1. Sharon Moffatt, RN, MSN

2. Cost of Chronic Conditions is both Personal and Financial Care for people with chronic conditions accounts for: 83% of health care spending 81% of hospital admissions 76% of all physician visits 91% of all prescriptions filled

3. Wagner Model for Chronic Disease Care with Public Health

4. Prepared, Proactive Practice Team Informed, Activated Patient Productive Interactions Prepared Activated Community Improved Health Outcomes –Healthier People

6. Healthy Living Workshops Individual Focus Stanford Patient Education Research Center - Self Management Program Evidence based research to affect individual health Empowers individual and families in requesting more of health care

7. Healthy Living Participants Medical Care MD Visits ED Visits Visits to a health care provider’s office and the Emergency Dept decreased significantly at 6 & 12 months

8. Community Care Team Supports individual and health care provider for improved health care Connects individual with community resources Replaces or enhances outside disease management programs

9. Community Care Team Medical Social Worker Dietician Community Health Outreach Worker Behavior Specialist Public Health Prevention Specialist

10. Community Care Team Connected with Local Public Health 12 Vermont District Health Offices Public Health Nurses Nutritionists Outreach Specialists Prevention Specialists Alburg Canaan Richford Enosburg Falls South Hero Milton Island Pond Barton Orleans Winooski Gilman Lyndonville Hardwick Hinesburg Waterbury Vergennes Bristol Waitsfield Chelsea Bradford Randolph Bethel Thetford Brandon South Royalton Woodstock Poultney Windsor Chester Manchester Towshend Putney Wilmington Ludlow Rochester Stamford Westfield Wells River Guildhall Castleton Bellows Falls District Health Offices Community Locations

12. Vermont 2-1-1 Call Specialists problem solve and refer callers from throughout Vermont to government programs, community-based organizations, support groups, and other local resources A local call from anywhere in Vermont Available 24 hours a day, 7 days a week Live translation services for 170 languages Access for persons who have special needs Ability to transfer emergency calls to E 9-1-1

13. Community Quality Health Care and Quality of Life  Communities have walking programs year round for all ages  Farmers’ Markets have doubled in the last 5 years

15. Diabetes Related Hospitalizations, per 1,000 Vermonters with Diabetes

16. Hospitalizations for Lower Extremity Amputations, per 1,000 Vermonters with Diabetes

18. Resources/References  The Chronic Care Model: Improving chronic illness care a national program of The Robert Wood Johnson Foundation, www.improvingchroniccare.org www.improvingchroniccare.org  Wagner, E.H. Chronic Disease Management: What will it take to improve care for chronic illness? Effective Clinical Practice 1998; 12-4.  National Estimated Cost of Obesity, CDC, BRFSS 1998-2000).

19. Resources/References  Crossing the Quality Chasm: A New Health System for the 21 st Centry, Institute of Medicine, National Academy of Sciences, 2001.  To Err is Human: Building a Safer Health System, Institute of Medicine, National Academy of Sciences, 2000.Institute of Medicine

20. Resources/References  The Model for Improvement by the Institute for Health Improvement www.ihi.org www.ihi.org  The Quality of Health Care Delivered to Adults in the United States. New England Journal of Medicine 2003, 348:26.  Vermont Department of Health website: www.healthvermont.gov