1 / 11

The Four Pillars

The Four Pillars. Four Pillars. Medication Self-Management Patient Centered Health Record (PHR) Primary Care Provider/Specialist Follow-Up Knowledge of Red Flags. Pillar #1: Medication Self-Management.

shanon
Download Presentation

The Four Pillars

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. The Four Pillars

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

  3. 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

  4. 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

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

  6. Before I leave the hospital…. • I have the instructions I need to keep my health condition from becoming worse. • I know what symptoms to watch out for. • I know the name and phone number of who to call if I see any of these symptoms. • My family or someone close to me knows what I will need once I leave the hospital. • I know what medications to take, how to take them, and possible side effects. • I will schedule a follow up appointment with my primary care doctor. • I will have a clear and complete copy of my discharge instructions. • 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 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: ____________________ Personal Health Record Remember to take this Record with you to all of your doctor visits My Medications are: Medication Dose ______________________________ ______________________________ ______________________________ ______________________________ ______________________________ ______________________________ ______________________________ ______________________________ ______________________________ ______________________________ Allergies: _____________________ Reason Side Effects ______________________________ ______________________________ ______________________________ ______________________________ ______________________________ ______________________________ ______________________________ ______________________________ ______________________________ ______________________________ ______________________________

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

  8. Response Categories • I have not worked on it • I have not met that goal, but am working on it • I have met the goal as well as I expected • I have met the goal better than I expected

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

  10. 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

  11. 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

More Related