Generic Planned Care for Chronic Diseases, Pain, and Emotional Problems

1. Generic Planned Care for Chronic Diseases, Pain, and Emotional Problems A “COOP” Practice-based Controlled Trial supported by The Robert Wood Johnson Foundation

2. Three Interrelated Aspects • Patient Assessmentand Activation for Better Self-Management • Practice Change for More Effective, Efficient Function and Support of Patient Self- Management • Supportive Technologies for Practice Change and Better Patient Assessment and Support

3. An Illustration of Interrelation The Patient The Practice

4. Other Examples, Same Story Cardiac Hypertension Diabetes

5. We Focus Here on Practice Change • The Function (or dysfunction) • Necessary Changes and Quick Tests • Regular Full Staff Meetings • Group Visits, CARE Vital Signs • Sharing of Ideas to Improve Practice Processes • Redesign around Patient Self-Management Confidence • Test and Use of Supportive Technologies

6. The Practice Must “Move the Dots” Patient Rating of Care Quality Staff Rating of Office Function

7. Office Function (or Dysfunction) • What Are We Doing, How Well Are We Doing It, D o We Want to Change? • The Need is Usually There • Attitudes and Habits are Hard to Change

8. Necessary Changes and Quick Tests such as: • Regular Full Staff Meetings • CARE Vital Signs, Group Visits • Sharing of Ideas to Improve Practice Processes • Redesign around Patient Self-Management Confidence

9. Staff Role Change Patient Activation Patient Confidence A C R E

10. Use of Supportive Technologies such as: HowsYourHealth for patient assessment, problem-solving, virtual group visits, portable health record Docssite Patient Registries Email and Telephone Outreach

11. What Patients Using Technology Can Tell A Practice • Emotional Problems, or Pain: doctor aware and treatment effect; • If Chronic Disease, quality of education and help and confidence in management; • CVD last total cholesterol and beta blocker and ASA if history MI, if CVA on ASA or warfarin, if CHF info for self management; • HBP info for self-management, how often checking, and last blood pressure; • DM info for self-management, how often blood sugar checked and in acceptable range, last blood sugar; last cholesterol and BP • Asthma info for self- management, on anti-inflammatory • BMI, Tobacco, Drinking, Colon Cancer, Symptoms and Bothers, Habits, Exercise, Disability days and "Presenteesm"; • Women only: Mammogram, Paps, Abuse

13. Examples of What Patients Will Do to Improve