San Diego Long Term Care Integration Project . LTCIP Planning Committee September 23, 2008. LTCIP “Vision” Today. Improve care for elderly and disabled persons in San Diego Utilize existing funding better, more effectively
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LTCIP Planning Committee
September 23, 2008
Improve care for elderly and disabled persons in San Diego
Utilize existing funding better, more effectively
Change “culture” of care from symptom response to “whole person” care
Organize health and social service providers to support effort
Health & social service providers, consumers, caregivers, advocates
With interest in promoting and supporting the “vision”
Have informed the process with 30,000+ hours over 10 years!
Input needed today!
Communication Strategy (Aging & Disability Resource Connection)
Physician Strategy (TEAM SAN DIEGO)
Fully Integrated Health Care Strategy
Building supports for better chronic care across providers, settings, and funding by:
Community development of “team dynamic” through education & practice
Empowerment of “patients” to better manage their own care
Formal feedback loops to “close the circle” for improved patient outcomes
Focus is review and team-building
5 hours to include working lunch
Aiming for geographic focus
Demo of Network of Care
Exhibit of tools for patient empowerment
Development of basis for formal feedback loops
Highlights from on-line modules
Stakeholder groups to simulate “teams”
Teams to discuss case scenario
Teams to report out on development of feedback loop in groups
See website for background & info: www.sdltcip.org
Call or e-mail: email@example.com
Highlights from: Review and Discussion of
1 in 2 Americans have 1 or more chronic illnesses
Increased diversity challenges medical practice
Physicians were not trained in chronic care
Systems are currently filled w/gaps & overlapsMedical & social service coordination for chronic care needs to improve:
Multiple chronic problems
Environmental / Cultural Diversity
Helps physicians and their patients’ other providers do a better job.
Provides array of “after office” support services that go beyond the immediate doctor’s office visit.
Improves systems to serve complicated and costly patients and improve satisfaction and outcomes.
Helps the physician’s office deal more efficiently with the complexity of using social supports along with medical services.
Results in efficiencies in practice management and patient safety.
Risk Management (improved patient safety)
More efficient patient visits due to patient activation
Fewer missed appointments through planned visits facilitated by community supports
More effective office staff support for patient access to and use of “after office” supportive services
Improved patient outcomes and satisfaction
Learn evidence-based models: “teaming”
Learn tools and techniques to activate patients
Learn to respond to the needs and preferences of “the whole patient”
Learn about aging and disability
Learn the basics of legal-ethical issues
Learn how to find resources for your mutual patients
Apply on a day-to-day basis
Primary care for chronic illness requires team approach
Primary care offices do not often work as teams
Lack of communication with other disciplines involved in patient care is the norm
Even if a team existed, it would be impractical to
meet at the same time and place
Practice management self assessment
Identify current community partners
Identify possible improvements
Implement workable improvements
Measure progress, adjust
Feedback loop with partners
Repeat this sequence
Health Care Organization
Resources and Policies
Figure 1 from Wagner, E.H. Chronic Disease Management: What Will It Take to Improve Care for Chronic Illness? Effective Clinical Practice, 1998; 1:2-4
Keep in touch regularly (phone, FAX, e-mail)
Alert the others of specific mutual patient problems
Educate patients on self-care management
Encourage patients to follow treatment plan
Assist patients in linking with support services
“Empowerment” as described by June IsaacsonKailes:
is self-perceived, personal power;
occurs on an internal, psychological level;
is a state of mind and a belief system;
is a developmental and ongoing process; occurs at each individual’s own pace;
cannot be given, BUT can be helped by providing information, tools, and skills.
Encourage patient to bring current medical history and medication list to appointments
Encourage patient to bring list of issues to discuss, acknowledging some may have to be dealt with later
Encourage patients to ask questions, seek clarification, offer preferences and feedback
Listening to the patient
Offering opportunities to choose
Involving patients as partners in their own care by encouraging them to prepare for the visit.
Providing information and support in finding services.
Providing education in skills for self-management
Providing tools to support self-management, such as a personal health record, discharge checklist
By default, patients and caregivers sometimes function as their own care coordinators
Patients are the first line of defense for transition related errors
In TEAM SAN DIEGO, patient is in central role as educated, activated, empowered team member
1. Medication self-management:
a) reinforcing knowing each medication – when, why, and how to take it
b) developing an effective medication management system
2. Personal Health Record
a) providing healthcare management guide
b) patient tracks own care plan and goals
3. Primary Care Provider/Specialist Follow-Up
a) involving patient in scheduling appointments
b) scheduling ASAP post discharge/transition
4. Knowledge of “Red Flags”
a) teaching patient indicators that condition is worsening
b) teaching patient how to respond
Need to recognize the values and strengths of ethnic persons and their communities
Understand and respect their cultures
Question personal stereotypes, attitudes and behaviors
Move beyond fear to find value in improving current situations and benefit from the richness of diversity
What do you think caused the problem?
What have you done to deal with this problem?
Have you asked anyone to help you?
Do you have traditional ways of treating this?
What do you want the treatment/service to do for you?
How does your faith/religion help you to be well?
Well documented patient-provider communication strategy
Health literacy approach: “Communication loop” that supports patient understanding of provider instructions
The “oldest-old” = 85 year olds +
The “old-old” = 75 to 84 year olds
The “young-old” = 65 to 74 year olds
The “Baby Boomers” = born between 1946 and 1964 (44 to 62 year olds today)
Boomers create the “age wave” estimated to triple percentage of seniors by 2020
Normal aging of major physical systems can be reviewed in the on-line training
A “red flag” is a sign or symptom of a new or worsening condition
Red flags are important for all members of the team to observe and report
Red flags are important to teach your patient to help manage chronic care
Define level of urgency
Speak with individual’s primary care physician or office staff based on urgency
Speak with individual’s caregiver about your observation
Offer assistance in finding resources for assessment and treatment/services
Document your activities
Prevention: routine visits, reminders to patients
Patient education on self-care, healthy choices
Referrals for support services and equipment
housing, public programs, transportation, personal assistance, home adaptation, etc.
Staying engaged and having social contact
Being active and keeping a healthy weight
Having activities that are mentally stimulating
Volunteering to have significance in life
Engaging in caregiving with family and/or friends or on a paid basis
That individuals in the video want providers to know:
They want quality in their life
They are doing what they need to do with assistance
They are not sick and in need of a cure
They want you to talk with/to them, not their assistant
That health is not their main occupation or concern
ADA accommodations can be hard to find but anyone can call a rehab center for help, and…
What they want most is for the provider to listen to them
They are often experts on the care of their disability and a resource to you and others
They have diverse needs within the same group (deaf example)
You don’t have to be perfect—don’t stress over developing a relationship
Make no assumptions!!
Health is not the absence of disability or disease
Health is maximizing our potential physical, social, emotional, spiritual, and intellectual wellbeing
Health and disability can and do co-exist
Health is the ability to function effectively in different environs, to get one’s needs met, and to adapt to stressors
Independent living is not doing things by yourself; it is being in control of how things are done.
Independent living is the conscious choice that individuals make to be responsible for managing significant issues in their lives.
From June Isaacson-Kailes
Health Insurance Portability & Accountability Act
To see and obtain copies of their health records
Have corrections or amendments added to their health info
Be notified of how their health info may be shared or disclosed
Decide to give permission before used or shared for certain purposes, such as for marketing
Get a report on when and why it was shared
Have a copy of the organization’s “Notice of Privacy Practice”
File a complaint if they believe their rights are denied or their info is not protected
Protect patient info as if it were your own
Have patient as team member agree to referrals
Have patient sign Consent for Release of PHI
Provide “minimum necessary” limited info for success of referral and continuum of care
Develop feedback loop with referral agency and get approval of patient
Document referrals and appointments