Evidence Based Care - ANSWER Helps us identify the most appropriate individualized treatment plan, improves patient outcomes, increase effectiveness and efficiency of interventions, and most current r... esearch and patient outcome measures Empanelment - ANSWER The act of assigning individual patients to individual primary care providers (PCP) and care teams with sensitivity to patient and family preference. The basis for population health management and the key to continuity of care. Strategic Partners Community Resources - ANSWER PCP. Outpatient clinics, Women's Health. Specialty care providers, therapists, pharmaceutical support, social workers Accountable Care Organization (ACO) - ANSWER Improve patient outcomes through coordination of care measures and service that improve a patient's quality of life. Goal: reduce hospital readmission and improve patient compliance in community settings. AIMS Care Coordination Model (PACO like TACO) - ANSWER Patient Engagement Assessment and Care plan Development Case Management Ongoing Care as Needed Patient Engagement Phase PACO - ANSWER Interact Ensure Provide guidance and resources Assessment and Care Plan Development Phase PACO - ANSWER Identify social and environmental factors that may affect medical plan adherence, health care serves utilization, and health care outcomes. Collect information that is helpful Develop care plan Case Management Phase PACO - ANSWER Patient stays on track and has the support Monitoring goal progress Modifying the care plan as necessary Ongoing Care as Needed Phase PACO - ANSWER Ensuring that community-based resources are in place Contact the care coordinator should new challenges arise Summarize achieved goals or negotiate continued work Closing the case if appropriate Value Based Healthcare - ANSWER Quality case as the leading driver. Quality over quantity Scope of Practice - ANSWER a set of regulations and ethical considerations that define the scope, or extent and limits, of the EMT's job fee-for-service - ANSWER Health plan that repays the policyholder for covered medical expenses Diagnostic Related Groups (DRGs) - ANSWER Patient classification system to help control and standardize costs for inpatient services. Used along with patient and regional demographic data to determine the median cost for a particular procedure/service. Categorize patients into groups based on -diagnoses, type of treatment (ex. surgical), complications or comorbidities, age, gender, discharge status. Determine length of stay, average cost the hospital should charge for similar patients. Care Coordination Process - ANSWER 1. Client identification and selection 2. Assessment and problem/ Opportunity identification 3. Development of the case management plan 4. Implementation and coordination of care activities 5. Evaluation of the case management plan and follow-up 6. Termination of the case manage Active Listening to Care Coordinators - ANSWER Undivided attention, appropriate body language signals, patient acknowledgment, behaviors that convey a nonjudgmental attitude and respectful respectful responses. Affortable Care Act - ANSWER Provides healthcare options via state-run insurance exchanges. The law prevents the use of medical history to refuse employment or insurance, if eligible. Key Communication Skills - ANSWER 1. Set the Stage 2. Elicit Information 3. Give Information 4. Understand the patient's perspective 5. End the Encounter Set the Stage - ANSWER Greet the patient Find out how the patient is feeling Introduce the computer Explain and reassure Elicit Information - ANSWER Look at computer intermittently while talking to patient Point to relevant areas Avoid computer when patient is emotional Involve patient in confirming data is correct Give Information - ANSWER Verify patient can see screen Encourage patient to ask questions Share Materials Keep balanced eye contact Understand Patients Perspective - ANSWER Patients perspective on the use of the computer in the healthcare environment End encounter - ANSWER Provide handouts or websites references Motivational interviewing - ANSWER Aimed at persuading patients and using positive reinforcement to maintain adherence with their treatment plan and follow through on appointments throughout care transitions with care providers and community resources. Collaborative relationship - ANSWER Interprofessional care teams works in partnership with the patient and the family in planning and implementing care Effective communication - ANSWER Verbal and/or nonverbal exchanges that establish trust with the patient Respectful care - ANSWER Considers values, preferences, and expressed needs of patient Holistic perspective - ANSWER Planning and delivering care based on knowledge of the multiple facts of the person and the family Individualized care - ANSWER Tailoring care plans and care delivery to the needs and wishes of the patient and family Interprofessional coordination - ANSWER Multiple people working together as a synergistic team Self-awareness - ANSWER Self-reflection to gain an understanding of one's own assumptions and becoming open to beliefs and values other than one's own Empowerment - ANSWER Providing patients or caregivers important health information and encouraging them to participate in the patient's care Interpersonal relationships - ANSWER Establishing trust, listening to families life stories, coming to know the family Cultural knowledge - ANSWER Gaining an understanding and appreciation for culturally specific beliefs and healthcare practices Cultural Skills - ANSWER Cultural knowledge and self-awareness incorporating into clinical practices Warm Transfer - ANSWER Ideal, providers are contacted when care will be transferred from one provider to another. Ensure services are not duplicated, unnecessary referral, or procedures that increase cost Cold Transfer - ANSWER From one provider to another without preliminary contact or introduction. Unclear expectations concerning the care to be administered Case management models - ANSWER 1. AIMS 2. Wraparound Care Coordination 3. Primary Care Coordination 4. Acute Care Coordination 5. Post-Acute/ long term 6. PCMH and Medical Neighborhood Collaborative Care Model 7. Brokerage AIMS - ANSWER Ambulatory Integration of the Medical and Social AIMS Engagement phase - ANSWER Validating concerns, reinforcing HSC role as a helper/resource, giving information to address immediate concerns Wraparound - ANSWER Team based coordination for children and youth with complex behavioral health needs Primary Care coordination - ANSWER Care for patients with chronic disease and conditions Ex: diabetes, high cholesterol, high blood pressure Think PCP Acute Care - ANSWER Requires more complex level of care due to the critical and emergent condition Ex: stroke or heart attack Think emergency room Post-acute/ Long term care - ANSWER Predominately senior aged patients with mental and/or memory disorder in addition to physical Ex: Post stroke, dementia PCMH & Medical Neighborhood - ANSWER PCMH = PCP medical home interacts within the "neighborhood" of resources Ex: outpatient caregivers, specialists, hospitals, mental behavioral health, etc. [Show More]
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