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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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san diego long term care integration project

San Diego Long Term Care Integration Project

LTCIP Planning Committee

September 23, 2008

ltcip vision today
LTCIP “Vision” Today

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

stakeholders
“Stakeholders”

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!

ltcip strategies developed to support vision
LTCIP Strategies Developed to Support “Vision”

Communication Strategy (Aging & Disability Resource Connection)

Physician Strategy (TEAM SAN DIEGO)

Fully Integrated Health Care Strategy

team san diego
TEAM SAN DIEGO!

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

team san diego today
TEAM SAN DIEGO TODAY
  • 8 on-line modules developed
    • With experts/Advisory Group
    • Loaded onto UCSD “Blackboard”
    • Combined with “resources”
    • Serving as basis for development of “virtual teams”
    • To be followed by in-class training
tsd in class training
TSD In-Class Training

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

slide9
Now…

Highlights from on-line modules

Discussion, questions

Stakeholder groups to simulate “teams”

Teams to discuss case scenario

Teams to report out on development of feedback loop in groups

for more information
For more information:

See website for background & info: www.sdltcip.org

Call or e-mail: brenda.schmitthenner@sdcounty.ca.gov

858-495-5853

team san diego11

TEAM SAN DIEGO

Highlights from: Review and Discussion of

On-line Modules

medical social service coordination for chronic care needs to improve
Chronic care is now the major reason for care

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 & overlaps

Medical & social service coordination for chronic care needs to improve:
san diego physicians perspective key issues in caring for the chronically ill
San Diego Physicians’ Perspective: Key Issues in Caring for the Chronically Ill

Multiple chronic problems

Drug-drug interactions

Physical disability

Functional Impairment

Environmental / Cultural Diversity

Economic Stressors

13

team san diego solutions
TEAM SAN DIEGO Solutions

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.

why change
Why Change?

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

how do we change
How Do We Change?

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

the importance of interdisciplinary teaming
The Importance of Interdisciplinary Teaming

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

how to implement virtual team care strategies
How to Implement Virtual Team Care Strategies

Practice management self assessment

Identify current community partners

Identify possible improvements

Implement workable improvements

Measure progress, adjust

Feedback loop with partners

Repeat this sequence

slide19

Chronic Care Model

Community

Health System

Health Care Organization

Resources and Policies

ClinicalInformationSystems

Self-Management Support

DeliverySystem

Design

Decision

Support

Prepared,

Proactive

Practice Team

Informed,

Activated

Patient

Productive

Interactions

Improved Outcomes

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

remember the feedback loop
Remember the Feedback Loop!

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

what is patient empowerment
What is Patient Empowerment?

“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.

21

better patients better care
Better Patients = Better Care

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

22

how tsd can empower patients
How TSD Can Empower Patients

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

23

patients as team members
Patients as Team Members

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

24

dr coleman s four pillars
Dr. Coleman’s Four Pillars:

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

four pillars continued
Four Pillars (continued)

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

diversity enriches us all
Diversity Enriches Us All

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

communication is the key
Communication Is The Key
  • Good communication, the key to good medicine:
    • recognizes the individual as unique,
    • helps prevent medical errors,
    • strengthens the patient-physician relationship,
    • makes the most of limited interaction time
    • leads to improved health outcomes
    • assists in discovering additional health-related concerns

30

communication approaches
Communication Approaches

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?

31

teach back method of communication
Teach Back Method of Communication

Well documented patient-provider communication strategy

Health literacy approach: “Communication loop” that supports patient understanding of provider instructions

32

different types of seniors
Different Types of “Seniors”:

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 change vs red flags
Normal Change vs. “Red Flags”

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

response to red flags
Response to Red Flags

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

what we can do everyday with team san diego
What We Can Do Everyday with TEAM SAN DIEGO

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.

tsd can promote healthy aging
TSD Can Promote Healthy Aging

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

in the video from the world institute on disability you heard
In the Video from the World Institute on Disability, You Heard…

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…

persons in the video said
Persons in the Video Said…

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!!

we need to look beyond disability
We Need to Look Beyond Disability

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
Independent Living

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

privacy and confidentiality hipaa
Privacy and Confidentiality: HIPAA

Health Insurance Portability & Accountability Act

  • Establishes safeguards to protect the privacy and security of protected health information (PHI)
  • Improves efficiency and effectiveness of health care systems by standardizing electronic transactions
  • Gives consumers more control over their health information, use and disclosure
hipaa patients rights
HIPAA Patients’ Rights

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

what hipaa means for you
What HIPAA Means for You:

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

major ethical principles
Major Ethical Principles
  • Self determination: respect patient right to make informed decisions
  • Duty to benefit others: educate patient so decision can be informed
  • Duty to protect others from harm
  • Justice and fairness to all parties: regardless of who they are or ability to pay
  • Honesty and trustworthiness
patient self determination act of 1990
Patient Self-Determination Act of 1990
  • Highlights of the law include:
    • Providing all adult patients with written information concerning care decisions
    • Asking patients whether they have an Advanced Directive (AD) & where to find it in emergency
    • Maintaining policies regarding discussions of an AD
    • Honoring Advanced Directives
    • Educating patients about Advanced Directives
finding resources
Finding Resources
  • Aging and Disability Resource Connection
    • Network of Care
    • AIS Call Center
    • a2i Independent Living Center
  • Document referrals
  • Implement feedback loop as “virtual” team
  • Improve patient outcomes