elderly man sitting with male nurse

On January 27, HealthIT Analytics reported that the American Hospital Association (AMA) and the Centers for Medicare & Medicaid Services (CMS) recently issued guidance on preventing hospital readmissions and creating a patient-centered care delivery system that places patient-provider relationships at the front of the care coordination process.

CMS indicated providers should “create a strong radar” for situations that could limit a patient’s ability to be fully engaged in their own health.  This may include racial and ethnic status, primary language and English proficiency, educational levels, the availability of social and community support, a patient’s disabilities, and the status of their relationship with primary care.

The AMA released four major requirements of every patient-centered population health management program, which include:

1.    Shared knowledge and shared decision making between clinicians and patients.
2.    Team-based, collaborative care involving caretakers, family members, and other members of a patient’s care team.
3.    Cultural sensitivity and respect when a decision is related to a cultural norm, religious belief, or lifestyle choice.
4.    Incentives for better choices from patients.

Read more about the four population health management tips: http://healthitanalytics.com/news/four-population-health-management-steps-for-safety-net-patients

For more information on the Great Plains Quality Innovation Networks’ efforts to improve coordination of care and other quality improvement efforts, visit our Web site. Join our Learning and Action Networks to get access to resources and connected on topics of interest to you.