Jeffrey Harris             Untangled Healthcare             Jeffrey Halbstein-Harris             Untangled Healthcare     ...
Syllabus1. Defining a persons needs and the evolving National Health Information   Infrastructure    1. Defining an emergi...
Untangled Healthcare Patient Advocacy Series                       Part Two     1. Samples of Levels of Support        Bas...
Untangled Health PatientsHave various support needs based on our social and physical, mental and social health            ...
The Patient Advocate Process                           Assist with                           reporting                  Bi...
Discovery•   disease mastery•   psycho-social stability•   patients knowledge•   functional status dimensions11/23/2011   ...
Functional Domains                                Cognition                             Problem Solving                   ...
Activate• If no insurance: Find a program e.g.  Medicaid, Safety Net Sliding Fee, Health  Choice, Insurance Exchange in 20...
Assist• Evaluate patient defined needs and goals:• Educational barriers• Educational Plan• Address functional deficits in ...
Education• Take learning barriers into account and use assistive  tools where necessary e.g. times medication  dispensing ...
Evaluate• Review care plan with patient• Make sure patient adds you to care team so you can access records  in patient por...
Monitor• Set up monitoring schedule with patient with goal  for complete independence if possible.• Teach patient to self ...
Case ExampleReal Life 2011In two years she:1. Was a victim of domestic     violence2. Transitioned from military to     pu...
Patient Medical Home or Procedural               Contracting11/23/2011                               14
Use Case: Care Coordination, Management and AdvocacyMiddle Aged Chronically Ill Woman Migrating To NC from Florida’s Safet...
Given patient status how would the present clinical world       find all of this information during assessment?           ...
The Patient Advocate Process                           Assist with                           reporting                  Bi...
Discovery and Documentation of                BaselineObjective:                                  My Medicare.Gov1. Gather...
Assemble on-line health record                  A repository that connects to multiple systems                    A PHR th...
Patient Information Flow In Sample      Patient Advocacy Case             Primary Portal To Patient                   Info...
Final Outcome         Combined Mayo           Transported Patient to UNC HealthCare with         PHR with Manual          ...
Advocates Care Plan11/23/2011                         22
Care Plan ElementsSummary11/23/2011                        23
Plan of care11/23/2011                  24
Weekly priorities11/23/2011                       25
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Untangled healthcare lecture series patient advocacy part two support and use cases

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Part two of patient advocacy series includes process and actual case

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Untangled healthcare lecture series patient advocacy part two support and use cases

  1. 1. Jeffrey Harris Untangled Healthcare Jeffrey Halbstein-Harris Untangled Healthcare Assisting communities to monitor and improve healthcare 919 627-5038 Cell 919-779-7368 Office Fax 888 783-6178 (Jeffrey Harris) email: JeffHarris@untangledhealthcare.com LinkedIn: http://www.linkedin.com/in/untangledhealth Blog: http://www.untangledhealth.com/ Website: http://www.untangledhealthcare.com/ Twitter: http://twitter.com/UntangledHealth Slide share: http://www.slideshare.net/jeffharris7511/23/2011 1
  2. 2. Syllabus1. Defining a persons needs and the evolving National Health Information Infrastructure 1. Defining an emerging Health Information Technology within the context of the US HealthCare System2. Support , Process and Use Case 1. Samples of Levels of Support Based on Functional Status 2. The Advocates Process 3. Real Use Case 20113. Personal Health Records 1. Selection 2. Components 3. Security 4. Process4. A Transition Model5. Why We Do It11/23/2011 2
  3. 3. Untangled Healthcare Patient Advocacy Series Part Two 1. Samples of Levels of Support Based on Functional Status 2. The Advocates Process 3. Real Use Case 201111/23/2011 3
  4. 4. Untangled Health PatientsHave various support needs based on our social and physical, mental and social health status Care Cycle Ultimately we need major help in planning our lives Assess At times our conditions become unstable , andMonitor Plan barriers to ‘getting better’ include lack or Care <management Our Health-Care support and a lack of understanding on how to Level of Assistance Needed Coordinate Plan System ‘STEPS manage multiple problems UP’ and manages Educate our conditions As we age and sometimes sooner we develop Care Coordination and Education uncomplicated chronic Drs and their staff conditions and monitoring collaborate, coordinate, WE ALL HAVE needs teach and coach us, addressing ALL OF OUR Primary and Secondary Prevention Rights PROBLEMS Sometimes we have acute Supported Self Management: temporary conditions Engaged by our doctors and assisted by their staff Informed Self Service : Education and Self Service Instructions Usual Care: Diagnosis & Treatment Services Our Life Span 11/23/2011 4
  5. 5. The Patient Advocate Process Assist with reporting Bio-Psycho-Social History outcomes to Discover Goals, Wants, Needs PCP Functional Status Physical Social Insurance Exchange Cognitive Monitor Activate Primary Care Compliance Comorbidity Medical Home Patient Contract Patient Compliance Disease Self Mastery Identify and link Learning Barriers community resources: Evaluate Assist Transportation, Meals on Wheels, Patient Peers Primary and Secondary Prevention Self Monitoring Resource Utilization Educate Urgent Care Guidelines Communication Skills11/23/2011 5
  6. 6. Discovery• disease mastery• psycho-social stability• patients knowledge• functional status dimensions11/23/2011 6
  7. 7. Functional Domains Cognition Problem Solving Memory Communication Psychosocial Expression Emotional Status Comprehension Adjustment To Limitations Reading Self Care Mobility Eating Transfers Elimination Grooming Toilet Bathing Shower Sphincter Control Dressing Car Bladder Toileting Locomotion Bowel Swallowing Walking/Wheelchair/St airs11/23/2011 Community Mobility 7
  8. 8. Activate• If no insurance: Find a program e.g. Medicaid, Safety Net Sliding Fee, Health Choice, Insurance Exchange in 2014• Patient and advocate select a PCP who claims to be a Primary Care Medical Home• During first visit: Suggest a compliance contract between patient and physician e.g. first point of contact unless life threatening event• Set follow up dates and responsibilities (COACH)11/23/2011 8
  9. 9. Assist• Evaluate patient defined needs and goals:• Educational barriers• Educational Plan• Address functional deficits in ADLs and IADLs• Connect to community resources• Connect to peer support• Follow-up several times per week in first month then decrease encounter frequency11/23/2011 9
  10. 10. Education• Take learning barriers into account and use assistive tools where necessary e.g. times medication dispensing containers. Connect patient with pharmacist if on more than five medications.• If patient is responsive to internet health records set up a PHR that exchanges data with physicians PHR or Microsoft Health Vault if Physician has not installed e- HR yet.• Otherwise create a paper based notebook that is the perpetual record of care and interventions and outcomes.• Test learning by return demonstration at least one week post educational sessions.• Don’t be afraid to involve family and friends11/23/2011 10
  11. 11. Evaluate• Review care plan with patient• Make sure patient adds you to care team so you can access records in patient portal at hospitals and practices and PHRs.• First things first: What is highest priority – Medication reconciliation with no gaps in long term medication fills without physician order – All testing appointments completed on time – All follow up appointments completed on time – Lifestyle changes are beginning to migrate into patients way of living – Quantify use of hospital or ER services for inappropriate reasons and try to define precipitating factors e.g. physician not available – Compare medications to insurance formulary and if physician agrees switch patient to lower tier medications to reduce cost for patient and insurance company – Assess any new functional limitations e.g. balance in the elderly and visual acuity.11/23/2011 11
  12. 12. Monitor• Set up monitoring schedule with patient with goal for complete independence if possible.• Teach patient to self record data from home medical devices and PHR tools.• Teach patient how to use secure communication tools with provider and yourself• When comfortable discharge with assurance of your availability when needed.• Send report to physician. If physician using e-HR and patient portal ask about submitting report through portal.11/23/2011 12
  13. 13. Case ExampleReal Life 2011In two years she:1. Was a victim of domestic violence2. Transitioned from military to public health systems3. Was treated by 12 physicians and surgeons and behavioral health specialists4. Was placed on twenty two different medications some of which were within the same class and directly contraindicated5. Lost her ability to think clearly6. Lost her family7. So here we are. • Our friend with her treatment records and medicine during data collection step11/23/2011 13
  14. 14. Patient Medical Home or Procedural Contracting11/23/2011 14
  15. 15. Use Case: Care Coordination, Management and AdvocacyMiddle Aged Chronically Ill Woman Migrating To NC from Florida’s Safety Net Patient Classification: Demographic: 50 y/o Caucasian female Bio- Complex comorbidity (degenerative spinal disease, acute trauma with questionable TBI, constellation of auto immune diseases Psycho- History of episodic substance abuse ETOH and prescription narcotics, depression, PTSD Social- Indigent, Income= $1300/MO; homeless; divorce in process, domestic violence victim, Medicare dually eligible SSDI, Post graduate degree in behavioral health Functional- Mental: Cognitive defects memory and executive function Physical: Chronic pain limitations to locomotion and IADL Summary: Can’t work, can’t drive, can’t think = NO HOPE11/23/2011 15
  16. 16. Given patient status how would the present clinical world find all of this information during assessment? Patient interview Patient SS Dept. attempt to locate data found on Repeated testing to R/O dx street in North Hospital Critical Path Carolina Discharge to community New Medical History Variant Patient ER Disconnected from future episodes Visit Patient Acute Admission Subjected to DC Planning Process DC next lower level care Classic Scenario Poor transition management No portable record11/23/2011 16
  17. 17. The Patient Advocate Process Assist with reporting Bio-Psycho-Social History outcomes to Discover Goals, Wants, Needs PCP Functional Status Physical Social Insurance Exchange Cognitive Monitor Activate Primary Care Compliance Comorbidity Medical Home Patient Contract Patient Compliance Disease Self Mastery Identify and link Learning Barriers community resources: Evaluate Assist Transportation, Meals on Wheels, Patient Peers Primary and Secondary Prevention Self Monitoring Resource Utilization Educate Urgent Care Guidelines Communication Skills11/23/2011 17
  18. 18. Discovery and Documentation of BaselineObjective: My Medicare.Gov1. Gather as much as possible and filter for sentinel information Claims extract 1. Diagnosis 2. Procedures 3. Providers 4. Medications 5. Hospitalization Episodes2. Store Data in secure online Good for preventive svcs, repository with proven connectors to providers EMRs, PHRs and Vendor Hubs e.g. Hospitalizations and visits. Quest, CVS Microsoft HealthVault – Central Cloud Data Repository – Using Standardized Clinical Mode Mayo Clinic Personal Health Record11/23/2011 18
  19. 19. Assemble on-line health record A repository that connects to multiple systems A PHR that has built in decision support Established Mayo Clinic Attempt to connect Health- Test Successful PHR and completed data Vault to Mayo Clinic PHR entry for patient CVS used Mayo PHR as Summary Pharmacy of Record choice11/23/2011 19
  20. 20. Patient Information Flow In Sample Patient Advocacy Case Primary Portal To Patient Information11/23/2011 20
  21. 21. Final Outcome Combined Mayo Transported Patient to UNC HealthCare with PHR with Manual Summary Documents and Films Clinical Summary Patient Team Today Mayo PHR Primary Care MD Psychiatrist Health Medicare Vault Physiatrist Patient Behavioral Health Program Portable Health Record Medications Start = >20 CVS UNC Today = 8 Functional Status Independent all IADL Self transportation Self perceived health status improved11/23/2011 21
  22. 22. Advocates Care Plan11/23/2011 22
  23. 23. Care Plan ElementsSummary11/23/2011 23
  24. 24. Plan of care11/23/2011 24
  25. 25. Weekly priorities11/23/2011 25

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