Healthcare Collaboration

Self-Management Plans & Flags

Better Care, Lower Costs

Across the nation, communities are organizing around “the triple aim”:

  • Better care for individuals
  • Better health for populations
  • Lower per capita health care costs

Aging and Disability Services (ADS) and other Area Agencies on Aging can help provide better health care for Medicaid and Medicare beneficiaries—and others—at significantly lower cost by coordinating transitional care for clients and coordinating longer-term interventions for high-risk patients with multiple medical and social needs.

Click on the headings below for more information.

Care Transitions & Coordination

ADS collaborates with hospitals and 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.

ADS promotes:

  • Effective medication self-management (accurate lists and instructions that patients understand)
  • Timely followup with health care providers
  • Understanding of green, yellow, and red “flags” (see below “Self-Management Plans & Flags”) or warning signs about specific conditions, and how to respond

For information about the annual Care Transitions Conference, click here.

Care Coordination

ADS provides face-to-face, longer-term intervention for high-risk patients with mulitple medical and social needs, including individuals who are dually-eligible for Medicare and Medicaid—often the most medically fragile residents of our community.

ADS care coordination helps patients navigate long-term services and supports, which reduces duplication of services and improves adherence to care plans.

ADS led a multi-year pilot program called King County Care Partners, which involved community-based, multidisciplinary, RN-led care management, education and assistance for medically vulnerable Medicaid fee-for-service adult patients in collaboration with UW Medicine Harborview Medical Center, several large clinical practices, and the State of Washington. Studies (posted here) showed that care coordination resulted in:

  • Lower psychiatric inpatient costs
  • Fewer total arrests and charges
  • Higher odds of receiving inpatient alcohol/drug treatment
  • Good, trusting relationships with an RN or MSW
  • Personal empowerment and goal achievement

As a result, ADS RNs and social workers can:

  • Assess risk factors, health literacy, health status and self-management skills
  • Screen for alcohol and substance abuse, depression and other mental health conditions, diabetes, heart disease, and other chronic conditions
  • Assist with understanding provider’s treatment plan and prescribed medications
  • Develop a medical treatment plan with the client’s provider, if a plan does not exist
  • Develop a care plan, helping clients set goals for self-management
  • Refer to services that address unmet needs identified in the assessment
  • Help clients address barriers to using the health care system
  • Track measures for evidence-based medicine guidelines for chronic illness
Evidence-based Programs & Services Self-Management Plans & Flags

flyerADS collaborates with community partners, including hospitals, Medicare QIOs, and various professional disciplines, to develop patient education materials for common chronic health conditions.

Our Self-Management Plans 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:

Each of these Self-Management Plans can be printed on 11×17 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 Harborview Medical Center, Highline Medical Center, Northwest Kidney Centers, Qualis Health, Valley Medical Center, and Washington Dental Service Foundation for input.

Tools for Patient Engagement

Aging and Disability Services RNs, social workers, and care transitions coaches are trained to use specific strategies for patient engagement:

Other resources & information

Medicare/Medicaid

Hot Spots

Other Resources

Click on the headings above for more information. For free, confidential access to aging network services in Seattle-King County, contact Community Living Connections.