This VNAA Best Practice includes the following critical interventions and actions:

• Symptom exacerbation/red flag lists need to be part of the comprehensive plan of care.
• Embed red flag identification in processes, provide tools and plan and measure success.
• Focus staff training on the importance of communication and patient engagement (self-management/activation).
• Make sure staff has the patient's personal health record and skills in motivating interviewing/coaching skills (see training in patient engagement topic on motivational interviewing, health literacy and communication).
• Focus patient education on the importance of using tools to enhance patients' self-management and communication with the home health agency and physician.
• Make sure the patient has their personal health record and uses it to manage their illness and communicate.
• Make sure the patient has and understands how to use zone tools, stoplight tools, SBAR (Situation, Background, Assessment and Recommendation), and their emergency plan.
• Include red flags, zone tools, stoplight tools and an emergency plan in patients' admission packets and make them part of their personal health records.
• Complete an individualized red flag document at admission for every patient.                                          
• Develop an emergency plan for every patient within 48 hours of admission.        
• Staff should use the teach-back technique to ensure comprehension.

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