D046 Care Coordination 101 Study Guide Graded A 2023 guaranteed Pass!!

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 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