Patient Centered Medical Home; The Army Medical Department Experience


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  • AUSA Family Forum Brief
  • Patient Centered Medical Home; The Army Medical Department Experience

    1. 1. Patient Centered Medical Home<br />The Army Medical Department Experience<br />29 April 2011<br />Gary A. Wheeler, MD, COL<br />Western Regional Medical Command CMIO<br />
    2. 2. “The views expressed are those of the author and do not reflect the official policy of the Department of the Army, the Department of Defense or the U.S. Government.”<br />Slide 2 of <br />
    3. 3. Board Certified, Internist<br />Fellow, American College of Physicians<br />Education: BS, UC Berkeley; MD, USUHS<br />Residency: Walter Reed Army Medical Center<br />Member, Army Medical Department PCMH WG<br />Internal Medicine Consultant, OTSG<br />Past jobs:<br />Department Chief, Madigan Army Medical Center<br />Deputy Commander for Clinical Services (CMO), Weed ACH<br />Chief, Clinical Informatics, MAMC<br />Chief, Internal Medicine Service, MAMC<br />Staff Internist, Walter Reed; Moncrief ACH, Ft Jackson, SC<br />Who Am I?<br />
    4. 4. Terminal Learning Objectives<br />Define Patient Centered Medical Home<br />Understand PCMH History<br />Identify principles of patient centered care<br />Review the current evidence for patient-centered care<br />Review the 2008 and 2011 NCQA standards<br />Review PCMH implementation in the Army Medical Department<br />Introduce the Comprehensive Care Plan<br />PATIENT CENTERED MEDICAL HOME<br />
    5. 5. PATIENT CENTERED MEDICAL HOME<br />Definition<br /><ul><li> Medical home, also known as Patient-Centered Medical Home (PCMH), is defined as "an approach to providing comprehensive care that facilitates partnerships between individual patients and their personal providers and when appropriate, the patient’s family”</li></li></ul><li>PATIENT CENTERED MEDICAL HOME<br />History<br /><ul><li> American Academy of Pediatrics introduced the term in 1967
    6. 6. Model in caring for children with special needs
    7. 7. Single source of patients’ medical information (medical record)
    8. 8. Grew to include a partnership approach with families to provide primary health care
    9. 9. Accessible
    10. 10. Family-centered
    11. 11. Coordinated
    12. 12. Comprehensive
    13. 13. Continuous
    14. 14. Compassionate
    15. 15. Culturally effective
    16. 16. Within a decade it was AAP policy</li></li></ul><li>PATIENT CENTERED MEDICAL HOME<br />History<br /><ul><li> Joint Statement of PCMH Principles – March 2007
    17. 17. Four groups
    18. 18. American Academy of Family Physicians (AAFP)
    19. 19. American Academy of Pediatrics (AAP)
    20. 20. American College of Physicians (ACP)
    21. 21. American Osteopathic Association (AOA)
    22. 22. Represent 333,000 physicians
    23. 23. Provide the vast majority of primary care services to children, adolescents, and adult patients in the United States.</li></li></ul><li>PATIENT CENTERED MEDICAL HOME<br />History - 2007 Joint Statement Principles<br /><ul><li> Personal physician
    24. 24. Physician directed medical practice
    25. 25. Whole person orientation
    26. 26. Care is coordinated and/or integrated across all elements of the complex health care system
    27. 27. Quality and Safety
    28. 28. Enhanced Access to Care
    29. 29. Payment appropriately recognizes the added value</li></li></ul><li>PATIENT CENTERED MEDICAL HOME<br />Personal Physician<br /><ul><li> Primary care physician
    30. 30. Could be a specialist or subspecialist for patients requiring ongoing care for certain conditions
    31. 31. Severe asthma
    32. 32. Complex diabetes
    33. 33. Complicated cardiovascular disease
    34. 34. Rheumatologic disorders
    35. 35. Malignancies
    36. 36. HIV
    37. 37. Primary care physicians are defined as physicians who are trained to provide first-contact, continuous, and comprehensive care</li></li></ul><li>PATIENT CENTERED MEDICAL HOME<br />Primary Care Manager Directed Medical Practice<br /><ul><li> PCM is team leader
    38. 38. The personal physician
    39. 39. Leads a team of individuals at the practice level
    40. 40. Team collectively take responsibility for the ongoing care of patients</li></li></ul><li>PATIENT CENTERED MEDICAL HOME<br />Whole Person Orientation <br /><ul><li> Respectful, patient centered
    41. 41. Not disease centered
    42. 42. Not provider centered
    43. 43. Family and cultural sensitive</li></li></ul><li>PATIENT CENTERED MEDICAL HOME<br />Whole Person Orientation <br /><ul><li> Personal physician
    44. 44. Provides for all the patient’s health care needs</li></ul> or <br /><ul><li>Takes responsibility for appropriately arranging care with other qualified professionals</li></ul>Includes care for all stages of life<br /><ul><li>acute care
    45. 45. chronic care
    46. 46. preventive services
    47. 47. end of life care</li></li></ul><li>PATIENT CENTERED MEDICAL HOME<br />Care is Coordinated and/or Integrated across all levels of care<br /><ul><li>Subspecialty care
    48. 48. Hospitals
    49. 49. Home health agencies
    50. 50. Nursing homes
    51. 51. Patient’s community</li></li></ul><li>PATIENT CENTERED MEDICAL HOME<br />Care is Coordinated and/or Integrated across all levels of care<br /><ul><li> Care is facilitated by
    52. 52. registries
    53. 53. information technology
    54. 54. health information exchange
    55. 55. other means </li></ul>to assure that patients get the indicated care when and where they need and want it in a culturally and linguistically appropriate manner.<br />
    56. 56. PATIENT CENTERED MEDICAL HOME<br />Care is Coordinated and Integrated across all levels of care<br />
    57. 57. PATIENT CENTERED MEDICAL HOME<br />Quality and Safety<br /><ul><li> Evidenced-based, safe medical care
    58. 58. Outcomes that are defined by a care planning process driven by a compassionate, robust partnership between physicians, patients, and the patient’s family
    59. 59. Evidence-based medicine and clinical decision-support tools guide decision making
    60. 60. Physicians in the practice accept accountability for continuous quality improvement through voluntary engagement in performance measurement and improvement</li></li></ul><li>PATIENT CENTERED MEDICAL HOME<br />Quality and Safety<br /><ul><li> Patients actively participate in decision-making and feedback is sought to ensure patients’ expectations are being met
    61. 61. Information technology is utilized appropriately to support optimal patient care, performance measurement, patient education, and enhanced communication
    62. 62. Practices go through a voluntary recognition process by an appropriate non-governmental entity to demonstrate that they have the capabilities to provide patient centered services consistent with the medical home model.
    63. 63. Patients and families participate in quality improvement activities at the practice level.</li></li></ul><li>PATIENT CENTERED MEDICAL HOME<br />Enhanced Access <br /><ul><li>Meet access standards from the patient perspective
    64. 64. Enhanced Access to care is available through systems such as open scheduling, expanded hours and new options for communication</li></li></ul><li>Comparison of PPC-PCMH and PCMH 2011 <br />PPC-PCMH (9 standards/30 elements)<br />Access and Communication<br />Processes <br />Results<br />Patient Tracking and Registry Function<br />Care Management<br />Continuity Between Settings<br />Self-Management Support<br />Electronic Prescribing<br />Test Tracking<br />Referral Tracking<br />Performance Reporting and Improvement<br />Measures of Performance<br />Patient Experience<br />Advance Electronic Communication <br />PCMH 2011 (6 standards/25 elements)<br />Access and Continuity <br />Access - Practice Organization<br />Continuity - Electronic Access<br />Medical Home Responsibilities<br />Identify/Manage Patient Populations<br />Plan / Manage Care<br />Care Management <br />Medication Management <br />Self-Management Support<br />Track and Coordinate Care<br />Test/Referral Tracking<br />Facilities<br />Community Resources / Referrals<br />Performance Measurement and Quality Improvement<br />Measures of Performance<br />Patient Experience<br />Quality Improvement <br />
    65. 65. NCQA 2011 standards<br />Slide 20<br />NCQA has refreshed their recognition standards effective February 1, 2011<br />6 Standards<br /><ul><li>Enhance Access and Continuity
    66. 66. Identify and Manage Patient Populations
    67. 67. Plan and Manage Care
    68. 68. Provide Self-Care Support and Community Resources
    69. 69. Track and Coordinate Care
    70. 70. Measure and Improve Performance</li></ul>Achieving NCQA standards will require the AMEDD to optimize all existing IT technologies by aligning them with defined PCMH care delivery processes.<br />
    71. 71. PCMH 2011 Alignment with Measures of Meaningful Use<br />E-prescribing – medication list, allergies<br />Patient tracking/registry – demographics, diagnoses, vital signs, smoking, population management, insurance <br />Care management – reminders for follow-up care, decision support, RX reconciliation<br />Electronic capability – e-health info. to patient, visit summary, e-access to health information, provider information exchange <br />Performance reporting/improvement <br />
    72. 72. PATIENT CENTERED MEDICAL HOME<br />Outcomes<br />Geisinger Health System<br /><ul><li> Implemented a Patient Centered Medical Home redesign in 11 of its primary care practices beginning in 2007.
    73. 73. Focus on Medicare beneficiaries, primary care-based care coordination with team models featuring nurse care coordinators, EHR decision-support, and performance incentives.
    74. 74. Two year follow-up results:
    75. 75. Better quality: Statistically significant improvements in quality of preventive (74.0% improvement), coronary artery disease (22.0%) and diabetes care (34.5%) for PCMH pilot practice sites.
    76. 76. Reduction in costs: statistically significant 14% reduction in total hospital admissions relative to controls, and a trend towards a 9% reduction in total medical costs at 24 months.
    77. 77. $3.7 million net savings from the implementation of its PCMH model, for a return on investment of greater than 2 to 1</li></li></ul><li>PATIENT CENTERED MEDICAL HOME<br />R. A. Paulus, K. Davis, and G. D. Steele, Continuous Innovation in Health Care: Implications of the Geisinger Experience, Health Affairs, Sept./Oct. 2008 27(5):1235?45<br />
    78. 78. PATIENT CENTERED MEDICAL HOME<br />Outcomes<br />Group Health<br /><ul><li> Quality
    79. 79. Pilot clinic had an absolute increase of 4% more of its patients achieving target levels on HEDIS quality measures
    80. 80. Patients also reported significantly greater improvement on measures of patient experiences, such as care coordination and patient activation.
    81. 81. Better work environment
    82. 82. Less staff burnout, with only 10% of pilot clinic staff reporting high emotional exhaustion at 12 months compared to 30% of staff at control clinics, despite being similar at baseline;
    83. 83. Major improvement in recruitment and retention of primary care physicians.
    84. 84. 29% reduction in ER visits 11% reduction in admissions.
    85. 85. Investment in primary care of $16 per patient per year was associated with a savings of $17 per patient per year</li></li></ul><li>The Quadruple Aim<br />Enabling a medically ready force, a ready medical force, and resiliency of all MHS personnel.<br />Experience of Care<br />Population Health<br />Patient and family centered care that is seamless and integrated. Providing patients the care they need , exactly when and where they need it. <br />Readiness<br />Improving quality and health outcomes for a defined population. Advocating and incentivizing healthy behaviors. <br />Per Capita Cost<br />Managing the cost of providing care for the population. Eliminate waste and reduce unwarranted variation; reward outcomes, not outputs. <br />25<br />
    86. 86. Creating Alignment: Military Health System Quadruple Aim<br />Readiness<br />Pre-, During, and Post-deployment<br />Family Health <br />Behavioral Health <br />Professional Competency/Currency<br />Population Health<br />Healthy service members, families, and retirees<br />Quality health care outcomes<br />A Positive Patient Experience<br />Patient and Family centered Care, Access, Satisfaction<br />Cost<br />Responsibly Managed<br />Focused on value<br /> Quadruple Aim as an Enduring Construct for Care<br />26<br />
    87. 87. Army Medical Home:Experience to Date<br />
    88. 88. 35 Hospitals (Parent Sites)<br /> 114 Child Sites<br />PCMH early adopters<br /> 11 MTFs with 66 PCMH Teams <br /> No NCQA recognized sites yet<br />PCMH in Army Inventory<br />10 of 11<br />
    89. 89. OPORD 11-20 published Feb 2011<br />9 of 11<br />
    90. 90. Army PCMH Model<br />PCMH ratios. <br />2 exam rooms per PCM<br />3.1 support staff <br />direct staff who work for a single PCM<br />shared staff who work among several PCMs in the PCMH Team<br />< two exam rooms per PCM, the enrollment cap will be reduced accordingly<br />
    91. 91.
    92. 92. Army Medical Home Initiative<br /><ul><li>OPORD 11-20 published Feb 2011
    93. 93. NCQA 2008 Self Assessments Feb-Mar 2011</li></li></ul><li>Army Medical Home Implementation Timeline<br />STAFFING ADJUSTMENTS<br /> Caveat: Implementation progress depends on Payment Reform, Workforce Transformation, Performance Measure Alignment, Facility Optimization, and Marketing/STRATCOM Effectiveness <br />
    94. 94. Phase 1: <br />Build the Team and Patient Centered Experience of Care<br />Duration: 6-12 Months<br />Phase 3: <br />Implement Advanced Medical Home Practices<br />Duration: 6-12 Months<br />Phase 2: <br />Manage Demand<br />Duration: 6-12 Months<br />Team STEPPS<br />Staff Roles and Responsibilities<br />Building the Patient Partnership<br />Service and Communication Standards<br />Patient Centered Workflow<br />The Huddle<br />Empanelment<br />Access Management<br />E-visits<br />Care Coordination<br />Population Health<br />Comprehensive Care Plan<br />Advanced Access<br />Team Care<br />
    95. 95. Army Medical Home Transformation Plan<br />Three phases:<br />1. MEDCOM trains Regional transformation teams in San Antonio (Apr 26-28 2011)<br />2. Regional teams assess MTF readiness and develop MTF-specific transformation plans. (May-Jun 2011)<br />3. Regions oversee and support MTF transformation plans. (Begin NLT Sep 11)<br />
    96. 96. Phase 1 Concept of Operation <br />1. Command guidance<br />Training topics: TSG on PCMH and standardization, Critical Performance Measures, PBAM, Funding, Work Force Transformation<br />2. Franchise Model of Operations (based on CBMH model)<br />Integrates Team STEPPS and Customer Service training already slated for Army-wide roll-out.<br />3. Transformation support<br />Informatics, Logistics, Facilities, Marketing and Strategic Communications<br />4. Expanding the Team and Scope of Practice<br />Integrated Behavioral Health, Post-deployment Health, Pharmacy, Health Promotion and Wellness, Subspecialty Care, Pain Management<br />
    97. 97. Key Points<br />Community-based and MTF-based PCMH are integrated<br />Key leaders for vision, strategy, and implementation plan support both versions of Army Medical Home<br />CBMH initiative is “clean slate, start from scratch” version<br />MTF MH initiative is “transformative” version<br />EHR Workflow reengineering is critical piece for both initiatives<br />Secure Messaging will begin deployment this year<br />CBMH’s are first priority<br />Team-based workflow and processes must be in place first<br />Ongoing Tri-Service integration efforts – will be essential component of our success<br />Common experience of care<br />Resourcing<br />Metrics<br />Payment reform<br />
    98. 98. Community based medical homes<br />
    99. 99. 17 Clinics in 11 Markets -- Beginning in Fall of 2010<br />Army Community Based Medical Homes<br />The Army is Investing inHealthcare Capacity<br /><ul><li> Improve the readiness of our Army & our Army Family
    100. 100. Improve access to and continuity of care
    101. 101. Facilitate Patient-Centered Medical Home
    102. 102. Reduce emergency room episodes
    103. 103. Improve patient and provider satisfaction
    104. 104. Implement Best Practices & standardize services
    105. 105. Increase space available in MTFs for expanded active </li></ul> duty and specialty services<br /><ul><li> Improve physical and psychological health promotion </li></ul> and prevention<br />FT Bragg, NC – 3 clinics<br />FT Campbell, KY – 2 clinics<br />FT Hood, TX – 3 clinics<br />FT Jackson, SC – 1 clinic<br />FT L. Wood, MO – 1 clinic<br />FT Lewis, WA – 2 clinics<br />FT Sam Houston, TX – 1 clinic<br />FT Shafter, HI – 1 clinic<br />FT Sill, OK – 1 clinic<br />FT Stewart, GA – 1 clinic<br />Ft Benning – 1 clinic<br />8 of 11<br />
    106. 106. The Screaming Eagle Medical Home Experience<br />29 Nov- Staff assembled for training, TSG ribbon cutting<br />29 Dec- Open for patient care<br />12,585 Square feet of leased space on Clarksville Gateway Hospital campus<br />Pharmacy, Moderate Complexity Lab, Tx Room, Vax onsite<br />Radiology from Blanchfield or Gateway<br />5/6 PCMs,1 float and Psych NP on-hand<br />
    107. 107. Typical Appointment<br />Greeted by Patient Care Coordinator<br />LPN takes to room, presents orientation packet, acquires vital signs, med reconciliation, allergies, PMH, SHx, acquires HPI, conducts ROS, identifies age appropriate preventive medical and wellness requirements, and documents all.<br />Conveys pertinent data to Provider<br />Provider engages patient, expounds on history, conducts PE while nurse documents findings<br />Assessment and Plan formulated, orders input. Care plan completed<br />Physician exits; nurse educates patient as needed<br />Warm handoff to lab, pharmacy, Care Coordinator as needed<br />
    108. 108. Military treatment facility army medical homes<br />
    110. 110. Internal Medicine ClinicMadigan Healthcare System<br /><ul><li>Approximately 15,000 patients
    111. 111. 22 internists / nurse practitioners
    112. 112. IM residency continuity clinic
    113. 113. Annual well-come visits Nov 2009
    114. 114. Pre-visit HEDIS review, lab / rad
    115. 115. 30 minute LPN screen pre-visit
    116. 116. De novo or copy forward PMHx, PSHx, SocHx, FamHx, Allergies, Med Rec</li></li></ul><li>
    117. 117. Source: APLSS<br />
    118. 118. Sources: a) RVU’s per FTE per Day – Decision Support Center<br />b) MEDCOM Target 16.04 RVU’s/FTE/Day – Decision Support Center<br />
    119. 119. Sources: a) RVU’s per encounter – Decision Support Center<br />b) Workload RVU’s per E/M Code – Decision Support Center<br />c) National Average – ACP Practice Management Center<br />
    120. 120. Source: June 2010 PIFA Report<br />
    121. 121. Source: June 2010 PIFA Report<br />
    122. 122. Source: June 2010 PIFA Report<br />
    123. 123. Source: June 2010 PIFA Report<br />
    124. 124. Source: June 2010 PIFA Report<br />
    125. 125. Source: June 2010 PIFA Report<br />
    126. 126. Source: June 2010 PIFA Report<br />
    127. 127. Army Medical Home:Comprehensive Care Plan <br />
    128. 128. Patient Care Landscape - Current<br />CPGs<br />RGs<br />Consults<br />Registries<br />Discharge<br />Summaries<br />Essentris ED note<br />
    129. 129. PATIENT CENTERED MEDICAL HOME<br />History - 2007 Joint Statement Principles<br /><ul><li> Personal physician
    130. 130. Physician directed medical practice
    131. 131. Whole person orientation</li></ul>Care is coordinated and/or integrated across all elements of the complex health care system<br /> Quality and Safety<br /><ul><li> Enhanced Access to Care
    132. 132. Payment appropriately recognizes the added value</li></li></ul><li>PATIENT CENTERED MEDICAL HOME<br />Communication of care<br /> One of the best benefits of implementation of the Patient Centered Medical Home is the establishment of standard work. Everyone has an expected role and a way to document. Before the PCMH, reviewing the medical record was like dumpster diving for data<br /><ul><li>Group Health Provider</li></li></ul><li>How Do We Integrate Care?<br />60<br />
    133. 133. Integrating Care Delivery Pathways:The Comprehensive Care Plan Concept<br />Slide 61<br />
    134. 134. Primary Caregiver Serves as a Portal Between Specialist and the CCP<br />The Patient Centered Medical Home (PCMH) Primary Care Team manages the CCP lifecycle with co-management roles defined for the Accountable Care Organization (ACO) and the patient.<br />Value Added CCP Lifecycle Activities<br />Outcomes (Quadruple Aim)<br /><ul><li>Experience of Care
    135. 135. Population Health
    136. 136. Readiness
    137. 137. Per Capita Cost</li></ul>Specialist<br />Specialist<br />Specialist<br />PCMH<br />CCP<br />ACO<br />Patient<br />All CCP activities are recognized allowing better attribution of value to MHS strategic outcome measures.<br />Slide 62<br />
    138. 138. Patient Today<br />Patient Ideal<br />Unhealthy behaviors/High disease burden<br />High utilization of resources<br />Lower PCMH empanelment capability<br />Healthy behaviors/Lower disease burden<br />Less utilization of resources<br />Higher PCMH empanelment capability<br />Comprehensive Care Plan (CCP) Overview<br />The Comprehensive Care Plan will be based on a database of organized and searchable<br />information and will serve as the primary portal for each patient touch point.<br />Patient<br />Comprehensive, CoordinatedCare Delivery<br />Electronic Representation<br /><ul><li>Individualized: Contains only the information relevant to that patient
    139. 139. Automated: Makes proactive requests for care activities
    140. 140. Integrated: Organizes information logically from all data sources </li></ul>Comprehensive Care Plan (CCP)<br />7 of 11<br />
    141. 141. Documentation Allows Provider Recognition<br />One of the key value propositions from the implementation of PCMH is increased patient-provider interaction and review. Increased documentation allows provider recognition.<br />MultipleInteractions<br />Documentation Result<br />PCM Team<br />Face to Face Visit<br />Group Visits<br />RN Visit<br />Case Management<br />Telephone<br />Email<br />Web Visit<br />VTC<br />Result Review<br />Specialty Input<br />Specialist<br />Specialist<br />CCP Documentation<br /><ul><li>Increased awareness of providers implementing the principles of PCMH within their respective teams.
    142. 142. Recognition in correlation with the value proposition of a PCMH</li></li></ul><li>Transforming into a PCMH:Capabilities Provided by the CCP<br />Slide 65<br />
    143. 143.
    144. 144. All CCP Elements copy forward from AIM to AIM within <br />the Triservice Workflow AIM Group<br />
    145. 145. Standard CCP<br />7 Condition Blocks (each ties to a CPG)<br />Metabolic Syndrome (DM, HTN, HLD, Obesity)<br />Asthma/COPD<br />Low Back Pain<br />CV Disease<br />Depression/PTSD/SPMI<br />Pain Management<br />Substance Abuse<br />68<br />
    146. 146. CCP – 7 Core Items<br />Diagnosis<br />Goal of Therapy: (Generally pre-populated – example “A1C <7, BP <130/80, LDL<100, BMI <25)<br />Actionable data: (Generally pre-populated with name of data – example A1C: 8.2 on 12/16/10)<br />Co-managing Team/Consultants: (“Which cooks are in the kitchen?” - nurse/tech will ask pt the 1st time this is documented, any additions can be added by ordering provider)<br />Barriers to achieving goal: Provider-driven entry (requires judgment)<br />Timeframe for f/u: Provider-driven entry<br />Patient’s goal for next appt: Provider-driven entry, negotiated between provider and pt at today’s visit (example: cut smoking rate in ½, exercise additional 1 hr/week, lose 2 lbs, take meds as prescribed)<br />Ideally, provider only has to enter these 3 fields. Additional data can be added at provider discretion and copied forward. The above 7 items are the minimum standard for CCP.<br />69<br />
    147. 147. New Patient To Your Clinic<br />36 year Old female<br />How do you learn of this patient?<br />How should you learn of this patient?<br />In a PCMH Clinic what should you do when you learn of your new patient?<br />70<br />
    148. 148. Initial Intake<br />Pro-active data gathering<br />71<br />
    149. 149. Chart ReviewConducted Prior to Visit By Nurse<br />Records review<br />Seasonal allergies<br />Hyperlipidemia<br />BMI 30<br />Generalized anxiety<br />Family Planning OCP’s<br />Smoker<br />72<br />
    150. 150. Now What?<br />Provider Concerns<br /> Smoking / OCP use<br /> Quit smoking<br /> Lipid management<br /> Weight loss to BMI 25<br />73<br />
    151. 151. Intake Nurse Visit<br />Patient Concerns<br /> Husband deployed<br /> Two children under age 8 (one with ADD)<br /> Full-time job<br /> Worries all the time<br />74<br />
    152. 152. Put It All Together(shared decision making)<br />Individualized Comprehensive Care Plan (CCP)<br />Pt satisfied with SAR tx if she can stop sneezing and itchy eye and not feel tired from any medication (has a job and kids)<br />Pt has been thinking about quitting smoking but too much stress right now (contemplative stage with barriers)<br />Willing to stop her OCP to reduce stroke risk since husband is deployed anyway<br />Willing to see someone about her anxiety but doesn’t want to start any medication that will “knock her out or get her addicted”<br />Wants help with her “hyper child” causing her a lot of stress and she gets very frustrated with him.<br />She has tried to lose weight many times and will be stressful right now to lose all the weight needed to get to BMI of 25 but willing to work with team to achieve 10% weight loss to reduce risk of medical complications <br />75<br />
    153. 153. QUESTIONS ?<br /><br />76<br />