The faculty have no conflict of interest with regard to
any information presented, and will not endorse any
specific produ...
 Discuss Current Healthcare System
 Describe Wagner’s Integrated Chronic Care Model
 Describe the Care Delivery Practic...
 2/3 of the nations hospitals will be penalized in Medicare's
campaign to reduce the number of patients admitted in
one m...
Meet
Harold…
 Fragmented health system
 Increasing incidents of chronic disease
 Complexity of care
 Acute based system
 Poor tran...
 Poorly controlled disease
 Increased avoidable Re-Hospitalizations and
ED visits
 Unnecessary changes in treatment
 I...
3%
16%
26%
23%
15%
6%
11%
No Physician
1 Physician
2 Physicians
3 Physicians
4 Physicians
5 Physicians
6+ Physicians
Sourc...
50
40
30
20
10
0 1 2 3 4 5
3.7
10.4
17.9
24.1
33.3
49.2
Number of Chronic Conditions
Source: Anderson, G; Chronics Conditi...
 Patients understanding and adherence to medication
instructions is a key factor in avoiding a return to the
hospital 8
...
Person
Centered
 Goals Drive Care
Member of Team
Dignity & Respect
Evidence Based
Clinical
Engagement/Self
Managing Sup...
John Charde, MD, VP Strategic Development, Enhanced Care Initiatives, Inc. (April 2006)
Source: “Improving Primary Care for Patients with Chronic
Illness”, Bodeheimer, Wagner, Grumbach, Jama, October 9, 2002, V...
Relationships/ Patient Centered:
•Holistic Assessments
•Trust Building
•Patient Engagement
•Face to Face Visits
Self-Manag...
Expertise/Coordination:
•Patient is “expert” of self
•Evidence based care delivery
•Interdisciplinary team
•Learning Envir...
 Provides an avenue for health care professionals from
various disciplines to meet and discuss issues and best
practices ...
“Life is a pond.
We are all
pebbles. Never
underestimate
the difference one
pebble can make.”
Hardwiring Excellence
Quint ...
In Search of What Works: Re-Defining Post Acute Partnerships to Reduce Readmissions, Using the Integrated Chronic Disease ...
In Search of What Works: Re-Defining Post Acute Partnerships to Reduce Readmissions, Using the Integrated Chronic Disease ...
In Search of What Works: Re-Defining Post Acute Partnerships to Reduce Readmissions, Using the Integrated Chronic Disease ...
In Search of What Works: Re-Defining Post Acute Partnerships to Reduce Readmissions, Using the Integrated Chronic Disease ...
In Search of What Works: Re-Defining Post Acute Partnerships to Reduce Readmissions, Using the Integrated Chronic Disease ...
In Search of What Works: Re-Defining Post Acute Partnerships to Reduce Readmissions, Using the Integrated Chronic Disease ...
In Search of What Works: Re-Defining Post Acute Partnerships to Reduce Readmissions, Using the Integrated Chronic Disease ...
In Search of What Works: Re-Defining Post Acute Partnerships to Reduce Readmissions, Using the Integrated Chronic Disease ...
In Search of What Works: Re-Defining Post Acute Partnerships to Reduce Readmissions, Using the Integrated Chronic Disease ...
In Search of What Works: Re-Defining Post Acute Partnerships to Reduce Readmissions, Using the Integrated Chronic Disease ...
In Search of What Works: Re-Defining Post Acute Partnerships to Reduce Readmissions, Using the Integrated Chronic Disease ...
In Search of What Works: Re-Defining Post Acute Partnerships to Reduce Readmissions, Using the Integrated Chronic Disease ...
In Search of What Works: Re-Defining Post Acute Partnerships to Reduce Readmissions, Using the Integrated Chronic Disease ...
In Search of What Works: Re-Defining Post Acute Partnerships to Reduce Readmissions, Using the Integrated Chronic Disease ...
In Search of What Works: Re-Defining Post Acute Partnerships to Reduce Readmissions, Using the Integrated Chronic Disease ...
In Search of What Works: Re-Defining Post Acute Partnerships to Reduce Readmissions, Using the Integrated Chronic Disease ...
In Search of What Works: Re-Defining Post Acute Partnerships to Reduce Readmissions, Using the Integrated Chronic Disease ...
In Search of What Works: Re-Defining Post Acute Partnerships to Reduce Readmissions, Using the Integrated Chronic Disease ...
In Search of What Works: Re-Defining Post Acute Partnerships to Reduce Readmissions, Using the Integrated Chronic Disease ...
In Search of What Works: Re-Defining Post Acute Partnerships to Reduce Readmissions, Using the Integrated Chronic Disease ...
In Search of What Works: Re-Defining Post Acute Partnerships to Reduce Readmissions, Using the Integrated Chronic Disease ...
In Search of What Works: Re-Defining Post Acute Partnerships to Reduce Readmissions, Using the Integrated Chronic Disease ...
In Search of What Works: Re-Defining Post Acute Partnerships to Reduce Readmissions, Using the Integrated Chronic Disease ...
In Search of What Works: Re-Defining Post Acute Partnerships to Reduce Readmissions, Using the Integrated Chronic Disease ...
In Search of What Works: Re-Defining Post Acute Partnerships to Reduce Readmissions, Using the Integrated Chronic Disease ...
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In Search of What Works: Re-Defining Post Acute Partnerships to Reduce Readmissions, Using the Integrated Chronic Disease Care at Home Model

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In Search of What Works: Re-Defining Post Acute Partnerships to Reduce Readmissions, Using the Integrated Chronic Disease Care at Home Model
Ms. Ann Rodriguez-McConnell, R.N.

Mano y Corazón Binational Conference of Multicultural Health Care Solutions, El Paso, Texas, September 27-28, 2013

Published in: Health & Medicine, Business
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In Search of What Works: Re-Defining Post Acute Partnerships to Reduce Readmissions, Using the Integrated Chronic Disease Care at Home Model

  1. 1. The faculty have no conflict of interest with regard to any information presented, and will not endorse any specific products or specific service vendor.
  2. 2.  Discuss Current Healthcare System  Describe Wagner’s Integrated Chronic Care Model  Describe the Care Delivery Practice  Define Self Management Support  Discuss Principles of Adult Learning  Discuss Health Literacy  Discuss the Principles of Motivational Interviewing  Discuss Goal Setting
  3. 3.  2/3 of the nations hospitals will be penalized in Medicare's campaign to reduce the number of patients admitted in one month. 1  Medicare identified 2,225 hospitals that will have payments reduced for one year starting October 1, 2013. 2  Hospitals that treated large number of low income patients were more likely to penalized than those treating the fewest impoverished people. 3  Averting 1 out of every 10 of those returns [Re-Admissions] could save Medicare $1Billion dollars. 7  Solutions involve a coalition of post-acute providers to work collaboratively, breakdown silos, and get patients to the right care setting. 4
  4. 4. Meet Harold…
  5. 5.  Fragmented health system  Increasing incidents of chronic disease  Complexity of care  Acute based system  Poor transitions  Language barriers  Changing healthcare landscape  Patient labeled “non-compliant”  What a patient does at home is different than what the doctor ordered  Uncoordinated care
  6. 6.  Poorly controlled disease  Increased avoidable Re-Hospitalizations and ED visits  Unnecessary changes in treatment  Increase incidences of Chronic Disease  Miscommunication and Confusion  Medication mismanagement  Non Adherence and non-compliance  Lack of follow up/Missed MD Visits
  7. 7. 3% 16% 26% 23% 15% 6% 11% No Physician 1 Physician 2 Physicians 3 Physicians 4 Physicians 5 Physicians 6+ Physicians Source: Anderson, G: Chronic Conditions: Making the Case for Ongoing Care, Johns Hopkins University; November 2007 @2010 Penta Health (All Rights Reserved)
  8. 8. 50 40 30 20 10 0 1 2 3 4 5 3.7 10.4 17.9 24.1 33.3 49.2 Number of Chronic Conditions Source: Anderson, G; Chronics Conditions: Making the Case for Ongoing Care; Johns Hopkins University ; November 2007
  9. 9.  Patients understanding and adherence to medication instructions is a key factor in avoiding a return to the hospital 8  The Home Health Quality Improvement (HHQI) National Campaign helps home health stakeholders and multiple health care settings improve medication management and reduce avoidable re-hospitalizations. 9  www.homehealthquality.org  The campaign offers free Best Practice intervention packages (BPIPs)  “Fundamentals of Reducing Acute Care Hospitalizations”  “Improving Management of Oral Medications”
  10. 10. Person Centered  Goals Drive Care Member of Team Dignity & Respect Evidence Based Clinical Engagement/Self Managing Support Transitions Coordinated Time Settings Providers Better Care, Better Health, Lower Cost
  11. 11. John Charde, MD, VP Strategic Development, Enhanced Care Initiatives, Inc. (April 2006)
  12. 12. Source: “Improving Primary Care for Patients with Chronic Illness”, Bodeheimer, Wagner, Grumbach, Jama, October 9, 2002, Vol. 288, No.14
  13. 13. Relationships/ Patient Centered: •Holistic Assessments •Trust Building •Patient Engagement •Face to Face Visits Self-Management support: •Patient specific SMART goals •Motivational Interviewing •Facilitation of behavior change •Problem Solving
  14. 14. Expertise/Coordination: •Patient is “expert” of self •Evidence based care delivery •Interdisciplinary team •Learning Environment •SBAR Communication Technology/Decision Support: •Early Identification of Exacerbation •Positive reinforcement & SMS •Meaningful data exchange •Make “right thing to do the easy thing to do”
  15. 15.  Provides an avenue for health care professionals from various disciplines to meet and discuss issues and best practices for reducing hospital readmissions. 5  It breaks down barriers by giving health care providers a look into what's involved in other providers’ roles and a view of the complete information needed to achieve well-coordinated, patient–centered care. 6  Examples:  University Medical Center RHP 15  Sierra Providence Post Acute Coalition Committee (PACC)  Mano y Corazon Conference 2013  Southwest Association for Healthcare Quality (SWAHQ)  Project Amistad (Community-based Care Transitions Health Coaches)
  16. 16. “Life is a pond. We are all pebbles. Never underestimate the difference one pebble can make.” Hardwiring Excellence Quint Studer

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