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Chronic care
 

Chronic care

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  • The goal of this presentation is to show you how to manage your practice with registries. This presentation will discuss how use of health information technology and disease registries can be used to 1. (CLICK) improve health care quality,2. (CLICK) increase efficiency of health care delivery, 3. (CLICK) evaluate current prevalence of chronic disease and the interventions currently used to manage chronic disease.
  • Our hope is that you will recognize the great value of the EMR is not recording notes, but what we do with the data once we have it.
  • (CLICK) Disease registries are allowing practices to easily identify and reach out to the patients most in need, thereby delivering the high quality care that is expected of medical care. According to healthy people   "access to health care services in the United States is regarded as unreliable and many people do not receive the appropriate and timely care they need. The U.S. health care system, which is already strained, will face an influx of patients in 2014, when 32 million Americans will have health insurance for the first time.”
  • The beauty of disease registries is that they allow us to use conditional logic to evaluate a patients needs in terms of care, thereby (CLICK) improving health care quality In addition, you are able to manually add patients to a registry of your choice. For example, in our practice, we rely on a relationship with our patients that no form of technology could understand. We have used this to our advantage to create a high-risk registry for patients that are either non-compliant, clinically high-risk or high maintenance. This not only aids in quality of care, but (CLICK) efficiency. ----- Meeting Notes (10/16/12 00:25) ----- The best way is to identify the people who have the most to gain with simple interventions >> insert before we have used… hypertension- bp dm-hba1c hyperlipidemia- hdl and ldl cholesterol
  • In addition, you are able to manually add patients to a registry of your choice. For example, in our practice, we rely on a relationship with our patients that no form of technology could understand. We have used this to our advantage to create a high-risk registry for patients that are either non-compliant, clinically high-risk or high maintenance.
  • A lot of you are physicians, your job should not be to send letters and contact the patients that need follow-up appointments. This is a job that can and should be done by other members of your staff. As their chronic care coordinator, I was able to figure out the process of disease management and work with other staff members to do the same. Through delegation of these jobs and overseeing that these jobs are complete, you will play a role in 1. (CLICK) improving health care quality, 2. (CLICK) increasing efficiency of care delivery and 3. (CLICK) evaluating current prevalence of chronic disease and the interventions currently used to manage chronic disease My attempts to manage chronic disease in our practice involves constant communication with the patients. I send registry letters and make follow-up visits. In order to evaluate the current interventions in our practice that are used to manage chronic disease. I ANALYZE the RESULTS OF OUR REGISTRIES and compare these results with previous months and through collaboration with Dr. Zaid and Dr. Shively, we are able to tweak our system to better our patients.
  • A lot of you are physicians, your job should not be to send letters and contact the patients that need follow-up appointments. This is a job that can and should be done by other members of your staff. As their chronic care coordinator, I was able to figure out the process of disease management and work with other staff members to do the same. Through delegation of these jobs and overseeing that these jobs are complete, you will play a role in 1. (CLICK) improving health care quality, 2. (CLICK) increasing efficiency of care delivery and 3. (CLICK) evaluating current prevalence of chronic disease and the interventions currently used to manage chronic disease My attempts to manage chronic disease in our practice involves constant communication with the patients. I send registry letters and make follow-up visits. In order to evaluate the current interventions in our practice that are used to manage chronic disease. I ANALYZE the RESULTS OF OUR REGISTRIES and compare these results with previous months and through collaboration with Dr. Zaid and Dr. Shively, we are able to tweak our system to better our patients.
  • While the process of getting the patient into the office is one thing, the process of ensuring their time at the office is beneficial and we maintain efficiency is another. The doctor not only reviews whether or not the patient was contact by the staff for registry purposes but counsels the patients on appropriate methods to control their chronic disease. The medical assistants are now responsible for reviewing the patients overdue order and health maintenance. We have tweaked how we deal with chronic disease patients many times. A perfect system requires an evaluation of interventions used in the office and the input from all of the staff on what could be done better
  • While the process of getting the patient into the office is one thing, the process of ensuring their time at the office is beneficial and we maintain efficiency is another. The doctor not only reviews whether or not the patient was contact by the staff for registry purposes but counsels the patients on appropriate methods to control their chronic disease. The medical assistants are now responsible for reviewing the patients overdue order and health maintenance. We have tweaked how we deal with chronic disease patients many times. A perfect system requires an evaluation of interventions used in the office and the input from all of the staff on what could be done better
  • While the process of getting the patient into the office is one thing, the process of ensuring their time at the office is beneficial and we maintain efficiency is another. The doctor not only reviews whether or not the patient was contact by the staff for registry purposes but counsels the patients on appropriate methods to control their chronic disease. The medical assistants are now responsible for reviewing the patients overdue order and health maintenance. We have tweaked how we deal with chronic disease patients many times. A perfect system requires an evaluation of interventions used in the office and the input from all of the staff on what could be done better
  • While the process of getting the patient into the office is one thing, the process of ensuring their time at the office is beneficial and we maintain efficiency is another. The doctor not only reviews whether or not the patient was contact by the staff for registry purposes but counsels the patients on appropriate methods to control their chronic disease. The medical assistants are now responsible for reviewing the patients overdue order and health maintenance. We have tweaked how we deal with chronic disease patients many times. A perfect system requires an evaluation of interventions used in the office and the input from all of the staff on what could be done better
  • *Information adapted from diabetes registry at PrimeCare of Novi under the supervision and consent from Dr. Theodore Shively and Dr. Robert Zaid As a chronic care coordinator for a family practice comprised of three physicians, my goal is to reduce the number of patients on the diabetes registry through various methods. I work with a total of fifteen registries for this practice but for the purpose of this assessment, I will be analyzing data strictly for diabetes patients. Patients are placed on the diabetes registry if test results (HbA1c or random blood glucose) indicate abnormal levels. My attempts to reduce the number of people on this registry involves constant communication with the patients. I send registry letters, make follow-up visits and counsel diabetes patients in the office about appropriate methods for maintaining their blood glucose levels. I began this registry in February, 2012. On March 1 st ,192 patients met the criteria for placement on the registry. This is compared to 183 people on the registry 5 months later on August 1 st , 2012. This means that nine people were taken off of the registry. While improvements are seen throughout this data collection process, it would be naïve of the practice to assume that the reason for these improvements were solely based on our interventions. A confounding factor would be patients that left the practice… The total patients with a HbA1c of 7.0 or above in March was 66, compared to 64 in August, 2012. This means that two patients tested below a HbA1c of 7.0 which is a very good accomplishment for a patient with diabetes. This indicates that the practice is maintaining control over the blood sugars of their diabetes patients. As a method of determining the effectiveness of the registry letters, the number of letters that were sent to patients with a HbA1c of 7.0 or higher who have not been seen within 3 months was counted. This was 34 in March, 2012 and decreased to 23 in August, 2012. In other words, 11 people were seen who otherwise had not been seen within 3 months of their last appointment. Protocol in this practice requires diabetes patients be seen every three months to evaluate the disease. Confounding factors should be addressed. These factors may play a role in the findings and cannot be ruled out. For example, a patient may have already intended to come into the office for a visit, regardless of whether or not this letter was sent.

Chronic care Chronic care Presentation Transcript

  • Chronic Disease ManagementYourLogo Ihr Logo
  • Disease Registries can: Improve health care quality Increase efficiency of care delivery Evaluate current interventions YourLogo Ihr Logo
  • Meeting These Goals Improve health care quality Increase efficiency of care delivery Evaluate current interventions Your Logo
  • Meeting These Goals Improve health care quality Your Logo
  • Disease registries areallowing practices toeasily identify and reachout to the patients mostin need, therebydelivering the highquality care that isexpected of medical care. Improve health care quality Increase efficiency of care delivery Here co Evaluate current interventions mes you r fo o t er  Page Your Logo 5
  • Registry Format Sorted by Lab Data Here co mes your f oote r  P age Your Logo 6
  • Registry Format Sorted by Lab Data Here co mes your f oote r  P age Your Logo 7
  • Registry Format Sorted by Lab Data Here co mes your f oote r  P age Your Logo 8
  • Registry Format Sorted by Lab Data Here co mes your f oote r  P age Your Logo 9
  • Meeting These Goals Identify the Patients at the Greatest Risk Improve health care quality Increase efficiency of care delivery Your Logo
  • Meeting These GoalsManually add patients Identify the Patients at theto a registry of yourchoice Greatest RiskHigh risk patientsNon-compliantClinically high-risk Improve health care quality Increase efficiency of care delivery Your Logo
  • Meeting These Goals Delegate and Oversee Improve health care quality Increase efficiency of care delivery Evaluate current interventions Your Logo
  • Meeting These Goals•Chronic care coordinator•Other Staff Delegate and Oversee•Meet with them often toaddress any concerns,complications or neededchanges Improve health care quality Increase efficiency of care delivery Evaluate current interventions Your Logo
  • Meeting These Goals Ensure Continuity of Care Improve health care quality Increase efficiency of care delivery Evaluate current interventions Your Logo
  • Meeting These GoalsRegistry Letters Your Logo
  • Meeting These GoalsRegistry Letters Your Logo
  • Meeting These GoalsRegistry Letters Your Logo
  • Your Logo
  • That’s a wrap… And don’t forget thatwhile you’re doing this: Your Logo
  • That’s a wrap…I’m doing this: Your Logo
  • Questions? Your Logo