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Brenda Schmitthenner, MPA

Activating Chronic Disease Self-Management, Improved Communication and Care Coordination through an Electronic Personal Health Record. Brenda Schmitthenner, MPA. Infusing Technology into CTI. San Diego’s ADRC implemented Care Transitions Intervention (CTI) in August 2010

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Brenda Schmitthenner, MPA

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  1. Activating Chronic Disease Self-Management, Improved Communication and Care Coordination through an Electronic Personal Health Record Brenda Schmitthenner, MPA

  2. Infusing Technology into CTI • San Diego’s ADRC implemented Care Transitions Intervention (CTI) in August 2010 • Evidence based Coleman Model “to coach, not do,” using Four Pillars • Establish and maintain a PHR • Establish and maintain a Medication List • Prompt follow up with specialists • Recognition of “Red Flags” • Building Better Health by building better systems-10 year strategy in San Diego • Improve care coordination and communication across healthcare and social service providers by virtual teaming • Engaged community providers in TEAM SAN DIEGO training

  3. San Diego’s Tech4Impact Program • Goals: • To activate chronically ill patients to manage their chronic conditions through the PHR on the Network of Care • Engage formal and informal caregivers in supporting chronically ill patients by communicating and coordinating care “teaming virtually” through the PHR on the Network of Care • Activate patients to use the Network of Care site to locate services and resources, plan for their long term care needs and learn how to improve their health and wellbeing

  4. Network of Care Main Page URL Link: www.sandiego.networkofcare.org/aging

  5. Who is it For ? Network of Care Website

  6. 6 Easy Accessible Links • Service Directory • Library • Assistive Devices • Links • Legislate • My Folder

  7. Service Directory

  8. Library

  9. PHR My Folder *Personal Health Record *Grant Visitor Access

  10. PHR Folder

  11. PHR Sections

  12. Conditions

  13. Medication List

  14. Granting Access to Caregivers

  15. PHR Owner Engages Team

  16. Virtual Teaming

  17. LTC Options Counselor

  18. Lessons Learned • Delays and challenges • Contracting • Equipment • Target population • Timing • Opportunities to link technology into broader system changes: • Beacon-Health Information Exchange • West Wireless Health Institute • Community-based Care Transitions Program

  19. Questions

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