Transcript Document
Making Community Connections: Chronic Disease Self-Management Education in FQHCs Christine Katzenmeyer Executive Director Consortium for Older Adult Wellness Lakewood, Colorado Lynnzy McIntosh, Vice President/Implementation Director Consortium for Older Adult Wellness Lakewood, Colorado Learning Objectives • • • • To assist you in initiating, or further developing, a chronic disease self-management program within a Federally Qualified Health Center. To discuss the connection between chronic disease selfmanagement education and patient centered medical home recognition. To improve the quality of health care by fostering a collaborative interaction between patients, providers, and community-based organizations. To discuss COAW’s statewide initiative with FQHCs and patient-centered medical homes and success stories. Who Are We? • • • • • COAW: A 501(c)(3) non-profit organization founded in 2001 by Colorado Gerontologist, Christine Katzenmeyer. A statewide consortium with 90+ partnering organizations/agencies across Colorado. Expertise focusing on healthy aging of the older adult; provision of evidence-based training to health professionals and lay leaders on Falls Prevention and Self-Management. Expertise in practice transformation and the art and science of Self-Management Support. Evidence-based offerings include: 1) Healthier Living Colorado™ (CDSMP), 2) N’Balance™, 3) Tai Chi for Falls Prevention, 4) Matter of Balance ™, and 5)Stepping On ™. What is Self-Management? The tasks that individuals must undertake to live well with one or more chronic conditions. These tasks include having the confidence to deal with medical management, role management and emotional management of their conditions. Institute of Medicine 2004 How does Self-Management work within Healthcare Transformation, Patient Centered Medical Home (PCMH), Patient Activation, any YOUR organization? Self-Management and PCMH Recognition • 2011 Version Reinforces the critical role of patient Self-Management and practice SelfManagement Support • Document Self-Management capabilities • Document Self-Management goals; provide tools and resources • Counsel on healthy behaviors • Assess/provide/arrange for mental health/substance abuse treatment • Provide community resources Engaging the patient is the ONLY way to successfully impact clinical outcomes… as opposed to process measures. CDSMP as a Key Component of NCQA PCMH Standards PCMHI: Access and Continuity D. Use of Data for Population Management F. Culturally and Linguistically Appropriate Services PCMH4: Provide Self-Care Support and Community Resources (Must Pass) A. Support Self-Care Process B. Document Goals, Ability, SelfManagement Tools, Referrals to Community Resources PCMH2: Identify and Manage Patient Populations C. Patient Panels, Comprehensive Health Assessment PCMH5: Track and Coordinate Care B. Referral Tracking and Follow-Up C. Coordinate with Facilities/Care Transitions PCMH3: Plan and Manage Care B. Identify High-Risk Patients C. Care Management, Pre-Visit Planning, Treatment Plan and Goals, Identify Barriers D. Manage Medications PCMH6: Measure and Improve Performance B. Measure Patient/Family Experience E. Report Performance A nonprofit service and advocacy organization © 2012 National Council on Aging 7 What makes a self-management program work for you…and your patient? • Designed to enhance medical treatment. • Evidence-based: a tested model-intervention that has demonstrated, replicable results. • Use multiple strategies and interventions. • Empower (activate) patients to increase control. • Promote collaboration among providers, organizations, individuals, families, caregivers and community. • Resources need to have a fidelity component to ensure that programs are being delivered to achieve the proven outcomes. Why CDSME? Over 20 years of proven impact ‘Gold standard’ of evidence-based programming Offered locally and worldwide Available in 21 languages Premise – people with ongoing health conditions Have similar concerns and problems Deal not only with their condition, but its impact on their lives and emotions Lay Leaders teach the workshop as effectively as health professionals CDSMP 6 Week Class Series Exercise and nutrition Medication usage Stress management Talking with your doctor Dealing with emotions and depression Action Planning! CDSMP Benefits to the Practice •External resource •No need to re-create the wheel •Reinforces communication “feedback loop” •Documents self-management in PCMH terms •Documents the shift in patient interaction •Quality measures •Delivery of data to practice •Patient activation and patient engagement •Increase in patient confidence levels Results- Federally Qualified Health Centers •10 new FQ sites in collaboration with the CCHN. •6 FQs now active, 4 in winter of 2012. •Range from large multi-site, to small one-site clinics. •8 of the 10 practices will have classes in English and Spanish. •5 of 10 now offering classes on site with provider referrals. •5 of 10 now have at least one CDSMP trained staff member. •Clinical and front office involvement in referrals. •Transportation is an issue. Referral Results •26 % of all COAW attendees in CDSMP are referred by physicians •Recent project started with 10 new internal medicine clinics in Denver’s Front Range •Practices ranged from single provider, to single location to a large multi-site FQ practice •Practices requested classes in Spanish •All classes are on their sites •Roughly 52% of referrals attended first available CDSMP class. •Additional % enrolled in the next class •Referrals continuing, no one has said “no” •Transportation is a major issue, 40% of practices •Communication within the practice is an issue. The Process and the Details Provider uses letter in followup with patient in goal-setting. COAW and Clinic meet to discuss selfmanagement. Clinician introduces CDSMP opportunity to patient. Leader mails week six letters to providers. Patient agrees and signs referral form. As part of the CDSMP program, patient writes a letter to provider describing what he/she has learned. Referral form faxed to COAW. Patient attends CDSMP. COAW communicates with practice weekly regarding patients who decline scheduling for class. COAW Coordinator contacts referred patient and enrolls in class. Feedback Form Referral Form Feedback Form My Name___ Mary Smith_____________ Today’s Date__ January 8, 2012_____ Dear Health Care Providers, I wanted to let you know that I have been attending the Healthier Living Colorado™ class to help me better manage my own health. Today we are in our final class of the 6 weekly sessions and we are sending you our thoughts about our chronic conditions, taking care of ourselves, and what we want our Health Care Providers to know about what we are learning and doing. What I have learned about my health is: This isn’t going to go away just because I take a pill three times a day. I can make some changes in how I deal with the pain. Eating a few more fruits has helped my digestion. I didn’t know that my chronic condition was affected by: Worrying about what I can’t do won’t help me any. I need to fix my sights on what I enjoy doing. I am working on being more positive. It has been nice to talk with others with similar concerns. The things that have helped me the most to manage my chronic conditions are: Exercising a little more has helped my knees. I am going to keep with it and maybe take a water exercise class. I’ve been using a pill box so I keep track of when I am taking the pills better—I didn’t know it would hurt me to skip some. My Action Plan for the next six months is: Long term goal: This is my life and I want to stay as healthy as I can for as long as I can. I want to lower my blood pressure so I can be here to see my grandkids graduate from college Specific action step: Walk with a neighbor to the library and back. How much/often? 3 times a week Confidence Level (0-10): When? Monday, Wednesday and Saturday 9 COAW will forward this letter to your provider listed below: My health care provider’s name and address is: Dr. Smart 1234 Main St. Denver 80202 Consortium for Older Adult Wellness 2575 S. Wadsworth Blvd. Lakewood, CO 80227 888-900-COAW(2629) Fax: 303-984-5962 [email protected] Thank You! Christine Katzenmeyer, Executive Director [email protected] Lynnzy McIntosh, Vice President/Implementation Director [email protected] 303-984-1845, 888-900-2629 www.COAW.org [email protected]