# Presentation: 040410

## Welcome to theChronic Care Initiative’s Readiness Curriculum Call Series

- Wednesday July 23, 2008

## What is the Readiness Curriculum?

**What is the Readiness Curriculum?**

- The Readiness Curriculum is a monthly web-based call series that includes training on improvement and care models, project management, and leadership for improvement.  This call series is a resource for all health care organizations across the Indian health system.

## Readiness Curriculum Call Goals

- To address stimulating topics of interest that relate to improving planned care for all,
- To share useful tools and references for attendees to learn more about improvement methodologies and how to use them to transform their organizations, and
- To share lessons learned from the Innovations in Planned Care work

## Conference Call Tips

- Please place your phone line on mute
- Please don’t place the call on hold – many organizations have “hold music” that will interfere with the call
- Feel free to use the chat function or to raise your hand if you have any questions in between pauses for questions and comments

## The Patient Will See You Now

*Judith Schaefer, MPH*
*Laurel Simmons, MA*

## If you are thinking about helping patients self manage chronic illness, here are some things you might consider. You might want to talk about changing any of these and add other concerns in the blank circles.

**Sharing information **
**with patients**

**Helping patients **
**set goals**

**Saving time in **
**patient visits**

**Implementing **
**Guidelines**

**Depression**

**Motivating **
**patients**

**How to best use **
**a care team**

**Registries**

- Adapted from Stott et al, Fam Practice, 1995  by Barbara Kondilis of the RI Chronic Care Collaborative

**Empanelment**

## SMS: What is it?

**“****Self-Management Support** is the assistance caregivers give *patients and their self-defined circle of support* so patients can manage their conditions on a day-to-day basis and develop the confidence to sustain healthy behaviors for a lifetime.”
- T Bodenheimer, et al. Helping Patients Manage their Chronic Conditions. Available at http://www.chcf.org

## Evidence for SMS

- From the literature review, Bodenheimer, CHCF.org:
- “Didactic patient education does not improve health-related behaviors or clinical outcomes.”
- “Collaborative decision making ... improves patient outcomes.”
- Studies on goal setting and associated activity is less robust but promising
- T Bodenheimer, et al. Helping Patients Manage their Chronic Conditions. Available at http://www.chcf.org

## SMS: What is it?

## New Collaborative Partnership

## Acute vs. Chronic Conditions

|  | ACUTE | CHRONIC |
| --- | --- | --- |
| Beginning | Rapid | Gradual |
| Cause | Usually one | Many |
| Duration | Short | Indefinite |
| Diagnosis | Commonly accurate | Often uncertain |
| Diagnostic tests | Often decisive | Often limited value |
| Treatment | Cure common | Cure rare |

- Table describes differences in acute vs. chronic conditions re: beginning, cause, duration, diagnosis, diagnostic tests and treatment.

## Acute vs. Chronic Care Roles

|  | ACUTE | CHRONIC |
| --- | --- | --- |
| Role of Professional | Select and conduct therapy | Teacher/coach and partner |
| 
Role of Patient

Lorig 2000 | 
Follow orders | 
Partner/ Daily manager |

- Table describes role of professional and patient in acute vs. chronic care roles.

## Symptom Cycle

- Vicious Cycle

**Disease**

**Tense muscles**

**Fatigue**

**Depression**

**Anger/Frustration/Fear**

**Stress/Anxiety**

## Laying the Foundation

- Sells Service Unit
- Linda Cohen and Pete Ziegler
- White River
- Cindy Stickelman

## Sells Service Unit

- July 23, 2008
- “Getting to Self-Management”

## 
Innovations in Planned Care (IPC) pilot site since January 2007.

Sells Service Unit:
4 sites spread throughout the reservation
2-4 hours travel required daily by staff
Work assignments currently rotational

- Innovations in Planned Care (IPC) pilot site since January 2007.
- Sells Service Unit:
- 4 sites spread throughout the reservation
- 2-4 hours travel required daily by staff
- Work assignments currently rotational

- Sells Service Unit

## Sells Service Unit

## 
Added new Case Manager (CM) positions; 1 in July and 1 in September.

CM roles have not been traditional secondary to needing staff to drive the IPC. Eventually seen as managing the higher use/risk patient population as an adjunct to the care teams.

- Added new Case Manager (CM) positions; 1 in July and 1 in September.
- CM roles have not been traditional secondary to needing staff to drive the IPC. Eventually seen as managing the higher use/risk patient population as an adjunct to the care teams.

- Sells Service Unit

## Care Team Development

- Very recently, yesterday, we met to begin care team development at each of our 4 sites
- Care teams are the foundations for patients’ “medical homes” and continuity of care
- Care Teams:
- 1 RN/LPN – panel management, phone calls, etc.
- 1 CMA or equivalent – clinical management
- Provider – sees patients
- “Tools” to improve patient access to Care Team

- Sells Service Unit

## Sells Service Unit

## Empanelment and Medical Homes...

- Allows a panel of patients to identify with a specific Care Team that becomes their “Medical Home”.
- Provides continuity of care which ultimately decreases visits and eliminates the need for the patient to repeat their story at each visit.
- Establishes a relationship between the patient and their Care Team, laying a foundation for self-management goal setting and support.
- Patients’ ownership of their health is essential, as is a Care Team’s ownership and _accountability_ to their panel of patients.

- Sells Service Unit

## Slide 22

## My Health Plan

-        Not important   1     2       3	    4         5	             6	           7	          8	       9	10     Very important
- 2.   How sure am I that I can improve my health? (circle a number)
-        Not sure         1	2          3	     4         5	         6	7        8	       9	10	Very Sure
- 3.   Do I want to talk with clinic staff about doing something to 	improve my health?
-             (Circle 1 answer)   	                                     Yes	 	No
_**If you said yes to #3**_, please answer the questions on the back of this paper.
_**If you said no to #3**_, please sign and date this paper and give it to your nurse.

**My Health Plan**

- Whiteriver Service Unit

## The most important thing I want to do for my health right now? 

- 5. _I am doing well with_:			6.  _I want to do better with_:
-     ___  Be active				    ___  Be active
-     ___  Eat better foods   			    ___  Eat better foods
-     ___  Drink less sugar drinks		    ___  Drink less sugar drinks
-     ___  Use less salt			    ___  Use less salt
-     ___  Take my medicine			    ___  Take my medicine
-     ___  Reduce my stress			    ___  Reduce my stress
-     ___  Drink less alcohol			    ___  Drink less alcohol
-     ___  Cut down on smoking		    ___  Cut down on smoking
-     ___  Get help from family & friends	    ___  Get help from family & friends
-     ___  Manage my weight			    ___  Manage my weight
-     ___  Check my blood sugar (diabetes)	    ___  Check my blood sugar (diabetes)
-     ___  Check my feet (diabetes)		    ___  Check my feet (diabetes)
-     ___  Get health check ups 		    ___  Get health check ups
-     ___  Other:  				    ___  Other:
- (Circle one thing in #6 that is most important to you.   Then go to #7 and write what you will do)

- Whiteriver Service Unit

## 7. To improve my health, I will work on one thing that I want to do.  

-    What I will do:  ________________________________________________
-    How much:  __________________________________________________
-    How often: ___________________________________________________
-    When: ______________________________________________________
- 8.  How important is doing this to me?  (circle a number)
-     Not Important    1	 2        3	   4            5             6	          7	       8	  9	10   Very Important
- 9.  How sure am I that I can do this?   (circle a number)
-      Not Sure        1	2       3	4	5             6	          7	        8	     9	10    Very Sure
- Things that might get in the way?  (barriers)   _________________________________
- 11. My follow-up plan:  ______________________________________________________________
- Signature___________________________			Date__________

- Whiteriver Service Unit

## Care Model

## Planned Care Model

**Planned Care Model**

## SMS Core Competencies

- Relationship Building
- Assessing patients’ needs, expectations and values
- Information Sharing
- Collaborative Goal Setting
- Action Planning
- Problem Solving

## If you have DIABETES, here are some things you can talk about with your  health care provider

***Choose to talk about changing any of these and add other concerns in the blank circles.***

**Blood glucose**
** ****monitoring**

**Taking medications **
**to help control**
** ****blood sugar**

**Losing weight**

**Daily foot care**

**Depression**
- 

**Smoking**

**Taking insulin**

**Diet**

- Adapted from Stott et al, Fam Practice, 1995  by Barbara Kondilis of the RI Chronic Care Collaborative

**Physical Activity**

## Simple Tools for Action Planning/Goal Setting

- _[http://](http://www.newhealthpartnerships.org/)__[www.newhealthpartnerships.org](http://www.newhealthpartnerships.org/)__[/](http://www.newhealthpartnerships.org/)_
- Diabetes Action Plan

## Why Do Our Patients Struggle?

- Almost no one is unmotivated to live a long and healthy life.
- The rewards for good self-management are relatively subtle and mostly long-term
- “If you do everything perfectly, you can expect to feel...nothing!”  What a concept to motivate a person to strive hard on a daily basis!

## Unachievable Self-Care Plans

**Unclear**
***“******I’m supposed to start exercising.”***
**Unrealistic**
***“******My doctor told me to lose 10 lbs before the next visit.”***
***“******Taking care of my diabetes means I’m supposed to eat perfectly and never cheat.”***

## Is There Time for Management of Patients With Chronic Diseases in Primary Care?

**METHODS **
- Applied guideline recommendations for 10 common chronic diseases to a panel of 2,500 primary care patients with an age-sex distribution and chronic disease prevalence similar to those of the general population, estimated the minimum physician time required to deliver high-quality care for these conditions.
**RESULTS**
- Top 10 chronic diseases (STABLE) 828 hours per year, or 3.5 hours a day
- Top 10 chronic diseases (Poor Control) 2,484 hours, or 10.6 hours a day.
**CONCLUSION?**
*Ann Fam Med *2005;3:209-214.
- Duke University Dept. of Community and Family Medicine

## Slide 34

## How can we do all this?

- How do we help patients become better partners with us and to better self-manage their chronic conditions when, as it is, we have so little time?

## Defining Tasks

## Visit Flow

- RN reviews MD’s upcoming schedule for patients with Hypertension and sends letters

- MD recruits patient during visit for SMS

**Patient declines**

**Patient accepts**

- SMS with RN

- Ask again at next visit

- MD/ RN huddle

## SMS

- RN provides SMS

- Patient’s folder

- Patient Survey

- My Care brochure

- Living Well Workshop brochure

- Negotiate follow up

- Action Plan

## Dancing vs. Wrestling

- Tips on succeeding with SMS competencies
- Open the conversation in a positive way
- Offer a menu of options
- Ask what is important to the patient
- Make a plan
- Specify to make changes clear
- Support small changes
- Ask about confidence
- Adjust the plan until success is likely

## My Health Choices 

**“****Here are the things we have talked about.  Which one is most important to work on right now?”**

- Irritating
- foods

- Walking

- Testing Blood
- Sugar

- Managing stress

- (write in others
- here)

- Write in others here

- Write in others here

## Partner ExerciseUsing an Action Plan

- Something you WANT to do
- Behavior specific
- What
- When
- How much
- How often
- Confidence level
- Follow-up plan

## Online Resources

- _[http://](http://www.improvingchroniccare.org/)__[www.improvingchroniccare.org](http://www.improvingchroniccare.org/)_
- _[http://](http://www.newhealthpartnerships.org/)__[www.newhealthpartnerships.org](http://www.newhealthpartnerships.org/)__[/](http://www.newhealthpartnerships.org/)_
- _[http://](http://www.chcf.org/topics/chronicdisease)__[www.chcf.org/topics/chronicdisease](http://www.chcf.org/topics/chronicdisease)_
- _[http://](http://www.familycenteredcare.org/)__[www.familycenteredcare.org](http://www.familycenteredcare.org/)_

## For More Information

- For more information about the Readiness Curriculum Call Series, or to provide feedback on this call or other calls, please contact:
**Tracy Jacobs, **_[tjacobs@ihi.org](mailto:tjacobs@ihi.org)_
**Pat Lundgren, **_[pat.lundgren@ihs.gov](mailto:pat.lundgren@ihs.gov)_

## Next Readiness Curriculum Call

**Learning to See:  Waste Identification and Reduction**
**Maureen Bisognano**
**Chief Operating Officer**
**Institute for Healthcare Improvement**
- Wednesday, August 27  12:00 - 1:30pm ET