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The experience of health care organizations serving some of the most complex populations (patients who are dually eligible for Medicare and Medicaid), has helped identify core components for this kind of person-centered care:
- Timely, Comprehensive Health Risk Assessments
- Assessments should include functional status information, cultural and linguistic preferences and information about caregiver roles in order to create an individualized plan of care.
- Incorporation of a Patient Preferences into the Plan of Care
- A care plan must be developed in accordance with the patient’s values, goals and preferences, and with the patient at the center of the conversation. Care shaped by patient’s goals and preferences is important at every point in the care continuum but is particularly critical in palliative and end-of-life care.
- Seamless Care Transitions
- Transitions should be safe, seamless, and person-centered across care settings. When preparing for discharge from the hospital, for example, the patient must be central to the planning process. Instructions must be clear and understandable to the patient and family caregiver (where applicable). The discharge plan must be communicated to other members of the patient’s care team, and appropriate post-discharge care should be arranged for the patient.
- Culturally Competent Care Teams
- The care team should include diverse providers that understand the needs and preferences of the person being served. Aside from clinical providers, team members could include long-term service and supports providers, peer recovery counselors and/or community health workers.