# Presentation: 190271

## Nashville Area

- Dr. Tim Ricks, OPH Director
- Mary Wachacha, Health Education
- Michelle Ruslavage, HPDP
- Dr. Palmeda Taylor, Behavioral Health

## Nashville Work Plan to Meet the 3 Initiatives

- Trigger Alerts to Comprehensive Care

- HPDP

- Behavioral Health

- Chronic Disease

- GPRA – Government Performance & Results Act

- CRS – Clinical Reporting System

- Standards of Care

- Gender

- Age

- Healthy People 2010

## Trigger Alerts to Care

- Emphasis to follow the Standards of Care for the illness, disease state or condition
- Age and gender triggers:
- additional tests,
- procedures,
- patient education, self-management, encourage/support decision-making
- referrals to other resources in the community

**Notes:**
The Nashville Area has spent a great deal of time educating our providers, on what we call...Trigger Alerts.  Trigger Alerts is education/training to our providers to understand and be prepared to act. First....our providers have to be aware of latest Standards of Care.  Obviously these Standards of Care will dictate the services provided – while the Standards of Care maybe a “given” – we find out providers appreciate being notified of .  Triggers: Additional tests/procedures:  based upon age/gender.  Examples: Pregnant?  Tobacco use, CAGE, FAS, DV, seat belt use, fitness.  Male?  Correctol screening, CAGE, cholesterol, tobacco use.  Over 45?  Cholesterol, tobacco use, BMI, nutrition/lifestyle adaptation education.  In Nashville, we consistently stress the importance of providing patient education – patient education that includes not only educating the patient but also determining the level of understanding of the patient to the education and helping the patient to set some personal goals for themselves.  We encourage all our providers to make referrals to other resources in the community. 

## Documentation

- Trigger Alerts to Care also require accurate, consistent documentation
*“**Tips and Tools for Routine Health Screening and Documentation in Primary Care*”
- Northern and southern 2- day training
- Geared towards the primary providers, medical records, and data entry staff

**Notes:**
NAO strives to ensure that all our staff remain knowledgeable on how to document correctly, consistently and that they are aware of the appropriate and applicable screening exams required.  We offer 2-day trainings to provide up-to-date information to staff.   This training is called ”Tips and Tools for Routine Screening and Documentation in Primary Care.”

## “Tips and Tools for Routine Health Screening and Documentation in Primary Care”

- How to Document correctly
- Where to Document correctly
- Actual “hands-on” experience with the Screening Tools:
- DV screening exams
- Depression screening
- Suicide screening
- PAPs, mammograms,
- Cardiovascular disease

**Notes:**
In Nashville we find that our providers want to do a good job – and as our statistics will demonstrate, they are doing a good job, but it helps to be reminded of the need to document correctly consistently and correctly.  Also, we have found that when providers do not document consistently or correctly, it is often because they have not been trained on how to use the PCC or the EHR correctly.  We also find that they may have never been given orientation on the various screening forms, exams and requirements needed for documentation. 

## “Tips and Tools for Routine Health Screening and Documentation in Primary Care”

- Assist the providers to learn how to encourage and support the patient to manage their illness and to encourage and facilitate decision-making
- Encourage providers to work to change/design their own local “system” so that the “system” fits the needs of the patient
- Document...document...document so that we can track each patient’s progress/needs
- Involve not only community resources but work to change the community’s focus on specific health care issues

**Notes:**
Encourage/support providers so that they can support the patient to self-manage their illness, help the patient make personal decisions and become involved in their own health – this includes determining if the patient understands the verbal instructions, the written instructions, what is the patient health literacy level?  We offer suggestions of how the system might change locally to facilitate the delivery of care.  We hope to cease the practice of forcing the patient to fit in our system and adapt the system to better meet the needs of the patient.  In order to better understand if we are making any progress, we cannot track our success and failures unless we document, document, document and that includes knowing which forms to use, we provide the actual screening form, many of our providers have never seen a depression screening form, we try to improve how to document in the EHR or on the PCC – and in some instances, assisting the Tribes to better design their own forms and track changes if they are not using RPMS.  Lastly, we are encouraging hospital and clinics without walls - we try to provides examples of how to better integrate community resources into the hospital and clinic setting.  

## Identification of Best Practices to Integrate Behavioral Health with HPDP and Chronic Disease 

- The integration of health care services via a multidisciplinary team (multidisciplinary team = medical providers, behavioral health providers, nutritionists, fitness experts, community health representatives and injury prevention specialists.)
- a) The inclusion of a spiritual advisor as a multidisciplinary team
- 	member.
- b) The integration of routine behavioral health screening in primary
-           care.
- c) The use of evidence-based practices for the treatment of
- 	     depression.
- d) The use of holistic psychotherapy for the healing of Post Traumatic
-           Stress Disorder.
- e) The assessment of community resources toward the development
-           and implementation of community-based wellness plans.
- f)  Encourage self-management, support and encourage patient’s
-          need to make personal decisions.
- g) Change the “system” to support the patient rather requiring the patient
-          to “fit” the system.

## Behavioral Health Initiatives

- FAS Prevention
- 2005 = 25%
- 2006 = 47%
- Domestic Violence/IPV (Intimate Partner Violence) Screening
- 2005 = 6%
- 2006 = 34%
- Depression Screening
- 2005 = 20%
- 2006 = 28%

**Notes:**
I think our numbers speak for our providers!

## Chronic Disease -Nashville

- Train the provider on encouraging the patient to become active participants in their own health care:
- Give the patient time to explain/tell what they is wrong with them
- “Teach Back/verbalize” what the patient heard the provider say
- Motivational interviewing – probing
- Empower the patient by providing patient education that results in encouraging self-management, personal decision-making by the patient
- Ensure that the patient understands the information (health literacy) and makes a conscious decision for change: what do I need to do?
-  Patient understands their role in health care and what it is that they need (or need not) to do.

**Notes:**
The Nashville Area encourage the adoption of the documentation and coding of patient education using the IHS Patient Education Protocols and Codes (PEPC).  This method of documentation requires providers who provide education to document that patient and community education in accordance with this standardized method of documentation and coding.   Providing patient and community education to groups requires the provider to share to adhere to established guidelines for education, to document the patient’s level of understanding, and to assist the patient to set goals for themselves. 

## Chronic Care Focusing on: 

- Standards of Care
- Ensuring that the provider understands what the “gold” standard is so that they can provide appropriate treatment
- Documentation
- Making sure that the providers know how to document...document...document the services, tests, screening provided
- Changing the “system”
- Ensuring that the patient comes first...and not the “system”

**Notes:**
Many times our providers are so ”tied to the job” that they may not have become knowledgeable on new information or may not have had the time to integrate new guidelines or standards into their health care – we strive to make them aware of changes in the standards of care based upon new guidelines....and to document the care provided so that we can track each patient’s care.  Too often, our hospitals and clinics become addicted to “routine” and sometimes need to consider system changes that ensure and established better care. 

## Chronic Diseases

- Cholesterol Screening (CVD)
- 2005 = 61%
- 2006 = 64%
- Controlled Blood Pressure
- 2005 = 30%
- 2006 = 33%
- Tobacco Cessation
- 2005 = 12%
- 2006 = 18%

## Increase in Patient Education provided after Tips/Tools Training (from RPMS)

| Tribe | 2005 | 2006 | Percentage |
| --- | --- | --- | --- |
| Tribe A
 | 356 | 2,178
 | +511%  |
| Tribe B
 | 141  | 551 | +291%  |
| Tribe C | 35 | 254 | +626%  |
| Tribe D | 754 | 767 | +2%  |

## Identification of Best Practices to Integrate HPDP with Behavioral Health and Chronic Disease 

- The integration of health care services via a multidisciplinary team (multidisciplinary team = medical providers, behavioral health providers, nutritionists, fitness experts, community health representatives and injury prevention specialists.)
- a) The integration of HPDP in primary care:
- Activities of Daily Living
- Automobile safety/car seat safety
- Safety and injury prevention
- Health Screenings/tests
- Cultural/spiritual aspects of health
- Exercise
- Hygiene
- Lifestyle adaptations
- Nutrition
- Stress management
- Sexuality

**Notes:**
June 27-29, 2006

## Identification of Best Practices to Integrate HPDP with Behavioral Health and Chronic Disease

- The assessment of community resources toward the development and implementation of community-based wellness plans.  Guidance on:
- 	1) conducting community needs assessment surveys and a community readiness assessment and, using that information to,
- 	2) develop and implement a community wellness/action plan.
- Encourage self-management; support and encourage patient’s need to make personal decisions
- Change the “system” to support the patient rather requiring the patient to “fit” the system
- Documentation...documentation...documentation....

## In Conclusion:

- Recognition of the need for _statistics_ to demonstrate success/failure: GPRA, CRS, HP 2010
- Understanding that those statistics are only available with correct _documentation_
- Awareness of _Trigger Alerts_ (Standards of Care, Age, Gender)
- _Integration_ of all 3 initiatives: HPDP, Behavioral Health, Chronic Care
- _Adapt the “system”_ to the patient, not the patient to the system

## Questions?