1 / 34

Getting the Most Out of Chronic Care Management Plans

Getting the Most Out of Chronic Care Management Plans. What is a Care Plan?. What is a Care Plan?.

sasson
Download Presentation

Getting the Most Out of Chronic Care Management Plans

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Getting the Most Out of Chronic Care Management Plans

  2. What is a Care Plan?

  3. What is a Care Plan? Holly F. Sox, RN, BSN, RAC-CT -Clinical Editor, Careplans.com defines care plans as an essential part of healthcare, but is often misunderstood or regarded as a waste of time. Without a specific document delineating the plan of care, important issues are likely to be neglected.

  4. Ultimate Purpose The ultimate purpose of the CCMP is to provide thestudent with appropriate treatment for optimal outcome during his/her stay in Job Corps.

  5. Goals of CCMPs • Promote healthy living • Prevent unnecessary complications • Treat diseases effectively • Provide appropriate care* *World Health Organization Department of Chronic Disease and Health Promotion (CHP) http://www.who.int/chp/en/

  6. Nursing Diagnosis A nursing diagnosis deals with human response to actual or potential health problems and life processes. Nursing diagnoses also direct nursing interventions to obtain patient-specific outcomes*. * http://www.nanda.org/NursingDiagnosisFAQ.aspx

  7. Nursing Process • Assessment • Diagnosis • Planning • Implementation • Evaluation • Subjective • Objective • Assessment • Plan When initiating and updating a care plan, the five steps of the nursing process should be followed.

  8. CCMPs • Focus on actions which are designed to solve or minimize the existing problem • Are a product of a deliberate systematic process • Relate to the future • Are based upon identifiable health and nursing problems* • Are holistic • Nursingcrib.com

  9. Rationale and Goals of CCMPs • Improvement at all levels of care • Promote effective strategies • Open and systematic handling of errors • Provide incentives • Facilitate care coordination within and across organizations/community* *Chronic Care Management PowerPoint Right Time. Chronic Care Management Model. 3. Self-Management. Support. 4. Delivery 5. Decision 6. Clinical. System Support Information. Design Systems. www.dhss.mo.gov/ChronicDisease/ChronicCareManagement.ppt

  10. Team Approach to Care • Define roles and distribute task • Planned interactions for evidence-based care • Clinical case management services for chronic care patients • Regular provider initiated follow-up • Cultural sensitive care* *Chronic Care Management PowerPoint Right Time. Chronic Care Management Model. 3. Self-Management. Support. 4. Delivery 5. Decision 6. Clinical. System Support Information. Design Systems. www.dhss.mo.gov/ChronicDisease/ChronicCareManagement.ppt

  11. Self Management • Student has a central role in managing health • Self-management support strategies • Community resources to support self-management* *Chronic Care Management PowerPoint Right Time. Chronic Care Management Model. 3. Self-Management. Support. 4. Delivery 5. Decision 6. Clinical. System Support Information. Design Systems . Retrieved online fromwww.dhss.mo.gov/ChronicDisease/ChronicCareManagement.ppt

  12. Community Resources • Students participate in effective community programs • Form partnerships to fill gaps in needed services and avoid duplicating efforts • Advocate to improve patient care* *Chronic Care Management PowerPoint Right Time. Chronic Care Management Model. 3. Self-Management. Support. 4. Delivery 5. Decision 6. Clinical. System Support Information. Design Systems. Retrieved online from www.dhss.mo.gov/ChronicDisease/ChronicCareManagement.ppt

  13. Barriers to CCMPs Some barriers to managing chronic illnesses include: • Rushed visit with medical provider • Lack of care coordination • Lack of follow up • Patients inadequately trained to manage their illnesses Reference: Allweiss, Pam, MD, MPH. Consultant CDC Division of Diabetes Translation; Faculty at University of Kentucky. ppt. The Chronic Care Model: A fancy name for “team approach” Found on the docstock.com

  14. Who updates a CCMP? • Assign a nurse (or nurses) to case manage students with chronic problems. That person is responsible for: • meeting with students • monitoring compliance with treatment or medications • case conferencing on students

  15. Quiz A CCMP relates to the future and is focused on actions which are designed to solve or minimize the existing problem. a) True b) False

  16. Let’s look at the Asthma CCMP.

  17. Asthma Scenario • MM on entry • Mild intermittent asthma with minimal episodes of coughing/wheezing, SOB or chest tightness • Peak flow greater than 80% (green zone) predicated • Last ER visit was more than one year ago • Smoker – 2 PPD • Rescue inhaler occasionally • Denies any symptoms of asthma with increase activity

  18. Asthma Scenario • Day 3 on center • MM comes to H&W with increasing asthma symptoms • PRN nurse tells MM to increase the use of his inhaler q 2-3 hours PRN • Day 23 on center • In the middle of the night, he had increasing symptoms of coughing and wheezing; RA called HWM at home

  19. Asthma Scenario • Day 24 on center • Describes mild, persistent symptoms for past month • Did not come to HWC because he didn’t want to be a burden and was afraid that he would be sent home • Expiratory wheezing/peak flow was 260 (60% of predicated yellow zone) • Two nebulizer treatments • CP added Advair BID • Follow-up appointment scheduled in one week

  20. Asthma Scenario • Recommendations? • Given this scenario, when should the CCMP have been initiated? • Could the situation been avoided? How?

  21. Let’s complete the asthma CCMP.

  22. Quiz Which is not the purpose of a care plan: • Provide appropriate care • So the HWM or on call nurse is not called on the weekend • Prevent complications

  23. Tracking System • The tracking system should be used to: • Manage a list or group of students • Track care/progress • Case conference • Monitor compliance • Provide education • CQI

  24. Sample Tracking Systems • Logs • Word • Excel Spreadsheet • Appointment Book • Calendar (outlook)

  25. CCMP Log

  26. How do we Manage?

  27. Time Management and Care Management

  28. Outlook Calendar

  29. Where to Find CCMPs Job Corps Community Website • Health and Wellness • Chronic Illnesses • Documents

  30. Available Medical CCMPs • Asthma • Diabetes • Hypertension • Obesity • Seizure Disorder • Sleep Apnea • Adherence Techniques

  31. TUPP/OH CCMPs • Tobacco Cessation • Xerostomia (chronic dry mouth)

  32. Available Mental Health CCMPs • Attention Deficit/Hyperactivity • Asperger’s Syndrome • Bipolar Mood Disorder • Borderline Personality • Depressive Disorders • Gender Identity • Obsessive Compulsive • Post-Traumatic Stress Disorder • Schizophrenia • Tourette’s

  33. Information Systems & Summary • Timely updates • Identify reminders for providers and populations for proactive care • Facilitate individualized student plan • Share information- need to know • Monitor outcomes* Continuous Quality Improvement *Chronic Care Management PowerPoint Right Time. Chronic Care Management Model. 3. Self-Management. Support. 4. Delivery 5. Decision 6. Clinical. System Support Information. Design Systems. Retrieved onlinewww.dhss.mo.gov/ChronicDisease/ChronicCareManagement.ppt

More Related