NPR, 1/18/11)
- Accountable Care Listserv—an e-mail based discussion forum to share information, ideas and opportunities on Accountable Care in our region.
- ADS Stakeholder Briefing on Duals 3/27/13
- Basic Health - Healthy Options Managed Care for Low-Income Clients (Washington State Health Care Authority)
- Medicare/Medicaid Integration Project (DSHS/Aging & Disability Services Administration)
- State Proposals - Financial Alignment Models (Integrated Care Resource Center)—each proposal includes an Invitation for Public Comment
- Health Homes: Opportunities for Medicaid (Center for Health Care Strategies, Inc.)
- Initial Considerations to Guide the Development of Medicaid Health Homes (Center for Health Care Strategies, Inc.)
- Health Care Reform, Medicaid Expansion and Access to Alcohol/Drug Treatment: Opportunities for Disability Prevention, by David Mancuso, PhD and Barbara Felver, MPA, MES, in collaboration with DSHS, October 2010. Given the planned expansion of Medicaid and shift in financial incentives for reimbursement, alcohol and drug treatment will be critical to meeting the objectives of maintaining and improving health status for people who have not yet become disabled.
- Expanding "Hot Spotting" to New Communities (RWJF, 3/29/12)
- Doctor HotSpot (Frontline video, 5/13/11)
- The Hot Spotters: Can we lower medical costs by giving the neediest patients better care? (The New Yorker, 1/24/11)
- Managed Care and the Aging Network in Washington State: Health Reform and Area Agencies on Aging, a presentation by ADS director Jesse Eller at the W4A 2012 Strategic Planning Retreat (4/9/2012)
- 10 Ways to Visualize How Americans Spend Money on Health Care, Derek Thompson, The Atlantic, 3/19/2012
- King County Care Partners
- Health Care Reform Integration Committee - Public Health Seattle-King County is leading a partnership effort to identify innovative integration models for mental Health, chronic disease management and primary care.
- Directions to the ADS South County Office
- Partnership for Patients: Aging and Disability Services has pledged to support the decrease of preventable hospital-acquired conditions (injuries and illness) and help decrease prevent complications during transition from one care setting to another.