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Summary C988 Task 3 Care and Sustainability Plan.docx C988 Care and Sustainability Plan College of Health Leadership, Western Governors University C988: Population Healthcare Coordination Wagner s Chroni
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C988 Task 3 Care and Sustainability P C988 Care and Sustainability Plan College of Health Leadership, Western Governors University C988: Population Healthcare Coordination Wagner s Chronic Care Model [ CITATION htt1 l 1033 ] Wagner s Chr...
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C988
Care and Sustainability Plan
College of Health Leadership,
Western Governors University
C988: Population Healthcare Coordination
Wagner’s Chronic Care
Model
, [ CITATION htt1 \l
1033 ]
Wagner’s Chronic Care
Model
Health System 1. Promote effective improvement strategies aimed at
comprehensive system change
2. Develop agreements that facilitate care coordination
within and across organizations
Delivery System Design 1. Use planned interactions to support evidence-based
care
2. Use planned interactions to support evidence-based
care
Decision Support 1. Embed evidence-based guidelines into daily clinical
practice
2. Integrate specialist expertise and primary care
, Clinical Information Systems 1. Identify relevant subpopulations for proactive care
2. Share information with patients and providers to
coordinate care
Self-Management Support 1. Emphasize the patient's central role in managing their
health
2. Use effective self-management support strategies that
include assessment, goal-setting, action planning,
problem-solving and follow-up
3. Organize internal and community resources to provide
ongoing self-management support to patient
Community 1. Encourage patients to participate in effective
community programs
2. Form partnerships with community organizations to
support and develop interventions that fill gaps in
needed services
[ CITATION htt1 \l
1033 ]
Care
Coordination
Care coordination is defined as "the deliberate organization of patient care activities
between two or more participants involved in a patient's care to facilitate the appropriate delivery
of health care services" [CITATION Red11 \l 1033 ]. In terms of obesity, combining both
clinical and community organizations are necessary. Care delivery and coordination are essential
to improve health outcomes, including the Chronic Care Model, the patient-centered medical
home, accountable care organization (ACO’s), and community-centered health homes
[ CITATION Die \l 1033 ]. From years past, newly developed models have yet to meet the
standards of the Institute for Healthcare Improvement’s (IHI) triple aim, which seeks to improve
both the patient’s experience and population health and reduce healthcare costs[ CITATION
Usi15 \l 1033 ]. These efforts have not been successful when applied to societal and
environmental issues related to better health and reduced costs. Despite the continual rise in
obesity and the associated health risks, there has been little coordinated, comprehensive
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