Person and family engagement initiatives can nurture collaboration between patients, families, and clinicians to move toward goal-setting, better self-care management and outcomes in a person- and family-centered health system. Recently the Centers for Medicare & Medicaid Services (CMS) updated their Quality Strategy to advance the ongoing work to shift Medicare from paying for the number of services provided to paying for better outcomes for patients. One of the six goals outlined in the update was the Person and Family Engagement (PFE) Strategy which is to “strengthen person and family engagement as partners in care.”
Health systems are challenged with reevaluating transitional care practices, to reduce 30-day readmission rates, prevent adverse events, and ensure a safe transition of patients. Care transitions entail moving patients between health care practitioners and settings as their conditions and care needs change during the course of a chronic or acute illness. The settings involved in care transitions include hospitals, nursing facilities, the patient’s home, rehabilitation facilities, home health agencies, primary and specialty care offices, community health centers, community-based settings, hospice, long-term care facilities, and others. Better care transitions have the potential to reduce readmissions—the “back and forth” movement of a patient between these settings and the instability, anxiety, and risks to health this may cause.
More primary care physicians (PCPs) and healthcare providers are using Electronic Health Records (EHRs) and Electronic Medical Records (EMRs) than ever before. With the many anticipated changes in healthcare including value-based care and incentive payments related to health information technology growth in EMR/EHR use is expected to continue. There is a slight, but significant difference between EMR and EHR. Both are digital versions of the paper charts in the clinician’s office, hospital or other care settings, and each contains the medical and treatment history of patients. However, EHRs have the unique added feature of going beyond standard collected clinical data by providing a more comprehensive view of patient care. EHRs are designed to integrate information beyond the health organization to include other health care providers, such as laboratories and specialists, as well as referrals and assessments for social services and home care.
Coordinating and managing health care services for older adults with two or more chronic diseases for improved population health requires establishing patient self-care and sustaining communication between patients, caregivers, and health care providers. Chronic Care Management (CCM) for population health includes care planning and using population-level measures for better health outcomes. Healthcare organizations that have the ability to obtain, review, and apply analytical data are well on their way to improving patient care coordination. Data analytics help providers to understand the individual and collective health care needs of the populations they serve.
Older patients with two or more chronic diseases may have multiple reasons for experiencing vertigo or dizziness. They may lose their balance due to muscle weakness, misalignment of the spine, brittle bones, vascular problems, vision loss, polypharmacy, or a sedentary lifestyle. Vertigo and dizziness affects approximately 70% of individuals age 65 or older. Heart disease, medication reactions, and inner ear problems are often the top causes of dizziness in older adults. In many instances complaints of dizziness and imbalance lead to hospitalization.