The Four Pillars

Four Pillars Medication Self-Management Medication Self-Management Patient Centered Health Record Patient Centered Health Record (PHR) Primary Care Provider/Specialist Follow- Up (PHR) Primary Care Provider/Specialist Follow- Up Knowledge of Red Flags Knowledge of Red Flags

Pillar #1: Medication Self-Management Focus: reinforcing the importance of knowing each medication – when, why, and how to take what is prescribed, and developing an effective medication management system Focus: reinforcing the importance of knowing each medication – when, why, and how to take what is prescribed, and developing an effective medication management system

Pillar #2: Personal Health Record (PHR) Focus: providing a health care management guide for patients; the PHR is introduced during the hospital visit and used throughout the program Focus: providing a health care management guide for patients; the PHR is introduced during the hospital visit and used throughout the program

Key Elements of the Personal Health Record Record of patient’s medical history Record of patient’s medical history Red flags, or warning signs Red flags, or warning signs Medication list and allergies Medication list and allergies Advance Directives Advance Directives Structured Checklist of critical activities (instructions, f/u appointments) Structured Checklist of critical activities (instructions, f/u appointments) Space for patient questions and concerns Space for patient questions and concerns

My Medications are: Medication Dose ______________________________ Allergies: _____________________ Reason Side Effects ______________________________ Remember to take this Record with you to all of your doctor visits PersonalHealthRecord The Personal Health Record of: Josephine Patient Personal Information: Address: Home Phone#: Birth Date: Patient ID# PCP Name: Advanced Directives?: Hospitalization Information: Admitted: _/_/_ Discharged: _/_/_ Reason for Hospitalization: ___________________________________________ Caregiver Information: Name: Phone #: Relation to Patient: Personal History Please check any illnesses or health problems listed below that you have ever experienced.  Arthritis  Abnormal Heart Rhythm  Cancer  Diabetes  Hardening of the Arteries  Heart Disease  Heart Failure  High Blood Pressure  Hip Fracture  Lung Disease  Medical/Surgical Back conditions  Pneumonia  Stroke  Other: ____________________ After I leave the hospital… 1. I will write down questions I have about my condition. 2. I will take all bottles of medicine I am using to each doctor visit. 3. I will call _________________ immediately at (XXX) XXX-XXX if I experience any of the following: Temperature above 101° F Uncontrollable pain Increased confusion Increased redness or d drainage around wound Questions about which medications to take Before I leave the hospital…. qI have the instructions I need to keep my health condition from becoming worse. qI know what symptoms to watch out for. qI know the name and phone number of who to call if I see any of these symptoms. qMy family or someone close to me knows what I will need once I leave the hospital. qI know what medications to take, how to take them, and possible side effects. qI will schedule a follow up appointment with my primary care doctor. qI will have a clear and complete copy of my discharge instructions.

Goal Attainment “What is one personal goal that is important for you to achieve one month after you get home?”

Response Categories 1. I have not worked on it 2. I have not met that goal, but am working on it 3. I have met the goal as well as I expected 4. I have met the goal better than I expected

Findings Patients who worked with the Transition Coach were more likely to achieve their goals around symptom control and functional status Patients who worked with the Transition Coach were more likely to achieve their goals around symptom control and functional status

Pillar #3: Primary Care Provider/Specialist Follow-Up Focus: enlist patient’s involvement in scheduling appointment(s) with the primary care provider or specialist as soon as possible after discharge Focus: enlist patient’s involvement in scheduling appointment(s) with the primary care provider or specialist as soon as possible after discharge

Pillar #4: Knowledge of Red Flags Focus: patient is knowledgeable about indicators that suggest that his or her condition is worsening and how to respond Focus: patient is knowledgeable about indicators that suggest that his or her condition is worsening and how to respond