Healthcare Collaboration

Care Coordination and Case Management | Care Transitions | Evidence Based Programs and Services | Self-Management Plans and Flags | Northwest Geriatric  Workforce Enhancement Program | Other Resources and Information

Better Care, Lower Costs

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

  • Better care for individuals
  • Better health for populations
  • Lower per capita health care costs
  • Improve the work life of health care providers

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 Case 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

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.

HealthierHere, the Accountable Community of Health for King County, is working across medical, behavioral health, social service, and the community to improve the health and wellbeing of King County residents. This includes work to promote safe and successful transitions. Aging and Disability Services is represented on the HealthierHere Board of Directors. Learn more and get involved by visiting their website HealthierHere.

Evidence Based Programs and Services

Aging and Disability Services works collaboratively with King County Veterans, Seniors and Human Services Levy (VSHSL) to fund 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 and Flags

Aging and Disability Services collaborates with community partners, including hospitals, Medicare QIOs, and various professional disciplines, to develop patient education materials for


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common chronic health conditions.

Our Self-Management Plans include flags and Personal Health Records that help patients track providers, medications, and questions for their health care team.

Flags are categorized by three colors: Green flags indicate health,  Yellow flags indicate warnings, and Red flags indicate emergencies.


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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. Your 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 their input.

Northwest Geriatric Workforce Enhancement Program

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 and Information

Falls Prevention


Hot Spots

Other Resources


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