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.
- 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.
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
ADS 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:
- Alcohol Use & Liver Disease
- Anxiety Management
- Brain Health
- Clostridium difficile (C. diff)
- Chronic Pain
- Congestive Heart Failure (flags only in Vietnamese )
- COPD (flags only in Russian and Vietnamese )
- Diabetes (Russian )
- Digestive Health
- Eye Health
- Falls Prevention (full literacy)
- Falls Prevention (low literacy)
- Heart Disease (Russian )
- Kidney Health
- Liver Disease
- Mood and Depression
- Multiple Sclerosis (MS)
- Oral Health (full literacy)
- Oral Health (low literacy)
- Osteoarthritis (Russian )
- Skin Health
- Sleep Apnea
- Urinary System & Your Health
- Weight Management
- Personal Health Record only (no flags)
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.
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).
- 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.
- 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
- 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.
- 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.
Click on the headings above for more information. For free, confidential access to aging network services in Seattle-King County, contact Community Living Connections.