This document summarizes the key aspects of a health management program. It discusses how the program addresses various health risks and conditions across the care continuum from wellness to disease management. It provides data on common health risks and costs associated with them. The program utilizes nurses and health coaches to provide various services including wellness coaching, decision support, health coaching during pregnancy, case management, and disease management. It aims to help individuals better manage their health conditions and make healthcare decisions. Data is also presented on outcomes of the program, including improvements in clinical indicators, utilization, costs and member satisfaction.
Increasing self management of chronic conditions through the use of PAM and MINASHP HealthPolicy
This document discusses using the Patient Activation Measure (PAM) and motivational interviewing (MI) to increase self-management of chronic conditions. It provides information on PAM, which measures patient activation in managing their own health on four levels. MI is used to help patients progress to higher activation levels based on assessing their stage of change. The document includes a case study showing how a patient's PAM level increased from 2 to 3 after developing an action plan, and another where a level 1 patient lost 100 pounds and met surgery goals. It notes that motivation and activation can change with life events, and screening for depression is important as it impacts self-management.
As patient engagement (aka consumer engagement) earns attention, the question increasingly arises: “Where do we start? What can we do?” More specifically, “What do we mean when we say ‘patient engagement’?” The Patient Activation Measure is a powerful tool for understanding where someone's at and how to interact with them differently.
Using the Patient Activation Measure to improve quality of care for patients ...Ben Harris-Roxas
The document summarizes research using the Patient Activation Measure (PAM) to improve quality of care for patients with chronic conditions. The PAM gauges a patient's knowledge, skills, and confidence in managing their own health. The research included a literature review finding the PAM has been used to tailor care and assess risk profiles. A retrospective audit in one local health district found the PAM score improved after a pulmonary rehabilitation program. A pilot study is currently testing using the PAM in clinical practice to improve quality of care. Barriers and facilitators to implementing the PAM as a tailoring tool are being examined.
Population Health Management & Volume To Value Based CareIFAH
A session by Amish Purohit, CEO and CMO, US Health Systems on the topic of 'Population Health Management & Volume To Value Based Care' at IFAH USA 2019 held at Caesars Palace, 18-20 June, 2019.
Dr. Judith Hibbard presents The Case for Patient Activation - Activate 2017 b...mPulse Mobile
Leading patient activation researcher, Dr. Judith HIbbard, delves deep into the research findings of countless studies to reveal the definition, value and outcomes of patient activation during Activate 2017.
This presentation discusses chronic disease management in older adults. Chronic disease management aims to address chronic illnesses in an integrated and cost-effective way to achieve the best patient outcomes. Eighty percent of older adults have at least one chronic disease. The nursing process can be used to support patient self-management of chronic diseases through assessment, diagnosis, goal-setting, implementation, and evaluation. Setting SMART goals and providing education are keys to effective chronic disease management.
Increasing self management of chronic conditions through the use of PAM and MINASHP HealthPolicy
This document discusses using the Patient Activation Measure (PAM) and motivational interviewing (MI) to increase self-management of chronic conditions. It provides information on PAM, which measures patient activation in managing their own health on four levels. MI is used to help patients progress to higher activation levels based on assessing their stage of change. The document includes a case study showing how a patient's PAM level increased from 2 to 3 after developing an action plan, and another where a level 1 patient lost 100 pounds and met surgery goals. It notes that motivation and activation can change with life events, and screening for depression is important as it impacts self-management.
As patient engagement (aka consumer engagement) earns attention, the question increasingly arises: “Where do we start? What can we do?” More specifically, “What do we mean when we say ‘patient engagement’?” The Patient Activation Measure is a powerful tool for understanding where someone's at and how to interact with them differently.
Using the Patient Activation Measure to improve quality of care for patients ...Ben Harris-Roxas
The document summarizes research using the Patient Activation Measure (PAM) to improve quality of care for patients with chronic conditions. The PAM gauges a patient's knowledge, skills, and confidence in managing their own health. The research included a literature review finding the PAM has been used to tailor care and assess risk profiles. A retrospective audit in one local health district found the PAM score improved after a pulmonary rehabilitation program. A pilot study is currently testing using the PAM in clinical practice to improve quality of care. Barriers and facilitators to implementing the PAM as a tailoring tool are being examined.
Population Health Management & Volume To Value Based CareIFAH
A session by Amish Purohit, CEO and CMO, US Health Systems on the topic of 'Population Health Management & Volume To Value Based Care' at IFAH USA 2019 held at Caesars Palace, 18-20 June, 2019.
Dr. Judith Hibbard presents The Case for Patient Activation - Activate 2017 b...mPulse Mobile
Leading patient activation researcher, Dr. Judith HIbbard, delves deep into the research findings of countless studies to reveal the definition, value and outcomes of patient activation during Activate 2017.
This presentation discusses chronic disease management in older adults. Chronic disease management aims to address chronic illnesses in an integrated and cost-effective way to achieve the best patient outcomes. Eighty percent of older adults have at least one chronic disease. The nursing process can be used to support patient self-management of chronic diseases through assessment, diagnosis, goal-setting, implementation, and evaluation. Setting SMART goals and providing education are keys to effective chronic disease management.
Dave deBronkart came to focus on participatory healthcare after being diagnosed with stage IV kidney cancer in 2007. Through online research and connecting with other patients, he learned about an immunotherapy treatment that significantly extended his survival, whereas his doctors had given him only a few months to live. This experience led him to become an advocate for empowering patients through technology and social media. He argues that empowered, engaged patients who actively manage their own healthcare can help doctors spend more time with each patient and potentially achieve better health outcomes.
Improving the Health of Adults with Limited Literacy: What's the Evidence?Health Evidence™
Health Evidence, in partnership with the National Collaborating Centre for Determinants of Health (NCCDH), hosted a 60 minute webinar, funded by the Canadian Institutes of Health Research (KTB-112487), on interventions to improve the health of adults with limited literacy, presenting key messages, and implications for practice on Wednesday October 31, 2012 at 1:00 pm EST. Maureen Dobbins, Scientific Director of Health Evidence, lead the webinar, which included interactive discussion with Karen Fish, Knowledge Translation Specialist, and Connie Clement, Scientific Director, both from the NCCDH.
This webinar focused on interpreting the evidence in the following review:
Clement, S., Ibrahim, S., Crichton, N., Wolf, M., Rowlands, G. (2009). Complex interventions to improve the health of people with limited literacy: A systematic review. Patient Education & Counseling, 75(3): 340-351.
Team as Treatment: Driving Improvement in DiabetesCHC Connecticut
Team-based care has been shown to improve outcomes for patients with diabetes compared to conventional care. Key members of the diabetes care team include nurses, registered dietitians, pharmacists, and community health workers. Technologies like telehealth, electronic health records, and dashboards help coordinate care and monitor patient populations. Community programs also support diabetes patients through services like the YMCA's diabetes prevention program.
The document discusses chronic care and the chronic care model. It notes that while 55% of people have no chronic conditions, those with chronic conditions account for the majority of health care visits, admissions, days in the hospital, and prescriptions. The chronic care model emphasizes a system-wide approach rather than just physician behavior, and includes elements like self-management support, delivery system design, decision support, clinical information systems, and community resources. Productive interactions between prepared practice teams and informed, activated patients are key. Payment issues around chronic care include how to pay providers for new services and share savings from reduced utilization.
The document discusses various stakeholders involved in the healthcare improvement process, including primary care physicians, nurses, dietitians, social support workers, volunteers, and patients themselves. It emphasizes the importance of effective health communication and education programs in empowering patients, improving health outcomes, and reducing healthcare costs through better disease management and prevention of complications. Ongoing evaluation of programs is needed to continuously improve quality of care.
Patient Directed Care; Why it’s important and what does it really mean?Spectrum Health System
Understanding the importance of effective patient centered communication for patient engagement and improved health outcomes. Will discuss the importance of patient directed care and its relationship to the quadruple aim. Will discuss the barriers and a framework for conversations that are critical to patient directed care and cultural competency.
Enhancing the quality of life for people living with long term conditions.
https://mhealthinsight.com/2016/06/27/join-us-at-the-kings-funds-digital-health-care-congress/
AHRQ Quality and Disparities Report, May 2015Joe Soler
The document is a presentation from the National Healthcare Quality and Disparities Report Chartbook on Care Coordination from May 2015. It discusses trends in care coordination measures from the report and provides data on various measures of care coordination, including rates of patients receiving discharge instructions, hospital readmission rates, and preventable emergency department visits. The goal is to assess quality of care coordination and identify areas for improvement, particularly in reducing disparities. Several charts display care coordination measure results over time and differences between demographic groups to examine health equity.
This webinar discussed the business case for self-management support. It outlined evidence that self-management programs can deliver savings to the NHS through reduced GP, nurse, outpatient, A&E and medication usage. A ROI model was presented that calculates potential savings for commissioners based on their population. Case studies showed programs achieving a £2.24 return for every £1 spent. Challenges like an aging population and rising long-term conditions were discussed. The webinar argued for an experienced provider and defined outcomes to make an evidence-based case for self-management.
This document discusses home healthcare services provided by Health @ Home in Nepal. It begins by listing some common myths about home healthcare. It then provides testimonials from satisfied clients who received cancer care or treatment for tuberculosis. The document outlines several benefits of home healthcare for hospitals and patients. It provides examples of different types of patients who have received care at home, from newborns to elderly patients with various medical conditions. It discusses the company's use of technology and opportunities for innovation. In the end, it calls for collaboration to further develop home healthcare.
The document provides an overview of the ASAM (American Society of Addiction Medicine) model for assessing patients and determining appropriate levels of care for substance use treatment. It describes the six dimensions that are used to evaluate patients' needs, including intoxication/withdrawal, medical conditions, mental health, motivation, relapse risk, and social environment. Treatment is individualized based on a patient's severity levels across these dimensions. The document also outlines the five basic levels of substance use treatment in the ASAM model, from outpatient to inpatient care. It emphasizes that treatment planning involves ongoing reassessment of patient needs and progress.
This document is the January 2017 issue of the journal Diabetes Care, which contains the American Diabetes Association's annual publication of the Standards of Medical Care in Diabetes. The Standards of Care provide evidence-based guidelines for healthcare professionals on the components of diabetes care and treatment goals. This issue includes revisions to the Standards as well as articles on promoting health and reducing disparities, classifying and diagnosing diabetes, lifestyle management, preventing and treating diabetes complications, managing diabetes in special populations and settings, and diabetes advocacy.
Tiffany N Ealey has over 10 years of experience as a patient care associate and medical assistant. She has worked at Memorial Hospital Miramar since 2007, where she monitors patients, assists with procedures, administers medications, and provides direct patient care. Ealey has also volunteered with Memorial Healthcare and has received certifications in areas such as phlebotomy, nursing assistance, CPR, and IV therapy. She is currently pursuing a Bachelor of Science in Psychology from Liberty University.
The document discusses key aspects of implementing a disease management program including:
1. Encouraging early detection of diseases through various forms of advertising and utilizing guidelines from organizations like the CDC and WHO.
2. Providing incentives for patients to proactively manage their health like lower costs, support groups, and easy access to their medical records.
3. Addressing factors like ensuring quality of care through measurements, making facilities accessible, and emphasizing the importance of prescription management.
Strategies to improve linkage to HIV care aim to increase the percentage of people who enter care after receiving a positive HIV test result from 65% to 85%. Studies show those who enter care early are more likely to start antiretroviral therapy, achieve viral suppression, and reduce risky sexual behaviors. The document discusses various strategies tested in studies and used by agencies to improve different aspects of the linkage process, including messaging at diagnosis, counseling approaches, active versus passive referrals, engagement strategies, and care team coordination. The goal is to establish a seamless system to immediately link people to continuous, coordinated, and high-quality HIV care.
The document provides an overview of palliative care, including:
1) It defines palliative care as the active total care of persons with advanced, progressive diseases, with a focus on controlling symptoms physically, psychologically, socially, and spiritually to improve quality of life.
2) It discusses the physical, psychological, social, and spiritual components of palliative care, highlighting how an interdisciplinary team assesses and manages symptoms using evidence-based guidelines while contextualizing treatment plans to patient's disease status and goals.
3) It emphasizes the importance of addressing psychological, social, and spiritual well-being through open communication, social support, spiritual assessments, and consideration of patients' and families' beliefs, relationships
This document discusses palliative care and advance care planning. It defines palliative care as specialized care focused on relieving symptoms and stress for patients with serious illnesses. Advance care planning involves discussing goals, values and treatment preferences with medical providers and family. Early research shows palliative care can improve quality of life and symptoms for patients with serious illness. The document encourages having conversations about values and goals, completing advance directives, and revisiting discussions over time.
The document discusses the benefits of group medical visits for patients, providers, and practices. It notes that group visits can enhance patient education, improve access to care, and increase practice productivity and revenue. Group visits allow for more time with patients to focus on lifestyle education and chronic disease management. They also provide social support from sharing experiences with other patients. The document outlines strategies for implementing group visits, including selecting topics, planning logistics, ensuring regulatory compliance, and billing insurance.
This document provides information about multiple sclerosis (MS) and the medication Avonex for treating relapsing forms of MS. It discusses how Avonex works as a once weekly injection to slow progression of the disease over time. After 2 years of treatment, patients saw a 37% decrease in progression, and after 5 years 90% were still very active. Avonex also has very few side effects, with only 2% stopping treatment due to side effects after 8 years. The document emphasizes the goals of Avonex which are to provide more treatment choices for patients and delay progression of MS.
This document provides information about the Seattle Shakespeare Company's production of All's Well That Ends Well running from June 5-29, 2008 at the Center House Theatre in Seattle. It includes the director's note from Stephanie Shine discussing the themes of love in the play, a quick synopsis to get readers up to speed, and biographies of the cast members.
The document provides details about free Shakespeare in the park productions by the Seattle Shakespeare Company and Wooden O Productions from July 9-August 2, 2009 at various parks in the Seattle area. It lists the dates, locations and times for 16 productions of Richard III and The Taming of the Shrew. It also includes welcome messages from the artistic director and director of outdoor performances, as well as production details and cast member bios.
Dave deBronkart came to focus on participatory healthcare after being diagnosed with stage IV kidney cancer in 2007. Through online research and connecting with other patients, he learned about an immunotherapy treatment that significantly extended his survival, whereas his doctors had given him only a few months to live. This experience led him to become an advocate for empowering patients through technology and social media. He argues that empowered, engaged patients who actively manage their own healthcare can help doctors spend more time with each patient and potentially achieve better health outcomes.
Improving the Health of Adults with Limited Literacy: What's the Evidence?Health Evidence™
Health Evidence, in partnership with the National Collaborating Centre for Determinants of Health (NCCDH), hosted a 60 minute webinar, funded by the Canadian Institutes of Health Research (KTB-112487), on interventions to improve the health of adults with limited literacy, presenting key messages, and implications for practice on Wednesday October 31, 2012 at 1:00 pm EST. Maureen Dobbins, Scientific Director of Health Evidence, lead the webinar, which included interactive discussion with Karen Fish, Knowledge Translation Specialist, and Connie Clement, Scientific Director, both from the NCCDH.
This webinar focused on interpreting the evidence in the following review:
Clement, S., Ibrahim, S., Crichton, N., Wolf, M., Rowlands, G. (2009). Complex interventions to improve the health of people with limited literacy: A systematic review. Patient Education & Counseling, 75(3): 340-351.
Team as Treatment: Driving Improvement in DiabetesCHC Connecticut
Team-based care has been shown to improve outcomes for patients with diabetes compared to conventional care. Key members of the diabetes care team include nurses, registered dietitians, pharmacists, and community health workers. Technologies like telehealth, electronic health records, and dashboards help coordinate care and monitor patient populations. Community programs also support diabetes patients through services like the YMCA's diabetes prevention program.
The document discusses chronic care and the chronic care model. It notes that while 55% of people have no chronic conditions, those with chronic conditions account for the majority of health care visits, admissions, days in the hospital, and prescriptions. The chronic care model emphasizes a system-wide approach rather than just physician behavior, and includes elements like self-management support, delivery system design, decision support, clinical information systems, and community resources. Productive interactions between prepared practice teams and informed, activated patients are key. Payment issues around chronic care include how to pay providers for new services and share savings from reduced utilization.
The document discusses various stakeholders involved in the healthcare improvement process, including primary care physicians, nurses, dietitians, social support workers, volunteers, and patients themselves. It emphasizes the importance of effective health communication and education programs in empowering patients, improving health outcomes, and reducing healthcare costs through better disease management and prevention of complications. Ongoing evaluation of programs is needed to continuously improve quality of care.
Patient Directed Care; Why it’s important and what does it really mean?Spectrum Health System
Understanding the importance of effective patient centered communication for patient engagement and improved health outcomes. Will discuss the importance of patient directed care and its relationship to the quadruple aim. Will discuss the barriers and a framework for conversations that are critical to patient directed care and cultural competency.
Enhancing the quality of life for people living with long term conditions.
https://mhealthinsight.com/2016/06/27/join-us-at-the-kings-funds-digital-health-care-congress/
AHRQ Quality and Disparities Report, May 2015Joe Soler
The document is a presentation from the National Healthcare Quality and Disparities Report Chartbook on Care Coordination from May 2015. It discusses trends in care coordination measures from the report and provides data on various measures of care coordination, including rates of patients receiving discharge instructions, hospital readmission rates, and preventable emergency department visits. The goal is to assess quality of care coordination and identify areas for improvement, particularly in reducing disparities. Several charts display care coordination measure results over time and differences between demographic groups to examine health equity.
This webinar discussed the business case for self-management support. It outlined evidence that self-management programs can deliver savings to the NHS through reduced GP, nurse, outpatient, A&E and medication usage. A ROI model was presented that calculates potential savings for commissioners based on their population. Case studies showed programs achieving a £2.24 return for every £1 spent. Challenges like an aging population and rising long-term conditions were discussed. The webinar argued for an experienced provider and defined outcomes to make an evidence-based case for self-management.
This document discusses home healthcare services provided by Health @ Home in Nepal. It begins by listing some common myths about home healthcare. It then provides testimonials from satisfied clients who received cancer care or treatment for tuberculosis. The document outlines several benefits of home healthcare for hospitals and patients. It provides examples of different types of patients who have received care at home, from newborns to elderly patients with various medical conditions. It discusses the company's use of technology and opportunities for innovation. In the end, it calls for collaboration to further develop home healthcare.
The document provides an overview of the ASAM (American Society of Addiction Medicine) model for assessing patients and determining appropriate levels of care for substance use treatment. It describes the six dimensions that are used to evaluate patients' needs, including intoxication/withdrawal, medical conditions, mental health, motivation, relapse risk, and social environment. Treatment is individualized based on a patient's severity levels across these dimensions. The document also outlines the five basic levels of substance use treatment in the ASAM model, from outpatient to inpatient care. It emphasizes that treatment planning involves ongoing reassessment of patient needs and progress.
This document is the January 2017 issue of the journal Diabetes Care, which contains the American Diabetes Association's annual publication of the Standards of Medical Care in Diabetes. The Standards of Care provide evidence-based guidelines for healthcare professionals on the components of diabetes care and treatment goals. This issue includes revisions to the Standards as well as articles on promoting health and reducing disparities, classifying and diagnosing diabetes, lifestyle management, preventing and treating diabetes complications, managing diabetes in special populations and settings, and diabetes advocacy.
Tiffany N Ealey has over 10 years of experience as a patient care associate and medical assistant. She has worked at Memorial Hospital Miramar since 2007, where she monitors patients, assists with procedures, administers medications, and provides direct patient care. Ealey has also volunteered with Memorial Healthcare and has received certifications in areas such as phlebotomy, nursing assistance, CPR, and IV therapy. She is currently pursuing a Bachelor of Science in Psychology from Liberty University.
The document discusses key aspects of implementing a disease management program including:
1. Encouraging early detection of diseases through various forms of advertising and utilizing guidelines from organizations like the CDC and WHO.
2. Providing incentives for patients to proactively manage their health like lower costs, support groups, and easy access to their medical records.
3. Addressing factors like ensuring quality of care through measurements, making facilities accessible, and emphasizing the importance of prescription management.
Strategies to improve linkage to HIV care aim to increase the percentage of people who enter care after receiving a positive HIV test result from 65% to 85%. Studies show those who enter care early are more likely to start antiretroviral therapy, achieve viral suppression, and reduce risky sexual behaviors. The document discusses various strategies tested in studies and used by agencies to improve different aspects of the linkage process, including messaging at diagnosis, counseling approaches, active versus passive referrals, engagement strategies, and care team coordination. The goal is to establish a seamless system to immediately link people to continuous, coordinated, and high-quality HIV care.
The document provides an overview of palliative care, including:
1) It defines palliative care as the active total care of persons with advanced, progressive diseases, with a focus on controlling symptoms physically, psychologically, socially, and spiritually to improve quality of life.
2) It discusses the physical, psychological, social, and spiritual components of palliative care, highlighting how an interdisciplinary team assesses and manages symptoms using evidence-based guidelines while contextualizing treatment plans to patient's disease status and goals.
3) It emphasizes the importance of addressing psychological, social, and spiritual well-being through open communication, social support, spiritual assessments, and consideration of patients' and families' beliefs, relationships
This document discusses palliative care and advance care planning. It defines palliative care as specialized care focused on relieving symptoms and stress for patients with serious illnesses. Advance care planning involves discussing goals, values and treatment preferences with medical providers and family. Early research shows palliative care can improve quality of life and symptoms for patients with serious illness. The document encourages having conversations about values and goals, completing advance directives, and revisiting discussions over time.
The document discusses the benefits of group medical visits for patients, providers, and practices. It notes that group visits can enhance patient education, improve access to care, and increase practice productivity and revenue. Group visits allow for more time with patients to focus on lifestyle education and chronic disease management. They also provide social support from sharing experiences with other patients. The document outlines strategies for implementing group visits, including selecting topics, planning logistics, ensuring regulatory compliance, and billing insurance.
This document provides information about multiple sclerosis (MS) and the medication Avonex for treating relapsing forms of MS. It discusses how Avonex works as a once weekly injection to slow progression of the disease over time. After 2 years of treatment, patients saw a 37% decrease in progression, and after 5 years 90% were still very active. Avonex also has very few side effects, with only 2% stopping treatment due to side effects after 8 years. The document emphasizes the goals of Avonex which are to provide more treatment choices for patients and delay progression of MS.
This document provides information about the Seattle Shakespeare Company's production of All's Well That Ends Well running from June 5-29, 2008 at the Center House Theatre in Seattle. It includes the director's note from Stephanie Shine discussing the themes of love in the play, a quick synopsis to get readers up to speed, and biographies of the cast members.
The document provides details about free Shakespeare in the park productions by the Seattle Shakespeare Company and Wooden O Productions from July 9-August 2, 2009 at various parks in the Seattle area. It lists the dates, locations and times for 16 productions of Richard III and The Taming of the Shrew. It also includes welcome messages from the artistic director and director of outdoor performances, as well as production details and cast member bios.
Rabbi Havlin and his wife Chanie have established themselves as Chabad representatives in Dresden, Germany, working to rebuild Jewish life in the city. They have adapted their home to serve as a synagogue and Jewish community center. Attendance at their events like Passover seders and holiday celebrations has grown from 50 to hundreds. A Jewish nursery school is set to open, and permission to use the old synagogue building is pending. The opening of a new Orthodox synagogue and Jewish community center is helping strengthen and publicly establish Jewish identity in the city after the Holocaust and years of communist rule discouraged such openness.
This document summarizes the key aspects of a health management program. It discusses how the program addresses various health risks and conditions across the care continuum from wellness to disease management. It provides data on common health risks and costs associated with them. The program utilizes nurses and health coaches to provide various services including wellness coaching, decision support, health coaching during pregnancy, case management, and disease management. It aims to help individuals better manage their health conditions and make improvements in clinical outcomes and costs through personalized support and education.
This document provides information about Seattle Shakespeare Company's 2008-2009 season, including productions of The Servant of Two Masters, Henry IV, The Turn of the Screw, The Merchant of Venice, and The Tempest. It also includes biographies of the cast members for the production of The Tempest, directed by George Mount.
1) The document discusses the opportunity for technology to improve organizational efficiency and transition economies into a "smart and clean world."
2) It argues that aggregate efficiency has stalled at around 22% for 30 years due to limitations of the Second Industrial Revolution, but that digitizing transport, energy, and communication through technologies like blockchain can help manage resources and increase efficiency.
3) Technologies like precision agriculture, cloud computing, robotics, and autonomous vehicles may allow for "dematerialization" and do more with fewer physical resources through effects like reduced waste and need for transportation/logistics infrastructure.
This document provides an overview of the Heal n Cure medical wellness center and its Inspire program. Key points include:
- Heal n Cure offers primary care services through board certified physicians to treat the underlying causes of illness.
- The Inspire program implements recommendations to deliver multi-component wellness care including behavioral changes, medical treatment, education and personalized plans.
- Research shows the Inspire program reduces healthcare costs by decreasing urgent visits and invasive treatments for conditions like obesity, diabetes and heart disease treated through the program.
When Decision-Making Is Imperative: Advance Care Planning for Busy Practice S...VITAS Healthcare
Complex, chronically ill patients present an opportunity to discuss and implement hospice and palliative care. Many elderly patients who present to the ED and other busy practice settings are hospice-eligible because of functional decline and multi-morbidity. Key tools can quickly facilitate goals-of-care (GOC) conversations, advance care planning, and hospice referrals amid time constraints and high-acuity challenges.
Patient activation: New insights into the role of patients in self-managementMS Trust
This presentation by Helen Gilburt, Fellow at The King's Fund, looks at why some people are active at managing their health while others are quite passive, and how levels of patient activation impact on health outcomes.
It was presented at the MS Trust Annual Conference in November 2014.
Our message is simple: RETHINK the way you view healthcare. Welcome to eHealth Companion, a Personal Healthcare Management System designed to help companies' of all sizes and their employees successfully transition to Consumer Directed Health Plans.
Heal and Cure is a physician supervised medical wellness & primary care center. We offer Insurance Covered medical services for wellness and healthy living, weight loss or weight management, and primary care – all under the supervision of Board Certified, Award Winning physicians.
Since 2003, Heal n Cure has been mirroring the recommendations of the U.S. Preventive Services Task Force* (USPSTF) for the screening and management of obesity and diabetes. Over the years, we have aligned our weight management program – “Inspire Core Wellness”, based off the Task Force’s findings. The program has delivered impressive results in reversing all modifiable health risk factors.
The USPSTF recommends that overweight and obese patients should be referred to a comprehensive, multicomponent weight loss program with 12 to 26 sessions in the first year. The Inspire Core Wellness program implements the USPSTF recommendations and has delivered impressive outcomes.
Apresentação realizada no I Seminário Internacional de Atenção às Condições Crônicas, pela diretora do Programa da Gestão de Doenças Crônica dos Serviços Sanitários De Alberta/Canadá, Sandra Delon.
Belo Horizonte, 11 de novembro de 2014
Transforming the Office Management of Heart Failure Using the Chronic Disease...MedicineAndHealthUSA
This document describes a project to transform the management of heart failure patients using a chronic disease model in a family medicine residency program. It discusses shortcomings in current chronic disease management and introduces the chronic care model. The project aims to improve guideline adherence, patient education and self-management, care coordination, and use of an electronic registry to track patients and monitor outcomes. Initial lessons learned include challenges with governance approvals and achieving buy-in from part-time providers during a cultural change.
This document discusses models of diabetes care in primary health care settings. It summarizes evidence that lifestyle interventions can reduce diabetes incidence by 57% by increasing physical activity and improving diet. However, uptake of lifestyle changes is poor. Several models are presented to help with uptake, including the diabetes nurse educator, coach program, and chronic disease self-management. The chronic disease self-management program empowers patients to better manage their condition through education and skills development.
The document summarizes Nevada Cancer Institute's (NVCI) employee wellness program called H.O.P.E. (Healthy Options Provided for Employees). The program aims to improve employee health and wellness through various initiatives like on-site fitness classes, health screenings, nutrition education, and incentives for participation. Evaluation of the program found increasing participation rates over time along with reductions in weight, waist circumference, and stress levels among employees. The wellness program has helped foster a positive work environment and culture of health at NVCI.
This presentation will walk the viewer through the following key moments:
Slide 2 – About Ochsner
Slide 3 – Book of business
Slide 4 – Key differentiators
Slides 5/6 – The problems we’re solving
Slides 7/8 – Care team and collaboration
Slides 9/10 – Results, outcomes and ROI
Slides 11/12 – Employer experience and ideal client profile
Slides 13/14 – Employee engagement
More than just condition monitoring:
Ochsner Digital Medicine is remote clinical management, including clinicians and pharmacists on the care team to adjust medications accordingly.
Full clinical management - including medication management and ordering labs. The only program delivering at national scale that is backed by a not-for-profit, Center of Excellence health system. The only program that augments the member's PCP care via seamless data integration with Epic electronic health record.
The document discusses lessons from the United States on caring for patients with chronic illnesses. It outlines three key functions of primary care teams: panel management to ensure patients receive evidence-based care, health coaching to support behavior change and medication adherence, and complex care management for high-needs patients. High-functioning teams with roles like registry use, panel managers, and health coaches are shown to improve health outcomes and lower costs compared to usual individual physician care.
The document discusses lessons from the United States on caring for patients with chronic illnesses. It outlines three key functions of primary care teams: panel management to ensure patients receive evidence-based care, health coaching to support behavior change and medication adherence, and complex care management for high-needs patients. High-functioning teams with roles like registry use, panel managers, and health coaches are shown to improve health outcomes and lower costs compared to usual individual physician care.
This document summarizes the benefits of highly organized primary care and medical homes. It discusses how organizing primary care into teams that focus on population health, care coordination, planned care for chronic conditions, and quality improvement can improve health outcomes, reduce costs, and enhance the patient experience. The document provides examples from Cambridge Health Alliance that show improved quality metrics, decreased hospital and emergency room use, and reduced costs after implementing a primary care reform model centered around medical homes and accountable care.
C-TAC 2015 National Summit on Advanced Illness Care - Master Slide Deckzbarehmi
This document provides an overview of the National Summit on Advanced Illness Care that took place on March 2-3, 2015 in Washington DC. The summit was hosted by C-TAC (Coalition to Transform Advanced Care) and brought together leaders, clinicians, researchers, and policymakers to drive improvements in advanced illness care. Over the two-day event, there were presentations on models of advanced illness care, engaging patients and families, improving clinician-patient communication, the role of research and policies to support high-quality end-of-life care for all Americans.
Creating value through patient support programsSKIM
Creating value through patient support programs. The document discusses how adopting a patient-centric approach through patient support programs can enhance patient engagement, improve adherence and outcomes, and increase brand loyalty. It provides an overview of traditional versus holistic support programs and outlines key elements such as benefits investigation, education, nursing support, and peer resources. The document also discusses frameworks for understanding patient journeys, stakeholder needs, and conducting market research to identify opportunities to intervene with support.
Journal Communications implemented a value-based benefit design to improve health outcomes and control costs. They promoted high-quality, low-cost providers and reduced barriers to preventive care. They also managed chronic diseases through a pharmacy compliance program offering coaching and incentives. Wellness programs were integrated, using data to connect participants with the right resources and motivate healthy behaviors. Through engagement and prevention, they achieved better health outcomes while lowering healthcare spending.
We will cover the topic of Palliative Care – specialized medical care for people with serious illnesses. It focuses on providing patients with relief from the symptoms and stress of a serious illness. The goal is to improve quality of life for both the patient and the family.
Presented by Dr. Jean S. Kutner, MD, MSPH a tenured Professor of Medicine in the Divisions of General Internal Medicine (GIM), Geriatric Medicine, and Health Care Policy and Research at the University of Colorado School of Medicine (UC SOM)
8 Surprising Reasons To Meditate 40 Minutes A Day That Can Change Your Life.pptxHolistified Wellness
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2. Reality Check
• The top three causes of death are heart disease, cancer
and stroke; The leading cause of all three is. A.) High
Blood Pressure B.) Fatigue C.) Obesity
• The director of the Behavioral Medicine Research Center
at Baylor College predicts what percentage of Americans
will be overweight or obese by 2040. A.) 50% B.) 90%
C.) 75%
• What percentage of US adults do not engage in any
leisure time physical activity. A.) 40% B.) 25% C.) 60%
(Department of Health and Human Services)
• An American Cancer Society report shows obesity and
lack of physical activity causes how many cancer cases in
the United States? A.) 1/5 B.)1/2 C.) 1/3
12. Reducing one health risk can…
•Reduce absenteeism by 2%
•Improve productivity by 9%
Reference: Pelletier B, Boles M, Lynch W. (2004). Change in health risks and work
productivity over time. J Occup Environ Med.
Small changes, Big
Impact
13. Activation!
Our level of personal activation (“Take
Chargedness”) determines our behavior,
our risks, our likelihood to change, and
our medical costs.
• Diet
• Exercise
• Disease specific self-management
• Consumeristic behaviors
14. 70%
46%
35%
21%
15%
12% 10%
Depression Stress Blood
Sugar
Control
Overw eight Smoking Blood
Pressure
Sedentary
Lifestyle
Increased health risk, increased cost
Impact of Modifiable Risk Factors on
Medical Expenses
Adapted from Goetzel RZ, Anderson DR, Whitmer RW, et al, Journal of Occupational and Environmental Medicine (40) (10) October 1998, 1-12
Annualadjustedmedicalexpenses
ie. Overweight individuals cost
21% more than those whose
weight is in the healthy range
15. Care Management: Every Day
Health
CareEnhance Health Coach Special Beginnings
Disease Management
Case Management
SUPPORT FOR EVERY DAY HEALTH
WELLNESS COACHING SUPPORT MANAGEMENT
Integration between systems, people, programs
Lifelong support for members at any health stage
Simplification for member, employer, physician
Transformation of health care system
17. CareEnhance: Decision
Support
24/7 toll-free phone access to registered nurses
• 5 call centers and support for more than 100 languages
Help knowing when, where (or whether) to seek care
Library of over 1,100 prerecorded health topics
Program reminders mailed to members quarterly
Administered by McKesson Health Solutions
.
20. Special Beginnings: Healthy
Pregnancy
Nurses provide one-on-one member
support
• Assess each member’s risk to determine education and outreach
• Member’s choice of pregnancy book or DVD (Spanish options)
• What to expect during pregnancy and birth
• Signs of premature labor and other complications
• Tailored pregnancy information
• 24/7 phone access (CareEnhance after hours)
Engine rewards for completing program
22. Case Management: Advocate,
Navigate
Support for serious illness or injury
One-on-one nurse support based on conditions
• Nurses advocate, navigate and coordinate care
• Promote optimal quality
• Match resources to needs
Avert unnecessary expenses ($20 million in
2005)
• 1% of members drive 30% of health care costs
Reminder: Case managers can help members
understand their conditions, work with multiple
providers and make the most of their benefits.
23. Disease Management: Change
the Future
The difference between…
an existence controlled by
your condition and taking
control of your life.
24. Disease Management: Change
the Future
Targets diabetes, cardiac, and respiratory
conditions
• AdviCare packages may cover additional conditions
Prevent or postpone complications
Nurses and clinicians offer one-on-one support
• Interventions based on members’ risk level
• Newsletters, care reminders, phone contact, other outreach
• Support treatment plans and improve compliance
• Improved clinical measures and outcomes
• Help members understand and manage their condition(s)
25. Disease Management: Change
the Future
Disease management is the difference between...
BEFORE
Uncontrolled Diabetic with Non-Healing Wound
3 Office Visits $ 375
Hospital Admission $25,000
Surgeon Fees $ 6,000
Prosthetic $12,000
Rehabilitation $24,000
Insulin $ 6,000
TOTAL $73,375
AFTER
Controlled Diabetic
6 Office Visits $ 750
Foot Care $1,100
Dietician $ 300
Physical Therapy $ 500
Insulin $4,500
Pharmacy Services $ 110
TOTAL $7,260
26. Why Regence Disease
Management Matters
45% of members with chronic conditions
do not receive evidence-based care*
• Medications, tests and exams, doctor visits
• Improve diet and exercise
• Reduce stress
Engaged members make better health care decisions
Improvements in quality of life may
• Increase productivity
• Reduce absenteeism and presenteeism
• Slow cost trends over time
• *Source: McGlynn, et al., New England Journal of Medicine, 2003.
29. Having A Chronic Illness Is
Complicated
Only about 20% of people with health conditions do what they
should to maintain good health
Take Medications
Do Prescribed Tests Visit Doctor Regularly
Reduce Stress
ExerciseFollow Diet
30. Physicians Have Challenges, Too
Health care systems have driven
physicians to “fix” patients, not
maintain their health
Lack of time with patients
Increasing prevalence of chronic
conditions
Shift to short term episodes rather
than long term health status.
Our goal is to support the physician with patient
behaviors between office visits
31. We Stratify the Population
Stratification of Risk
•Rules-based algorithms
•Individually stratifies the population so
we know where to start
Low Risk
High Risk
32. We Apply the Right Level of Intervention
4 levels of risk stratification
Program tailored to risk level
Fluid stratification algorithms (claims,
prescriptions, updates, self report, physician and
care calls)
Interventions based on member specific needs and
best practice guidelines
Level of intervention is based on individual stratification
and risk status of the member
33. What do members participating in
the program receive?
AdviCare participants will be
offered:
One-on-one nurse-based counseling
Support through telephone calls
designed to help the member through
coaching and education
Members talk by phone with a
knowledgeable
RN who:
One-on-one nurse-based counseling
Understands the complexities of their conditions
Can take the time to answer all of their questions
Has access to a variety of educational materials
34. We Address the Whole Person
It’s about people, not the
disease
Understand individual
behaviors and help the
participant modify them
In order to create change
you must establish
unconditional credibility
and positive intent
Set goals with the patient
that are achievable
Build on their successes
All co-morbidities and behaviors must be managed
simultaneously by the same trusted relationship
35. We Extend the Physician’s Reach
Expanded “interventions” between
office visits
Comprehensive health condition
protocols (evidence based
standards of care)
Behavioral modification
In market nurses supporting
practice patterns with tools and
education
A primary goal of our program is to support the physician
with patient behaviors between office visits
36. Outcomes Reporting
Financial – semi-annual report reflects pre-
versus post program results
Clinical Outcomes – semi-annual report on
members’ overall compliance with selected
standards of care
Utilization – semi-annual with % change in
admissions, length of stay, ER visits and bed days
Member Satisfaction - annually
Activity – quarterly report showing members
counts and type/frequency of member contact
Note: Client level reporting varies based on
group size.
37. Health Care Cost for Diabetes Population Declined During Years 1 and 2 both
in Real Terms and when Compared to Adjusted Base Period Costs
Year 1 Trend is 7%
Year 2 Trend is 12%
Program Results
39. Results
• 43,492 Program participants
• 677,940 Educational mailings
• 186,088 Telephonic interventions
Office Visits
ALOS (days)
ER visits
Admissions
Bed Days
Utilization
Other
Professional
Pharmacy
Outpatient
Inpatient
Overall Costs
6.56
6.0
263
157
938
$45
$97
$106
$58
$145
$431
Intervention
6.93
5.2
307
206
1,061
$47
$137
$118
$118
$147
$551
No Intervention
-5%
13%
-14%
-24%
-12%
-4%
-29%
-10%
-51%
-2%
-22%
% Change
40. Member Satisfaction
Percent of Members Rating
the Program Good to Excellent
Member satisfaction with healthcare increases steadily
so you hear less noise.
0.00%
10.00%
20.00%
30.00%
40.00%
50.00%
60.00%
70.00%
80.00%
90.00%
100.00%
Used AdviCare Suggestions
& Guidelines
Satisfied with Courtesy &
Sensitivity of AdviCare
Nurses
Overall Satisfaction with
AdviCare
78%
89%
78%
41. Success Story
Diagnosed with type 2 diabetes for over a decade.
During a Welcome Call, she told the AdviCare nurse
that upon receiving her AdviCare diabetes
workbook,she read it from "cover to cover." She
stated more than once how pleased she was with it;
in comparing it with others she had read, she found
AdviCare's to be "more readable" and to contain
"better dietary information" than others she had read.
She reported that despite her long time diagnosis,
she looked forward to participating in the AdviCare
program.
42. Making a Difference in
Someone’s Life
A member had a history of substance abuse and uncontrolled
diabetes prior to her calls from the AdviCare program. For four
years she had not been having regular laboratory testing or
reviews of her medications. In 2005, the AdviCare nurses sent
her workbooks and encouraged the member to review the
standards of care. The member also set a goal to call member
services and find a physician to help her manage her diabetes.
Since then the member has had her medications reviewed, her
annual exams, and A1C testing. She has continued to remain
sober and stated she attributes her current health with diabetes
to the information and support provided by the AdviCare
nurses.
43. Thank you for attending…
Jennifer Havlin, BA, BSN, RN
Regence BlueShield
(206) 332-5011
jxhavli@regence.com
Editor's Notes
Reality Check
Questions
“Weldo”
Review
Break down of Health Care Premium $
Transition:
Shifting the dialogue and at the same time involving everyone in finding equitable solutions for both employers and employees seems to be the trend
…and less likely to:
Engage in risky cost-saving behaviors
Use ‘unproductive’ chronic care visits
This translates into positive impacts for the employer. Members who feel better take fewer sick days and are more productive when they are at work. This coupled with a slowing claims trend can really add up.
We are pleased to offer our internally-administered disease management program to you. This program manages seven chronic conditions, including (national prevalence rates shown):
Diabetes (7%)
Asthma (7.5%)
Chronic Obstructive Pulmonary Disease (3.1%)
Congestive heart failure (CHF) (1-2%)
Coronary artery disease (CAD) (6.9%)
Depression (5.3% - 9.2%)
Anxiety (17%)
These programs are designed to postpone or even prevent future complications of these conditions and help our members take charge of their health and take an active role in managing their condition.