Patient education and engagement incorporates providing a robust learning experience to patients while promoting self-management to improve patients' overall health status. This section contains Structure, Process, and Outcomes in Patient-Centered Planning, Collaborative Teamwork, Education and Engagement of Patients and Families, Advocacy, and Coaching and Counseling of Patients and Families.
The law provides numerous rights and protections that make health coverage more fair and easy to understand, along with subsidies (through “premium tax credits” and “cost-sharing reductions”) to make it more affordable; including expanding the Medicaid program to cover more people with low incomes.
The IHI Triple Aim is a framework developed by the Institute for Healthcare Improvement that describes an approach to optimizing health system performance.
Guided Care® helps primary care practices meet the complex needs of patients with multiple chronic conditions. In this proven care model, a trained Guided Care nurse works closely with patients, physicians and others to provide coordinated, patient-centered care.
Under the direction of Eric A. Coleman, MD, MPH, the Care Transitions Program® will help you manage risk and empower patients during care hand-overs.
AAACN has developed a number of resources focused on CCTM; including the CCTM Model, CCTM Core Curriculum, and CCTM online modules.
As recent studies suggest, professional nurses have the potential for significant contributions to patient-centered, cost-effective care through the care coordination role. In order to fully achieve this potential, clear models and outcome measures are needed which specify the context for care coordination, identify nursing competencies, and value the nurse’s role within the health care team.
This clinical practice guideline (CPG) has been developed under a project conducted by the American Medical Directors Association (AMDA), and is intended for the members of the interdisciplinary team in long-term care facilities, including the medical director, director of nursing, practitioners, nursing staff, consultant pharmacist, and other professionals such as therapists, social workers, dietitians, and nursing assistants who care for residents of long-term care facilities.
The Ottawa Personal Decision Guide is for people who are facing tough decisions, such as those with critical health issues. It will help you instruct the patient on how to identify personal needs, plan next steps, track progress, and communicate views to others involved when making health care decisions.
The 5 A’s Behavior Change Model is intended for use with the Improving Chronic Illness Care Chronic Care Model (CCM), and was created with the goal of ensuring that all patients have a Self-Management (SM) Action Plan informed by and including all the 5 A’s elements (Assess, Advise, Agree, Assist, Arrange).
A resource that defines teach-back and provides guidelines for the successful use of that approach when assessing a patient's understanding of their condition and care.