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Meeting the Challenge of Caring for Chronically Ill Patients in the Home

Meeting the Challenge of Caring for Chronically Ill Patients in the Home. Alegent Health at Home Brenda Bergman-Evans, PhD, APRN Paula Egan, BSN, RN. Federal Interagency Forum on Aging-Related Statistics, “Older Americans 2000: Key Indicators of Well-Being,”

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Meeting the Challenge of Caring for Chronically Ill Patients in the Home

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  1. Meeting the Challenge of Caring for Chronically Ill Patients in the Home Alegent Health at Home Brenda Bergman-Evans, PhD, APRN Paula Egan, BSN, RN

  2. Federal Interagency Forum on Aging-Related Statistics, “Older Americans 2000: Key Indicators of Well-Being,” at www.agingstats.gov/chartbook2000

  3. Chronic Diseases Chronic disease epidemiology and control, 2nd Edition • Chronic diseases • A long latency period • Multiple risk factors • Prolonged course • Do not resolve spontaneously • Complete cure is rarely achieved • A prolonged course of illness • Uncertain etiology

  4. Chronic Diseases in the U.S. More than 90 million people affected (CDC). Leading causes of death and disability. Cause for 7 out of every 10 deaths. Accounts for 75% of annual total health care cost.

  5. Disproportionate Need for Hospital Care of the Elderly % of US population

  6. Chronic Disease and Hospitalization (3.1) (2.5) (1.7) (0.8) (0.4) (0.2) Source: Medical Expenditure Panel Survey, 2001.

  7. “Patients can undo a month’s worth of expensive and intensive care just going home and going about their normal routines.”John Charde, MDVP Strategic Development, Enhanced Care Initiatives, Inc (April 2006) • Hospitalization affect on ADLs • Ability declines for ~15% • - Another 20% leave without recovering pre-hospitalization abilities

  8. Home Care Population Elderly 85.6% are age 65+ Chronic Diseases 80% with one chronic condition Almost 50% with more than one chronic condition Cognitive impairment 23.7 % assessed with mild impairment 12.5 % assessed with moderate to severe impairment Depression Ranges from 10% - 40% depending on chronic disease Source: Murtaugh, et al. (2009) Complexity in Geriatric Home Healthcare. Journal for Healthcare Quality. Vol 31, No. 2, pp 34-43. Source: Jorge R. Petit, MD. Associate Commissioner of Program Services Division of Mental Hygiene, New York City Department of Health and Mental Hygiene

  9. Medication Mismanagement Source: Anderson, G.; Chronic Conditions: Making the Case for Ongoing Care; Johns Hopkins University; November 2007

  10. Polypharmacy • Adverse drug reactions (ADR) • # of drugs is single greatest risk for ADR • Exponential increase as the number of drugs rise • Decreased medication compliance • Poor quality of life • Unnecessary drug expense • Transition times • Drug-drug reactions

  11. Adverse Drug Events • Hospital • Admissions: 5-28% • Multiple medications cited as cause for many of the readmissions • Up to 70% of individuals enter ALFs secondary medication mismanagement (Pytlarz, 2006) • Estimated cost: $200 billion annually (Cameron, 1998)

  12. Non-Adherence: Significant Contributes to: • Increased number and length of acute care visits • 25% of hospitalizations due to medication errors • Increase in ED visits • Unnecessary changes • Overuse of scarce and expensive medical resources • Loss of productivity and decreased quality of life

  13. Health Literacy Defined “The degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions.” (Healthy People 2010)

  14. Why is Low Health Literacy Overlooked? • If we don’t ask…they won’t tell • Lack of awareness • Not sure how to ask • Not sure of a good response • Adequate reading skills = health literacy • Fearful of opening a “can of worms” 15

  15. Summary • Silo mentality • Poor communication and knowledge sharing • Lack of care coordination • Rushed practitioners • Lack of active follow-up • Pts unsure what to do • Pts seeking care via ER visits & hospitalizations

  16. Some Viable Models of Care • Transitions of Care • Wagner’s Chronic Care Model • Patient Centered Medical Home • Home-Based Chronic Care Model • Project Red

  17. PentaHealth Refined Vision of Value Expert in disease specific guidelines and care Highly trained in behavior change techniques Expert in care coordination “Sought after” partner that brings value Willing to share responsibility for outcomes • Facilitates • effective • transitions • Communication • competencies • & ability to share • data

  18. The Home-Based Chronic Care Model High Touch Delivery Self-Management Support Specialist Oversight Technology

  19. High Touch Delivery • Establishing trust • Determining barriers for changes • Connecting the dots • Building self-confidence • Plan for action

  20. Facilitating Behavior Change is the KEY to Pt Centered Care

  21. Shared Goals = Shared Success

  22. Management Support The systematic provision of education and supportive interventions to increase patients’ skills and confidence in managing their health problems, including regular assessment of progress and problems, goal setting and problem solving support

  23. Critical Aspects of Self-Management Support • Patient-Centered Focus • Patient-Clinician Relationship • Assessment and Tailoring • Collaborative Goal-Setting • Problem-Solving

  24. What is Really “Patient-Centered”? • Putting the person being served and his needs above all else – at the center of everything • Giving patient choices and enabling them to make decisions about their health. • An emphasis of the patient’s goals coupled with evidenced based care

  25. Danger Zones • Lecturing • Ignoring readiness or lackthereof for change • Giving advise for action • Solving pt. problems • Setting goals for pts • Lack meaningfulness • Threatening • Dire consequences

  26. Specialist Oversight • Support Case Managers • Specialty Modules • Congestive Heart Failure • COPD • Diabetes • Depression • Other • Wound Care • Infusion Therapy

  27. Telehealth • Using health information exchanged via electronic communications to improve the health status of the consumer • Store and forward telehealth information • Phone visit – prescheduled with use of a protocol • Interactive video – for “real time” visits

  28. Pathway to New Model • Chronic Care Course for all clinical employees (8 hours, 158 employees over 9 months) • Repeat twice yearly for new employees • Certification of 25 direct-care and 12 non-direct staff • Initiation of new model for case conferences • Schedulers

  29. Phone Visits • Insure visits that are made are effective, and not just because of the order string (2w9) • Template to guide phone assessment for consistent practice (HHQI) • Determine patient need for f/u visit

  30. Outcomes • Decreased number of different nurses seeing patient • Increased • Patient satisfaction • Staff satisfaction • Staff involvement

  31. Thank You Brenda.Bergman-Evans@alegent.org Paula.Egan@alegent.org

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