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Monique Reese, ARNP, MSN, FNP-C, ACHPN, Vice President, Clinical Services and Chief Clinical Officer, Iowa Health Home Care Vicki Wildman, RN, MSN, Edu,

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Presentation on theme: "Monique Reese, ARNP, MSN, FNP-C, ACHPN, Vice President, Clinical Services and Chief Clinical Officer, Iowa Health Home Care Vicki Wildman, RN, MSN, Edu,"— Presentation transcript:

1 Monique Reese, ARNP, MSN, FNP-C, ACHPN, Vice President, Clinical Services and Chief Clinical Officer, Iowa Health Home Care Vicki Wildman, RN, MSN, Edu, Statewide Education, Integrated Chronic Care Disease Management Specialist Trainer IHS Spring Symposium 2011

2 Objectives Review the incidence and prevalence of chronic diseases Discover the importance of patient-centered care concepts List the components of Integrated Chronic Care Disease Management model List the positive outcomes to enhance clinical practice, increase quality and improve patient outcomes Describe the impact of decreasing re-hospitalization rates

3 Purpose A Broken Healthcare System Embrace, Embark, and Succeed! Envision a New Care Delivery System

4 22 5 Physical Therapists 37 Nurses A Year in the Life of a Patient 6 Social Workers 19 Clinic Visits 2 Home Care Agencies 6 Community Referrals 5 Months of Home Care 4 Occupational Therapists 13 Meds 2 Nursing Homes 16 Physicians 6 Weeks SNF Care 5 Hospital Admissions Source Johns Hopkins, RWJ 2010 (G Anderson)

5 “Patients can undo a month’s worth of expensive and intensive care just going home and going about their normal routines.” John Charde, MD VP Strategic Development, Enhanced Care Initiatives, Inc (April 2006)

6 Incidence of Chronic Disease Total U.S. population Source: Wu S, Green A. Projection of Chronic Illness Prevalence and Cost Inflation. RAND Corporation, October million Americans ( 45%) have one or more chronic diseases

7 The Number of People With Chronic Conditions Is Rapidly Increasing Source: Anderson, G.; Chronic Conditions: Making the Case for Ongoing Care; Johns Hopkins University; November 2007

8 Epidemic of Chronic Diseases Increasing incidence of chronic disease Complexity of care Poor transitions Telehealth data: poorly controlled disease Lack of evidenced based care “Non compliant” patients

9 Think of Your New Year’s Resolutions Are you non compliant?

10 Cost of Chronic Disease People with chronic conditions are the heaviest users of healthcare services. The more co-morbid conditions the heavier the use.

11 Potentially preventable 30-day readmission rates

12 COMMONWEATLH STUDY New England Journal of Medicine April 2009 FINDINGS: 1 in 5 discharged patients are readmitted within 30 days 50% of discharged patients are readmitted within 1 yr In 2004, $17.4 billion was spent by Medicare in unplanned rehospitalizations

13 So what about coordination? So what about coordination?

14 Chronic Disease Management is Becoming More Complex Increased incidence of patients with multiple co- morbidities Elderly patients with age-related complexities Fewer resources to care for an ever increasing number of patients all seeking care in an acute environment Is that how you feel?

15 Non-adherence: Significant for those with chronic disease Increase in number and length of acute care visits (25% of hospitalizations due to medication errors) Increase in ED visits Unnecessary changes in treatment Overuse of scarce and expensive medical resources Loss of productivity and decreased quality of life

16 Additional Focus Area : Medication Non-Adherence Lower for patients with chronic diseases Lower medication persistence with chronic disease Low adherence = twice the healthcare expenditures

17 Do Non-Adherent People Care Less About Their Health? NIH Grant - Meta analysis of studies related to health behaviors Included interviews with adherent and non-adherent patients Major difference: non-adherent patients had lower self- efficacy but cared just as much about their health Butterworth, Prochaska, Redding –NIH CDC Grant -1-ROI DP000103/DP CDC HHS/United States

18 The State of Chronic Care Management Health care systems act as silos No uniform way to share knowledge Lack of care coordination Rushed practitioners Lack of active follow-up Pts inadequately trained to manage their illnesses Pts seeking care via ER visits & hospitalizations

19 Integrating “The Best of the Best Integrating “The Best of the Best” New Healthcare Delivery Paradigm Redesigned Care Delivery Models 60 Years Experience Disease Management Components Behavioral Management Lessons Learned CMS Demo Projects Evidenced Based Care

20 Redesigning Care Delivery Current healthcare systems cannot do the job Trying harder will not work Changing care systems will work

21 Wagner’s Chronic Care Model

22 Informed, Activated Patient Motivation Information Skills Confidence Prepared Practice Team Patient information Decision support Resources Prepared Practice Team

23 Key Derivatives: Wagner’s Model Informed, Activated Patient Prepared Practice Team

24 Vision of a Provider with Value Expert in disease specific guidelines and care Expert in care coordination Shares responsibility for outcomes Competent communication & ability to share data Facilitates effective transitions Highly trained in behavior change techniques “sought after” partner that brings value

25 Home-Based Chronic Care Mode Home-Based Chronic Care Model High Touch Delivery Self-Management Support Specialist Oversight Technology

26 Healthcare Providers Role: Explore Barriers to Change Understanding Financial constraints Energy level (depression) Support system Problem solving ability Relationship with healthcare provider Importance and confidence Ambivalence: Many patients simply lack confidence in their abilities and that contributes to ambivalence

27 Technology to Support High Quality Chronic Care Comprehensive Assessments Examples: Re-hospitalization risk to identify high risk/ high cost patients PHQ-9 Assessments by disease Medication Risk Assessment Multi-faceted Fall Risk Assessment Evidence-based care plans High quality educational materials

28 Example of Telehealth Unit

29 Defining Care Transitions “ ‘Care transitions’ refers to the movement patients make between healthcare practitioners and settings as their condition and care needs change during the course of a chronic or acute illness.” Eric A. Coleman, MD, MPH Care Transitions Program SM

30 Implications for Healthcare Delivery Coordination of care in the first 30 days critical Coordination of care is traditional role of homecare Developing a standard approach to care coordination should be a key strategic objective

31 Homecare’s Unique Role in Transitions Comprehensive assessments Evidenced-based screening tools Interdisciplinary team assessments Interdisciplinary approach to care intervention Medication reconciliation Process & outcome measures ICCDM : Skills for effective health coaching in self mgt support & evidenced based guideline care “Patient is a puzzle”

32 Appt Scheduled within a wk AND able to get there Comprehend S&S that require attention AND whom to contact Medication Management Medication Management Early Follow-up Early Follow-up Symptom Management Symptom Management Community-Based Transitions Model™ (CBTM) Adherence & Persistence Change in RX or TX Change in RX or TX Is patient familiar& competent AND have access

33 Sustaining ICCM Job description expectations Performance Appraisals Training of all staff on ICCM Computer Based-Learning training Demonstration of skills Competency of skills Case conference meetings Certification

34 Certification Course Content Self-Management Support Concepts Working collaboratively with patients Behavior change theories and tools Adult Learning Evidence-based guidelines as they relate to disease self-management Use of telehealth and technology to support care Transitions of care Health literacy

35 Showing an Improvement Data collection of outcomes Data collection of process measures Tracking certification Tracking use of tools

36 Bringing All Concepts Together Multidisciplinary Case Conference ST PT ICCM Team Leader ICCM Team Leader Pharmacist CPS- PC Telehealth CPS- PC Telehealth Model Champion SW RN - NCM Physician OT

37 Training Curriculum Making the Case for Integrated Chronic Care Principles of Adult Education and Health Literacy Problem Solving 101 Evidenced-Based facilitation of Behavior Change Theory –Based Telehealth Integrated Care Transitions Model Implementation into Practice

38 Computer-Based Modules Evidenced-based training: Heart Failure Chronic Obstructive Lung Disease Diabetes Depression Each module contains: Pathophysiology/ incidence Treatment Modalities Self Management Support Behaviors Each module contains: Pathophysiology/ incidence Treatment Modalities Self Management Support Behaviors

39 Vision : Develop Strategies to Achieve Delivery System Design Decision Support Clinical Information Systems Self-Management Support Health System Organization Links to Community Resources Leadership support Provider participation Leadership support Provider participation Guidelines Provider education Expert support Guidelines Provider education Expert support Telemonitoring Guidelines embedded Dashboard Telemonitoring Guidelines embedded Dashboard Proactive follow-up Planned visit Visit system changes Proactive follow-up Planned visit Visit system changes Patient activation Self-management assessment Self-management resources Guidelines to patients Patient activation Self-management assessment Self-management resources Guidelines to patients Source: Pearson, M. et. al. Chronic Care Model Implementation Emphases, Rand Health Presentation to Academy Health Meeting, 2004Chronic Care Model Implementation Emphases

40 Best Outcome for Every Patient Every Time Home Health will be a recognized leader in providing patient-centered, expert, quality care in the comfort of home.


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