A Person-Centered Plan of Care
Coordination of Care
Older Americans are admitted to the hospital more often than any other age group. Then, after they leave the hospital, one in five ends up back in the hospital within 30 days. Most of the time, a return to the hospital can be prevented. Often times, persons with Medicare receive care from several different healthcare professionals; there is no guarantee these providers are talking with one another regarding an individual’s care. This can lead to care that is not well coordinated and result in unneeded tests and medication errors.
We are working to change that. Great Plains QIN and healthcare providers in our communities are working together to help improve communication between healthcare providers; which will lead to improved care, less hospital visits, cost savings and better health outcomes.
Below are some things you can do:
- Be more involved in your healthcare
- When you leave the hospital, know what you need to do to continue to improve
- Ask questions when you talk to your healthcare providers
If you want to be more connected and have accesses to resources, education and information on healthcare topics and coordination of care, join the Great Plains Learning and Action Network. We welcome your participation. Join today.
|Words heard when at a medical visit and what they mean.||Good Health||Medical Terms All Patients Should Know||National Patient Safety Foundation|
|Workbook and companion videos, assists people with developmental delay make decisions about the end of their life.||Advance Care Planning||Thinking Ahead My Way, My Choice, My Life at The End||State of California Department of Developmental Services|
|Guidance for individuals who must make medical decisions for someone else.||Advance Care Planning||Making Medical Decisions for Someone Else: A How-To Guide||American Bar Association|
|Booklet to help families prepare for making end of life decisions for their loved one with dementia.||Advance Care Planning||End-of-life Decisions: Honoring the Wishes of the Person with Alzheimer's Disease||Alzheimer’s Association|
|Booklet provides an overview of issues commonly facing people caring for someone nearing the end of life.||Advance Care Planning||End of Life: Helping with Comfort and Care||National Institute on Aging|
|Booklet providing general information about advance care planning from an end stage renal disease perspective.||Advance Care Planning||Advance Directives: A Guide for Patients and Their Families||National Kidney Foundation|
|Every time you talk with a doctor, nurse, or pharmacist, use the Ask Me 3 questions to better understand your health||Good Health||AskMe3 - Good Questions for Your Good Health||ScriptYourFuture.org|
|Helps you prepare so you are ready to care for yourself when you leave the hospital.||Care Coordination||Taking Care of Myself: A Guide for When I Leave the Hospital||AHRQ.gov|
|This brochure gives you tips to use before, during, and after your medical appointment to make sure you get the best possible care.||Consumer Engagement||Be More Involved in Your Health Care: Tips for Patients||AHRQ.gov|
|Caring Connections provides people with information and support when they are planning ahead, caring for a loved one, living with an illness or grieving a loss.||Advance Care Planning||Caring Connections||National Hospice and Palliative Care Organization|
|Tools including a Conversation Starter Kit to help individuals and families discuss their wishes for end of life care.||Advance Care Planning||The Conversation Project||The Conversation Project|
|News story video of a family's experience having a conversation about their end-of-life care preferences.||Advance Care Planning||The Conversation: A Family’s Private Decision||ABC News|
|Information on becoming a more engaged healthcare consumer and self-management skills||Consumer Engagement||Lead Yor Health||KFMC|
|Short quiz that helps you learn how to be a smarter patient.||Good Health||The Smart People Quiz||Council on Patient Safety in Women’s Health Care|
Learning and Action Network
We invite you to join the Great Plains Learning and Action Network (LAN). All LAN partners will be invited to attend educational sessions on a variety of topics, have opportunities to learn from peers throughout the state and region and have access to an abundance of resources and tools. The LAN is a great opportunity to get connected and demonstrate your commitment to quality improvement.