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 and longer-term interventions for high-risk patients with multiple medical and social needs.

Click on the headings below for more information.

Care Coordination and Management

ADS provides in-person support for high-risk patients with multiple medical and social needs. Screening and assistance enrolling in services is available through Community Living Connections.

Care Coordination

Aging and Disability Services (ADS)  provides short-term case management for patients who are unable to access services on their own, and who have no one in their support system to help them understand their options and obtain services in the community. This can include patients who are transitioning home from a hospital stay or time in other care settings. Care Coordinators engage patients in a face-to-face assessment, then partner with the patient to develop and implement an individualized service plan.

Case Management

Aging and Disability Services (ADS) is contracted by Washington State Department of Social and Health Services (DSHS) to provide long-term case management and other services to medically complex Medicaid clients in Seattle-King County.  Case management includes a comprehensive in-home assessment, service planning and authorization for in-home supports. Case managers have regular follow-up contact with clients and service providers to ensure that needs are being met.

Care Transitions

Hospitalizations contribute significantly to the cost of health care—costs borne by insurance companies, taxpayers (Medicaid and Medicare), patients, and families—and take an emotional toll on patients and their families. ADS works across health and human service providers to decrease avoidable hospital admissions and healthcare utilization.

We currently facilitate a community-based conference planning team that brings health care and social services professionals together to discuss new ways to work together to decrease avoidable hospital admissions and health care utilization. For information about our Care Transitions Conference,  click here.

Evidence-Based Programs & Services

ADS funds evidence-based interventions that positively impact patient outcomes in the areas of chronic disease self-management, health promotion, and falls prevention. Screening and assistance enrolling in services is available through Community Living Connections.

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 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.

Integrated Care and Innovation

Accountable Communities of Health

An Accountable Community of Health (ACH) is a regional, multi-sector partnership with a common interest in improving health systems and the health of communities. In the King County ACH, Aging and Disability Services and other partners play a key role in the development and oversight of regional Medicaid Transformation projects – projects that seek to improve population health and achieve greater health equity.

Together, ADS and it’s ACH partners will help our region reach these goals by addressing social determinants of health, clinical-community linkages and whole person care.

End Stage Renal Disease Seamless Care Organization

Aging and Disability Services is a collaborating organization with the Northwest Kidney Care Alliance End Stage Renal Disease Seamless Care Organization (ESCO), the only ESCO in the Pacific Northwest. The purpose of the ESCO is to achieve better health, better healthcare, and lower costs through integrated and coordinated care interventions with End Stage Renal Disease (ESRD) beneficiaries.

A subset of ESCO patients receive intensive case management to avoid frequent hospital utilization. Support for these patients includes include home visits and regular follow up; coordination with the ESCO care team, nephrologist, primary care practitioner, other specialists; and home medication management.

Connect With Us

Clinical Support

Aging and Disability Services, in collaboration with the Northwest Geriatrics Workforce Enhancement Center, aims to positively impact the healthcare system for older patients and their families through targeted outreach and education.

A Primary Care Liaison is available to meet with primary care teams, discuss programs offered to patients in our community, and provide ongoing support to clinical and support staff.  Connect with our Primary Care Liaison to arrange a meeting or presentation with your clinical team.

Patient Resources

Healthcare providers can link patients and their families to services quickly and easily through Community Living Connections. Direct referrals can be made via phone or secure email and an advocate will follow up with the patient. Connect with our Primary Care Liaison for more details.

Other resources & information

For free, confidential access to aging network services in Seattle-King County, contact Community Living Connections.

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.