With Independence Day just behind us, the New England Quality Innovation Network (QIN) — the QIN-Quality Improvement Organization (QIN-QIO) for Massachusetts, Maine, Rhode Island, Connecticut, New Hampshire and Vermont — shares some tips and resources on how to encourage and support senior independence and quality care coordination.
1. Engage Patients and Caregivers
In order for patients to manage their health needs at home, they and their caregivers must be able to list their key medical conditions, potential warning signs and overall care plan, especially during care transitions.
2. Use “Teach Back” Methods
Do not assume the patient or caregiver understands instructions. Have caregivers and patients speak back basic care instructions in their own words to check for comprehension. Improve levels of understanding by using open-ended questions, sharing reader-friendly print materials to support learning, and identifying inconsistences with instructions and repeating until understood. To learn more about the teach back method, explore the Institute for Healthcare Improvement’s Always Use Teach Back resources.
3. Assess Clinical and Non-Clinical Needs
Be sure to identify all of the activities of daily living that the patient might need assistance with, such as nursing care or transportation. Surveys, such as the Barthel Index of Activities of Daily Living and the Assessment of Living Skills and Resources (ALSAR-R2) can help you gauge patients’ capability to complete actions like dressing or taking the stairs, and match needs to available resources. For more information on community resources, visit the Administration for Community Living.
For QIN – QIOs
1. Increase Communication among Health Care Providers
QIN-QIOs can enhance care coordination by connecting providers and facilitating awareness of each others’ role in providing care and supporting expectations for communication, especially during patient transitions. For more information about how QIOs can help providers establish communication guidelines, review the Safe Transitions Best Practice Measure resources that the New England QIN developed in partnership with community providers.
2. Connect Providers with Community Partners
Providers are increasingly recognizing the need for long-term service and support, especially for beneficiaries with a new health condition or recent hospital visit. Help providers explore how they might be able to form partnerships with community resources, such as Area Agencies on Aging, to identify and address clinical and socioeconomic needs. For more information on community resources, visit the Administration for Community Living.
3. Support Self-Management Initiatives
Empower patients and their caregivers to learn about disease self-management and encourage them to be active participants in their care. A strong model is the Everyone with Diabetes Counts (EDC) program, which is helping patients learn how to effectively manage diabetes and be a more active member of their own care team.