SCOPE Stanford Care Optimization for Patients & Education Mentor & Resident Orientation 2013-2014. Directors Jori Bogetz MD, Carrie Rassbach MD, & Julia Gabhart MD. Great Relationships, Great Medicine. “ The good physician treats the disease; - PowerPoint PPT Presentation
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SCOPESCOPEStanford Care Optimization for Patients Stanford Care Optimization for Patients
● SCOPE Pacts – What my SCOPE family and I have agreed upon. Co-management agreements with associated care providers.
6
● Key Consult Notes – Important information from specialists 7
● My Learning – Literature relevant to my patient and Children with Special Healthcare Needs
8
● Letter on CPR Wishes – Copy of my SCOPE patient’s wishes for end of life care
9
● Other Important References – Community, hospital, and other informational resources
10
● My Research – Related to my patient or Children with Special Healthcare Needs
11
My SCOPE Patient’s Picture
and Name
Me, the SCOPE physician
My SCOPE Family’s Picture and Names
SCOPE
The SCOPE Intervention: Your Toolkit
• The SCOPE Toolkit is tailored to each group: Patients & families, mentors, and residents.
• It is available in English, Spanish, and Vietnamese.
• Progress on completing the Toolkit is made according to the needs of each family, always with the idea of using it to help achieve:– Their GOALS– Their EMPOWERMENT.
SCOPE SCOPE TimelineTimeline:: Empower ME!Meet your SCOPE Doctor.
Your SCOPE Doctor will read about your child.
Your SCOPE Doctor will learn about your child in person.
Make goals and build plans to meet these goals.
Home visit and monthly check ins.
Learn to speak up (Advocate) and take steps (Empower) to meet your goals.
Family & Patient Graduation!
Visits to specialists, school, talks with other providers.
SCOPE Contact Tree
SCOPE Goal Keeper
You are ready for SCOPE Graduation when you:•Know your goals of care•Have a plan to meet your goals•Are ready to speak up about your goals and know who to speak to•Are ready to take steps to meet your goals
SCOPE:SCOPE: Empower ME!
Teach Each Other As We Go
Family & Patient Graduation
The SCOPE Intervention
• Meeting Worksheets for are simply guides, to be completed only as found useful.
• Key care coordination tools (to be completed by each SCOPE Team):– Goal Keeper: Guides each meeting, focus of
SCOPE intervention
– Contact Tree: Establishes for entire care team who the patient should contact, when, for what, and how.
My Contact Tree
SCOPE
Patients: If there is a change in your care plan, please contact your SCOPE doctor.
SCOPE doctors: If using your cellphone, provide on outgoing message with instructions for emergencies.
SCOPE should contact me by: (Circle the best way to reach you)
•Phone: • 1. _________________
• 2. _________________
• 3. _________________
•E-mail: ___________________
Last Updated: ________________
The SCOPE Intervention
• Initial training session for residents, mentors
• 3 Resident Case-Based Discussions
• End-Of-Year Feedback Session
The SCOPE Intervention
Case Managers/Care Coordinators and Social Workers as educators, expert navigators of our system
Graduated SCOPE families• May serve as peer resources?
FAQ: So the SCOPE physician’s role is social, not medical?
No.
The SCOPE physician’s role embodies the best parts of medicine:
•Caring for the whole patient•Understanding the disease in the context of the
patient and family•Studying the disease and treatment in depth, as it applies to the
patient’s and family’s goals•Advocating that others involved in the patient’s care work toward
the patient’s goals and patient/family empowerment
Expectations of every SCOPE physician
• Build a relationship with and provide continuity for 1 Child with Special Healthcare Needs (CSHCN)• Meet at least once monthly
(again, does not have to be in person)
• Participate in multidisciplinary care team with co-management with subspecialists
• Explore areas of potential research
• Complete in Toolkit:• Plan of Care (which is scanned into
Cerner)• Contact Tree• Goal Keeper• Home Visit
• Attend at least 1 of 3 Case-Based Discussions throughout year
• Attend at end of the year Feedback Session if possible
• Develop an understanding of the home and family in the context of a CSHCN
• 5/21 5-6:30 (End of year wrap-up/feedback session)- LPCH- 3 East
Expectations of every SCOPE family
• Set up goals for care & work with SCOPE physician regularly to meet these goals.
• Let resident physician know of non-emergent care issues.• Respond to SCOPE physician within 48 hours.
• Tell SCOPE physician of appointments or changes in
plan. • Learn who to call for specific problems, and how to call
them.
• Goal: Empowerment!
Expectations of every SCOPE mentor
• Meet with the patient, family, and SCOPE physician within the first 2 weeks of enrollment.
• Meet with the SCOPE physician (phone, e-mail, etc. all acceptable) every month.
• Be available to answer SCOPE physician’s questions and those triaged from the patient.
• Foster residents’ research interests related to SCOPE patient or SCOPE curriculum.
• Attend case discussions as able and all-participant feedback session.
• Attend Home Visit with resident.
Mentor Resources
• Ideas on how to optimize your mentoring relationship (also in your Toolkit)• Gusic ME, Zenni EA, Ludwig S, First LR. Strategies to design an effective mentoring
program. J. Pediatr. 2010 Feb;156(2):173-4.e1.
• A discussion of the balance of appropriate supervision for safe care and allowing professional growth (also in your Toolkit):• Patricia Hicks, MD. View from the Association of Pediatric Program Directors: The
Role of Supervision in Creating Responsible and Competent Physicians. Academic Pediatrics. Vol. 11, Issue 1, January-February 2011, Pages 9-10.
• For updated data on experiences families of CSHCN• Data Resource Center for Child & Adolescent Health. (2012). 2009-2010 National
Survey of Children with Special Healthcare Needs. http://www.childhealthdata.org/learn/NS-CSHCN
• More first-hand on the patient/family experience• Robert A. Naseef. “Special Children, Challenged Parents: The Struggles and
Rewards of Raising a Child With a Disability” [Paperback] • Philo, Jolene. “Different Dream Parenting: A Practical Guide to Raising a Child with
• Emergencies -- go to 911 or the ED. • We ask the family contact their SCOPE physician once the
patient is safely in the ED.
• We ask that they bring their SCOPE Toolkit, if possible.
• Urgent issues -- go to the outside PCP, 730 Welch Primary Care answering service (if the patient’s PCP is at 730 Welch), or the appropriate subspecialty service.
• Non-urgent issues – go to the SCOPE physician.• These correspondences will be returned as soon as possible,
but within 24 hours.
• Mentors are back-up if the resident does not return calls in 24 hours. Directors are mentors’ backup.
Communication Details: Mode
• If you e-mail with/regarding your patient/family:• Ensure families understand these e-mails may not be truly
secure. If they do want to communicate by e-mail, they must sign a consent form.
• When communicating to other caregivers about a patient, always use “SECURE:” as the start of your subject line.
• CC relevant care providers.
• If you give out your cellphone number:
• Ensure your outgoing message says: “If you are calling regarding a medical emergency, hang up and immediately dial 911.” Then record normal outgoing message.
Communication Details: Documentation
• Document in the medical record (Cerner) any conversation that could potentially influence your patient’s care.
• SCOPE physicians should detail that they have discussed this conversation and recommendations with the mentor/SCOPE director/other attending physician.
• CC relevant physicians, including attending with whom the SCOPE
physician discussed the topic. • Summarize phone calls under General Message/Phone Message.
• Summarize e-mails and meetings under General Message.
SCOPE Pilot #3 Timeline (2013-14)
SCOPE Support
Institutional Support• Stanford University Pediatrics Residency Program
• with special thanks to Lyn Kahana and Rebecca Blankenburg• Lucile Packard Children’s Hospital Complex Care Initiative
Designated as the educational arm of the Initiative• with special thanks to John Mark, Christy Sandborg, Karen Wayman
Curricular Support• All parties mentioned above• David Bergman• The Lucile Packard Family Advocacy Council• 1st and 2nd SCOPE Pilot Residents and Mentors!Financial Support• Lucile Packard Foundation for Children’s Health Young Investigator Award --
Children with Special Healthcare Needs• Department of General Pediatrics
• with special thanks to Fernando Mendoza
E-Copies of Toolkit, Patient Resources
• Many resources are available on the SCOPE Website (under
electives on peds.stanford.edu)
• All Electronic Copies of the SCOPE Toolkit and related
resources are shared with all SCOPE physicians via
SCOPE Dropbox.
• If you would like to have access to the Dropbox, SCOPE Directors will