Transcript Shirl Johnson, DNP, MSN, RN - Patient

“Knowing Your Population”
Health System Performance
Improvement
Shirl Johnson, DNP (c ) RN, MSN, CNS, MHA
OBJECTIVES
• Describe the challenges encountered, across
the continuum of care, associated with
managing patients with chronic disease.
• Discuss current strategies for improving the
patient’s transition from one care setting to
another.
Challenges with Managing Chronic Disease
• By 2020, the number of people with
chronic disease is projected to grow to an
estimated 157 million, with 81 million
having multiple conditions.
• More than 75% of all health care costs are
due to chronic conditions.
• The average cost of having one or more
chronic conditions are 5 times greater than
for someone without any chronic
conditions.
• Chronic diseases causes 7 out of every 10
deaths.
Challenges with Managing Chronic
Disease
• Driving significant cost: Hospitalization, ED utilization
• Who is managing care : “ Primary Care Physician or
Specialists”
• Lack of disease knowledge and skills for self
management
• Complicated drug regimens
Historical Gaps in Care Transition
• Historical silos between hospitals,
Rehabilitation, Skilled Nursing
Facilities, Home Health Agencies
• Fragmented reimbursement
• Poor hand- off to next site of care
• Not including patient/family in
informed decision making
Where Do We Go From Here?
Population Management
Leverage Electronic Medical Record:
– Data Mining: Predictive Analytics
– Identification of patients at risk
– Patient registries identify pts with
chronic diseases
• Interviewing the patient and or
family
• Methods of patient engagement
– Motivational Interviewing
• Transition to multi-disciplinary
resource to ambulatory settings
– Nurse Navigators, Social workers
Predictive
Modeling
Interviewing
patients
Chart
Reviews
Rx Claims
Risk
Stratification
EHR
PCMH (Patient Centered Medical Home)
primary care provider led
“model of care that strengthens the clinician-patient relationship by
replacing episodic care with coordinated care and a long-term healing
relationship.”
CRITICAL SUCCESS FACTORS FOR CARE
TRANSITION
1
• Interdisciplinary health care - a high degree of collaboration and
communication
2
• Handoff of patients between Acute and Post-Acute that involves
more than just the exchange of paperwork but physician to
physician communication
3
• No Gaps in Care – no longer working in silos but instead as true
partners in the entire care continuum
4
• PARTNERSHIP – driven by Health Systems, to help patients/ families
make decision
5
6
• Medication Management- implement meds to bed program
• Patient/Family- assessment and engagement, plan of care,
proactive decision making
Personal Touch to Patient Care
• Understanding the
patient and family
dynamics
• Patient engagement
• Advance care planning
with the patient and or
family
• Sharing information
with next care settings
We must face the epidemic of chronic
diseases. If we don’t, the human costs will
continue to soar. We might even face a lack of
available or affordable care when it is needed
most.
Centers for Disease Control and Prevention. Chronic Disease Overview, 2007
Questions