Presented by Vicki M. Young, PhD October 19, 2010 1.

Presented by Vicki M. Young, PhDOctober 19, 2010

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Informed,Empowered Patient & Family

Patient-Centered Prepared,

ProactivePractice Team

Improved Outcomes

Delivery

SystemDesign

Decision

Support

ClinicalInformatio

nSystems

Self-Managemen

t Support

Health System

Resources and Policies

Community Health Care Organization

Care Model

Productive Interactions

Coordinated

Timely andEfficient

Evidenced-basedAnd safe

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Include measurable goals for chronic illness in the organizational plan.

Senior leaders visibly support improvement in chronic illness care.

Use effective improvement strategies aimed at comprehensive system change.

Promote good chronic illness care through benefit packages.

Encourage better chronic illness care through provider incentives.

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Identify effective programs and encourage patients to participate.

Form partnerships with community organizations to support or develop evidence-based programs.

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Emphasize the patient's central role in managing their illness.

Assess patient self-management knowledge, behaviors, confidence, and barriers.

Provide effective behavior change interventions and ongoing support with peers or professionals.

Assure collaborative care-planning and problem-solving by the team.

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Define roles and delegate tasks amongst team members.

Use planned visits to support evidence-based care.

Build “effective” case management functionality into practice.

Assure continuity by the primary care team.

Assure regular follow-up.

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Embed evidence-based guidelines which describe stepped-care into daily clinical practice.

Integrate specialist expertise into primary care.

Use proven provider education modalities to support behavior change.

Inform patients about guidelines pertinent to their care.

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Include clinically useful and timely information on all patients in a registry.

Provide reminders and feedback for providers and patients.

Identify relevant patient subgroups and provide proactive care.

Facilitate individual patient care planning through the registry.

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Why National, State, and Local Measures?

“How will we know that a change is an improvement?”

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Use key measures to clarify a clinic’s aim and make it tangible.

Make use of the clinic’s patient population data base (registry) for measurement.

Integrate measurement into the daily routine.

Plot data on the key measures each month during the collaborative.

The question - How will we know that a change is an improvement? usually requires more than one measure. Improvement in a balanced set of five to nine measures should ensure that the system itself is improved.

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Established Best Practices

Allowed organizations to determine the effectiveness and/or need for change

Increased Quality ImprovementIn essence, measures focus on quality:Evaluation, Evaluation, Evaluation

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National and Local Faculty developed a set of measures to:

Address major aspects of care for patients with chronic illnesses.

Translate evidenced-based guidelines into clinical practice.

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Measure aspects of individual patient care and health.

Create summary reports and graphs

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American Academy of Pediatrics- late 1960s Institute of Medicine- late 1990s and early

2000 Various demonstration projects- from early

2000 to date National Committee on Quality Assurance

certification- 2007◦ Physician Practice Connections- Patient Centered

Medical Home Development of Joint Principles- AAP, AAFP,

ACP, AOA- 2007

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Mindfulness = Openness to new ideas and different perspectives; continuous creation of new categories

Respectful Interaction = Honest, tactful, and mutually valuing interchange where each person brings meaning and value to the other

Heedful Interrelating = Interaction where individuals are especially sensitive to the way their role and others fit into the larger group and its goals

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Channel Effectiveness = Appropriate use and mix of rich (eg, face-to-face) and lean (eg, e-mail) communications where rich channels are used when messages are highly ambiguous, complicated, or emotionally charged and lean channels are used when messages are clear, simple, and emotionally neutral

Mix of Social and Task Relatedness = Social relatedness includes non–work-related conversations and activities that are often based on friendships and family, whereas task relatedness consists of work-related conversations and activities.

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Diversity = Differences in mental models and in age, sex, and ethnicity.

Trust = Belief that you can depend on the other and the associated willingness to be vulnerable to another.

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Personal physician Physician directed medical practice Whole person orientation Care is coordinated or integrated Quality and safety Enhanced access Payment

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Refer to handout

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