Patient Intervention Paper

According to, Sofaer & Schumann patient’s engagement is the involvement of an individual in their own care. This allows patients to make competent and well- informed decisions about their health.

In an effort, to reduce costly and unnecessary hospital admissions among seniors in Montgomery County Maryland, The Center for Medicare and Medicaid Services(CMS) in conjunction with Nexus Montgomery Regional partnership established a program called WISH. This program stands for Well and Independence for Seniors at Home. The primary goal of the program is to actively engage patients in taking an active role in their healthcare to prevent hospital admission. Through this program, patients that are at a high risk for repeat or an initial hospital admission are linked with a health coach. The role of the health coach is to assist the patient in taking an active role in their healthcare. The coach works in conjunction with various providers to ensure the patient has all the tools they need to take an active role in their care. The program incorporates several tools to help senior mitigate their
The Colman model is a care transition intervention that is evidence based and supports self-management for older adults The model focuses on teaching self-management skills and it promote independence for senior. When clients are actively engaged, they transition from a passive non-engaged state to a more actively engaged state where they are able to fully participate in their care. In addition, the Patient Activation Measure (PAM) is used to gauge the patient’s level or readiness. The health coach helps the client begin to take an active role in their healthcare. The intervention is designed to meets the client where they are. The coach works with the patient to develop realistic goals and with these goals in mind the patients becomes motivated and are better equipped to manage their healthcare