Health literacy
a person's capacity to learn about and understand basic health information and services, and to use these resources to promote one's
... [Show More] health and wellness
Quadruple Aid
1. Improved patient experience
2. Improved physician experience
3. Lower cost of care
4. Improved patient outcomes
Accountable Care Organization (ACO)
New type of health care organization incentivized to improve quality of care, improve population health, and reduce the total cost of care.
relational coordination
Frequent effective horizontal coordination and communication carried out through ongoing relationships of shared goals, shared knowledge, and mutual respect.
Cold Transfer
Patients are transferred on for additional care or services with an individual or entity with whom the referring caregiver has no prior rapport or working relationship
What often happens with a cold transfer?
Patients try to follow up on referrals while they do not have a clear understanding of why additional service is important to their health
Clinical community linkages
Resources that help to connect health care providers, community organizations, and public health agencies so they can improve patients access to preventive and chronic care services
Clinical Decision Support
Patient medical history and other data
Computerized Disease Registries
Provide key information to providers for clinical decision-making
Computerized provider order entry (CPOE)
Used for the entry of patient treatments to initiate care at the point of service
Consumer health IT application
Online resources or provider websites that provide information for patients concerning their care
Electronic medical record systems
Electronic databases used to enter and store patient information such as demographic data, allergies, health history, medical treatment orders and medication administration orders
Electronic prescribing
Electronic systems used to transmit prescriptions electronically to a patients pharmacy of choice
Telehealth
Web based resource for patients to counsel with a health care providers concerning their healthcare needs, both for scheduled visits and for general advice related to medical, behavior health or medication use
Clinical reasoning
Every health care provider evaluates a patients info, history and treatment plan for a different perspective. Effective teams then pool resources to make both independent and shared decisions for each patients care
Care coordination models
designed to improve the continuum of care for patients with complex medical history and care needs
AIMS model
Helps to address both the medical and nonmedical needs of adult patients through 2 steps: patient engagement, assessment & care plan development, case management and ongoing care as needed
Engagement phase in AIMS model
allows care coordinators the opportunity to interact with the patient and their family; ensures questions are answered and provides guidance
Assessment & care plan in AIMS model
allows coordinators to identify social and environmental factors that may affect medical plan adherence and health care outcomes
Case management phase
Ensures the patient stays on track and has the support he/she needs. This includes monitoring goal progress; offering support; and modifying care plan as needed
Wraparound Model
Provides team based care coordination for children and youth with complex behavioral health needs
Motivational interviewing
strategy aimed at persuading patients and using positive reinforcements to maintain adherence with treatment plan and follow through on appointments throughout care transitions
warm transfer
transfer that was preceded by contact by a member of the care team
3 levels of change talk
Desire to change; ability to change; need to change
Commitment talk
Expressed at the end of a motivational interviewing session, this seals the patient's commitment to a care management goal
Health Catalyst Care Management Suite
host applications that can support the motivational interviewing process and help care managers optimize patient engagement
Collaborative relationship
Care teams work in partnership with the patient and family in planning care
Effective communication
Verbal or nonverbal exchanges establish trust with the patients; including actively listening, using simple language and an unhurried demeanor
Respectful care
Responsive to and accepting patients beliefs and values; open-minded
Holistic perspective
Planning and delivering care based on knowledge of the multiple facets of the person and family
Individualized care
Tailoring care plans and care delivery to the needs and wishes of patients and families
interprofessional coordination
Multiple people working together as a synergetic team that addresses patient/family needs
Self-awareness
Demonstration of self-reflection to gain understanding of ones own assumptions and becoming open to beliefs and values other than ones own
Empowerment
Providing patients or caregivers important health information and encouraging them to participate in their care [Show Less]