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UHF Highlights Methods to Improve SNF-to-Home Transitions

Home Health Care

Transitions of care involving seniors — especially those with multiple chronic conditions — can be risky. Despite this, there are a number of methods skilled nursing facilities (SNFs) and other health organizations can adopt to improve the transition from inpatient care to home for patients and their caregivers.

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California and Ohio Advancing Equity for Older Adults and Family Caregivers

NASHP

The strategies have the following commonalities: The goals, outcomes, and strategies have integrated principles of equity and inclusivity, with a special focus on addressing the needs and priorities of underserved populations and communities.

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Supporting the Continuum of Care for Serious Illness in Medicaid Managed Care

NASHP

People with serious and life-threatening health conditions experience care needs that drive costs, including hospital admissions , emergency department utilization , and nursing home care. Rhode Island is another state that has invested in coordinated care for complex populations enrolled in Medicaid.

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State Community Health Worker Models

NASHP

integrating?CHWs CHWs into evolving health care systems in key areas such as financing, education and training, certification , and state definitions, roles and scope of practice. Many provider types may supervise CHWs, including physicians, dentists, public health nurses and mental health professionals among others.

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Community Health Worker Models

NASHP

This map highlights state activity to integrate CHWs into evolving health care systems in key areas such as financing, education and training, certification, and state definitions, roles and scope of practice. South Dakota has incorporated payment for CHW services through a State Plan Amendment. 98961 – 2 to 4 patients.