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.
Advance Care Planning
Advance Directives: A Guide for Patients and Their Families
End of Life: Helping with Comfort and Care
End-of-life Decisions: Honoring the Wishes of the Person with Alzheimer’s Disease
Making Medical Decisions for Someone Else: A How-To Guide
The Conversation Project
The Conversation: A Family’s Private Decision
Thinking Ahead My Way, My Choice, My Life at The End
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.