patient centered medical home; the army medical department experience

Apr 7, 2023COL Gary A. Wheeler / (253) 477-3003 (DSN 677) / [email protected]

Patient Centered Medical Home

The Army Medical Department Experience

29 April 2011

Gary A. Wheeler, MD, COLWestern Regional Medical Command CMIO


“The views expressed are those of the author and do not reflect the official policy of the Department of the Army, the Department of Defense or the U.S. Government.”

Slide 2 of


• Board Certified, Internist• Fellow, American College of Physicians• Education: BS, UC Berkeley; MD, USUHS• Residency: Walter Reed Army Medical Center• Member, Army Medical Department PCMH WG• Internal Medicine Consultant, OTSG• Past jobs:

– Department Chief, Madigan Army Medical Center– Deputy Commander for Clinical Services (CMO), Weed ACH– Chief, Clinical Informatics, MAMC– Chief, Internal Medicine Service, MAMC– Staff Internist, Walter Reed; Moncrief ACH, Ft Jackson, SC

Who Am I?


•Terminal Learning Objectives– Define Patient Centered Medical Home– Understand PCMH History– Identify principles of patient centered care– Review the current evidence for patient-centered

care– Review the 2008 and 2011 NCQA standards– Review PCMH implementation in the Army Medical

Department– Introduce the Comprehensive Care Plan

PATIENT CENTERED MEDICAL HOME



Definition

• Medical home, also known as Patient-Centered Medical Home (PCMH), is defined as "an approach to providing comprehensive care that facilitates partnerships between individual patients and their personal providers and when appropriate, the patient’s family”


History

• American Academy of Pediatrics introduced the term in 1967

• Model in caring for children with special needs

• Single source of patients’ medical information (medical record)

• Grew to include a partnership approach with families to provide primary health care

• Accessible• Family-centered• Coordinated• Comprehensive• Continuous• Compassionate• Culturally effective

• Within a decade it was AAP policy



History• Joint Statement of PCMH Principles – March 2007

• Four groups• American Academy of Family Physicians (AAFP)• American Academy of Pediatrics (AAP)• American College of Physicians (ACP)• American Osteopathic Association (AOA)

• Represent 333,000 physicians

• Provide the vast majority of primary care services to children, adolescents, and adult patients in the United States.



History - 2007 Joint Statement Principles

• Personal physician

• Physician directed medical practice

• Whole person orientation

• Care is coordinated and/or integrated across all elements of the complex health care system

• Quality and Safety

• Enhanced Access to Care

• Payment appropriately recognizes the added value



Personal Physician

• Primary care physician

• Could be a specialist or subspecialist for patients requiring

ongoing care for certain conditions• Severe asthma

• Complex diabetes

• Complicated cardiovascular disease

• Rheumatologic disorders

• Malignancies

• HIV

• Primary care physicians are defined as physicians who are

trained to provide first-contact, continuous, and comprehensive care



Primary Care Manager Directed Medical Practice

• PCM is team leader

• The personal physician•Leads a team of individuals at the practice level•Team collectively take responsibility for the ongoing care of patients



Whole Person Orientation

• Respectful, patient centered

• Not disease centered

• Not provider centered

• Family and cultural sensitive



Whole Person Orientation

• Personal physician•Provides for all the patient’s health care needs

or

•Takes responsibility for appropriately arranging care with other qualified professionals

Includes care for all stages of life•acute care

•chronic care

•preventive services

•end of life care



Care is Coordinated and/or Integrated across all levels of care

•Subspecialty care•Hospitals•Home health agencies•Nursing homes•Patient’s community



Care is Coordinated and/or Integrated across all levels of care

• Care is facilitated by• registries• information technology• health information exchange• other means

to assure that patients get the indicated care when and where they need and want it in a culturally and linguistically appropriate manner.



Care is Coordinated and Integrated across all levels of care



Quality and Safety

• Evidenced-based, safe medical care

• Outcomes that are defined by a care planning process driven by a compassionate, robust partnership between physicians, patients, and the patient’s family

• Evidence-based medicine and clinical decision-support tools guide decision making

• Physicians in the practice accept accountability for continuous quality improvement through voluntary engagement in performance measurement and improvement



Quality and Safety

• Patients actively participate in decision-making and feedback is sought to ensure patients’ expectations are being met

• Information technology is utilized appropriately to support optimal patient care, performance measurement, patient education, and enhanced communication

• Practices go through a voluntary recognition process by an appropriate non-governmental entity to demonstrate that they have the capabilities to provide patient centered services consistent with the medical home model.

• Patients and families participate in quality improvement activities at the practice level.



Enhanced Access

• Meet access standards from the patient perspective

• Enhanced Access to care is available through systems such as open scheduling, expanded hours and new options for communication



Comparison of PPC-PCMH and PCMH 2011 PPC-PCMH (9 standards/30 elements)

1.Access and Communication– Processes – Results

2.Patient Tracking and Registry Function

3.Care Management– Continuity Between Settings

4.Self-Management Support

5.Electronic Prescribing

6.Test Tracking

7.Referral Tracking

8.Performance Reporting and Improvement– Measures of Performance– Patient Experience

9.Advance Electronic Communication

PCMH 2011 (6 standards/25 elements)

1. Access and Continuity – Access - Practice Organization– Continuity - Electronic Access– Medical Home Responsibilities

2. Identify/Manage Patient Populations

3. Plan / Manage Care– Care Management – Medication Management

4. Self-Management Support

5. Track and Coordinate Care– Test/Referral Tracking– Facilities– Community Resources / Referrals

6.Performance Measurement and Quality Improvement– Measures of Performance– Patient Experience– Quality Improvement


NCQA 2011 standards

Slide 20

PCMH 2011 Goals

Increase patient-centeredness

Align the requirements with processes that improve quality and eliminate waste

Increase the emphasis on patient feedback

Enhance the use of clinical performance measure results

Integrate behaviors affecting health, mental health and substance abuse

Enhance coordination of care

6 Standards• Enhance Access and Continuity

• Identify and Manage Patient Populations

• Plan and Manage Care

• Provide Self-Care Support and Community Resources

• Track and Coordinate Care

• Measure and Improve Performance

NCQA has refreshed their recognition standards effective February 1, 2011

Achieving NCQA standards will require the AMEDD to optimize all existing IT technologies by aligning them with defined PCMH care delivery processes.


PCMH 2011 Alignment with Measures of Meaningful Use• E-prescribing – medication list, allergies

• Patient tracking/registry – demographics, diagnoses, vital signs, smoking, population management, insurance

• Care management – reminders for follow-up care, decision support, RX reconciliation

• Electronic capability – e-health info. to patient, visit summary, e-access to health information, provider information exchange

• Performance reporting/improvement


OutcomesGeisinger Health System

• Implemented a Patient Centered Medical Home redesign in 11 of its primary care practices beginning in 2007.

• Focus on Medicare beneficiaries, primary care-based care coordination with team models featuring nurse care coordinators, EHR decision-support, and performance incentives.

• Two year follow-up results: • Better quality: Statistically significant improvements in quality of preventive (74.0% improvement), coronary artery disease (22.0%) and diabetes care (34.5%) for PCMH pilot practice sites. • Reduction in costs: statistically significant 14% reduction in total hospital admissions relative to controls, and a trend towards a 9% reduction in total medical costs at 24 months.

• $3.7 million net savings from the implementation of its PCMH model, for a return on investment of greater than 2 to 1



R. A. Paulus, K. Davis, and G. D. Steele, Continuous Innovation in Health Care: Implications of the Geisinger Experience, Health Affairs, Sept./Oct. 2008 27(5):1235?45



Outcomes

Group Health

• Quality•Pilot clinic had an absolute increase of 4% more of its patients achieving target levels on HEDIS quality measures•Patients also reported significantly greater improvement on measures of patient experiences, such as care coordination and patient activation.

• Better work environment•Less staff burnout, with only 10% of pilot clinic staff reporting high emotional exhaustion at 12 months compared to 30% of staff at control clinics, despite being similar at baseline; •Major improvement in recruitment and retention of primary care physicians.

• 29% reduction in ER visits 11% reduction in admissions.

• Investment in primary care of $16 per patient per year was associated with a savings of $17 per patient per year



25

The Quadruple Aim

Readiness

Improving quality and health outcomes for a defined population. Advocating and incentivizing healthy behaviors.

Patient and family centered care that is seamless and integrated. Providing patients the care they need , exactly when and where they need it.

Managing the cost of providing care for the population. Eliminate waste and reduce unwarranted variation; reward outcomes, not outputs.

Enabling a medically ready force, a ready medical force, and resiliency of all MHS personnel.


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Creating Alignment: Military Health System Quadruple Aim

• Readiness– Pre-, During, and Post-deployment– Family Health – Behavioral Health – Professional Competency/Currency

• Population Health– Healthy service members, families, and retirees– Quality health care outcomes

• A Positive Patient Experience– Patient and Family centered Care, Access, Satisfaction

• Cost– Responsibly Managed– Focused on value

Quadruple Aim as an Enduring Construct for Care


Army Medical Home:Experience to Date


• 35 Hospitals (Parent Sites)• 114 Child Sites•PCMH early adopters

– 11 MTFs with 66 PCMH Teams – No NCQA recognized sites yet

PCMH in Army Inventory

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OPORD 11-20 published Feb 2011

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Army PCMH Model

• PCMH ratios. – 2 exam rooms per PCM– 3.1 support staff

• direct staff who work for a single PCM• shared staff who work among several PCMs in the PCMH Team

– < two exam rooms per PCM, the enrollment cap will be reduced accordingly


Army Medical Home Initiative

Community Based Medical Homes (CBMH)

Military Treatment Facility based Medical Homes

Army Medical Home

• OPORD 11-20 published Feb 2011• NCQA 2008 Self Assessments Feb-Mar 2011


Army Medical Home Implementation TimelinePhase 1: Build the Team and Patient Centered Experience of Care

Duration: 6-12 months

• Team STEPPS• Staff Roles and

Responsibilities• Building the Patient

Partnership• Service and

Communication Standards

• Patient Centered Workflow

• The Huddle

Phase 2: Effectively Manage Demand


• Empanelment• Patient Welcome

Process• Access Management• E-visits• Care Coordination• Population Health

Phase 3: Implement Advanced Medical Home Practices


• Comprehensive Care Plan

• Advanced Access• Team Care • Patient Activation:

Coaching Wellness and Patient Self Management

Caveat: Implementation progress depends on Payment Reform, Workforce Transformation, Performance Measure Alignment, Facility Optimization, and Marketing/STRATCOM Effectiveness

STAFFING ADJUSTMENTS


Phase 1: Build the Team and Patient Centered

Experience of CareDuration: 6-12 Months

Phase 2: Manage Demand

Duration: 6-12 Months

Phase 3: Implement Advanced

Medical Home PracticesDuration: 6-12 Months

Team STEPPSStaff Roles and ResponsibilitiesBuilding the Patient Partnership

Service and Communication StandardsPatient Centered Workflow

The HuddleEmpanelment

Access ManagementE-visits

Care CoordinationPopulation HealthComprehensive Care Plan

Advanced AccessTeam Care


Army Medical Home Transformation Plan

Three phases:

1. MEDCOM trains Regional transformation teams in San Antonio (Apr 26-28 2011)

2. Regional teams assess MTF readiness and develop MTF-specific transformation plans. (May-Jun 2011)

3. Regions oversee and support MTF transformation plans. (Begin NLT Sep 11)


Phase 1 Concept of Operation • 1. Command guidance

– Training topics: TSG on PCMH and standardization, Critical Performance Measures, PBAM, Funding, Work Force Transformation

• 2. Franchise Model of Operations (based on CBMH model)– Integrates Team STEPPS and Customer Service training already slated

for Army-wide roll-out.

• 3. Transformation support– Informatics, Logistics, Facilities, Marketing and Strategic

Communications

• 4. Expanding the Team and Scope of Practice– Integrated Behavioral Health, Post-deployment Health, Pharmacy,

Health Promotion and Wellness, Subspecialty Care, Pain Management


Key Points• Community-based and MTF-based PCMH are integrated

– Key leaders for vision, strategy, and implementation plan support both versions of Army Medical Home

– CBMH initiative is “clean slate, start from scratch” version– MTF MH initiative is “transformative” version

• EHR Workflow reengineering is critical piece for both initiatives• Secure Messaging will begin deployment this year

– CBMH’s are first priority– Team-based workflow and processes must be in place first

• Ongoing Tri-Service integration efforts – will be essential component of our success

– Common experience of care– Resourcing– Metrics– Payment reform


COMMUNITY BASED MEDICAL HOMES


The Army is Investing inHealthcare Capacity

Improve the readiness of our Army & our Army Family

Improve access to and continuity of care

Facilitate Patient-Centered Medical Home

Reduce emergency room episodes

Improve patient and provider satisfaction

Implement Best Practices & standardize services

Increase space available in MTFs for expanded active duty and specialty services

Improve physical and psychological health promotion and prevention

17 Clinics in 11 Markets -- Beginning in Fall of 2010

FT Bragg, NC – 3 clinicsFT Campbell, KY – 2 clinicsFT Hood, TX – 3 clinicsFT Jackson, SC – 1 clinicFT L. Wood, MO – 1 clinicFT Lewis, WA – 2 clinicsFT Sam Houston, TX – 1 clinicFT Shafter, HI – 1 clinic

FT Sill, OK – 1 clinicFT Stewart, GA – 1 clinicFt Benning – 1 clinic

Army Community Based Medical Homes

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The Screaming Eagle Medical Home Experience

• 29 Nov- Staff assembled for training, TSG ribbon cutting• 29 Dec- Open for patient care• 12,585 Square feet of leased space on Clarksville Gateway

Hospital campus• Pharmacy, Moderate Complexity Lab, Tx Room, Vax onsite• Radiology from Blanchfield or Gateway• 5/6 PCMs,1 float and Psych NP on-hand


Typical Appointment

• Greeted by Patient Care Coordinator• LPN takes to room, presents orientation packet, acquires vital signs,

med reconciliation, allergies, PMH, SHx, acquires HPI, conducts ROS, identifies age appropriate preventive medical and wellness requirements, and documents all.

• Conveys pertinent data to Provider• Provider engages patient, expounds on history, conducts PE while nurse

documents findings• Assessment and Plan formulated, orders input. Care plan completed• Physician exits; nurse educates patient as needed• Warm handoff to lab, pharmacy, Care Coordinator as needed


MILITARY TREATMENT FACILITY ARMY MEDICAL HOMES


Q9 Q10 Q11 Q12 Q13 Q14 Q21

.00

.10

.20

.30

.40

.50

.60

.70

.80

.90

1.00

Q9 – OVERALL PHONE SERVICE

Q10 – CONSIDERATE SCHEDULE

Q11 – TIME BETWEEN SCHEDULE & VISIT

Q12 – WAIT TIME

Q13 – STAFF COURTESY / HELPFULLNESS

Q14 – COORDINATION OF VISIT

Q21 – OVERALL VISIT SATISFACTION

OCT NOV DEC JAN FEB MAR APR MAY JUN JUL AUG SEP

0

10

20

30

40

50

60

70

80

90

34 36 38 40 39 41 41 41 41 39 39 41

6671 69

7774 76

7277 75

7268

74

OCT NOV DEC JAN FEB MAR APR MAY JUN JUL AUG SEP

50

60

70

80

90

100

77 78 7982 81 82 82 82 82 81 81 8283

86 8588 88 88 88

90 90 90

84

90

60%

90%85.5%

PRIMARY CARE MANAGER (PCM) CONTINUITY PRIMARY CARE MANAGER TEAM CONTINUITY

HEDISARMY PROVIDER LEVEL SATISFACTION SURVEY (APLSS) 52 WEEK AVG.

DUNHAM CLINIC % TARGET %MEDCOM %

85%

% Mam-mogram

% Asthma on LTC Meds

% Diabetes w A1C

% Diabetes w A1C<9

% Diabetes w LDL <100

% Cervical Cancer Screen

% Colorectal Cancer Screen

40.00%

50.00%

60.00%

70.00%

80.00%

90.00%

100.00%DUNHAM % MEDCOM % 50th Percentile 90th Percentile

FY 2010 ATC Metrics: Dunham Clinic

Q11 – TIME BETWEEN SCHEDULE & VISIT

Q12 – WAIT TIME

Internal Medicine ClinicMadigan Healthcare System

• Approximately 15,000 patients• 22 internists / nurse practitioners• IM residency continuity clinic• Annual well-come visits Nov 2009

• Pre-visit HEDIS review, lab / rad• 30 minute LPN screen pre-visit• De novo or copy forward PMHx, PSHx, SocHx, FamHx, Allergies, Med Rec


Overa

ll Sat

isfac

tion

Staff

Courte

sy/H

elpf

ulne

ss

Overa

ll Pho

ne S

ervic

e80%

82%

84%

86%

88%

90%

92%

94%

PCMH = Customer Service

Internal Medicine Clinic PatientsMEDCOM Benchmark

Source: APLSS


FY2008

FY2009

FY2010

MEDCO

M T

arge

t02468

1012141618

PCMH = Trying Harder

Internal Medicine Clinic RVU's per FTE per DayLinear (Internal Medicine Clinic RVU's per FTE per Day)MEDCOM Target

Sources: a) RVU’s per FTE per Day – Decision Support Centerb) MEDCOM Target 16.04 RVU’s/FTE/Day – Decision Support Center


FY2007

FY2008

FY2009

FY2010

Nation

al Ave

rage

0

0.2

0.4

0.6

0.8

1

1.2

1.4

PCMH = Working Smarter

Internal Medicine Clinic RVU's per EncounterLinear (Internal Medicine Clinic RVU's per Encounter)National Average for Internal Medicine

Sources: a) RVU’s per encounter – Decision Support Centerb) Workload RVU’s per E/M Code – Decision Support Centerc) National Average – ACP Practice Management Center


2007 2008 2009 2010 HEDIS 90th

0%

10%

20%

30%

40%

50%

60%

70%

80%

PCMH = Quality Care

Internal Medicine Clinic Colorectal Cancer ScreeningLinear (Internal Medicine Clinic Colorectal Cancer Screening)HEDIS 90th Percentile

Source: June 2010 PIFA Report



Nov-09 Dec-09 Jan-10 Feb-10 Mar-10 Apr-10 May-10 Jun-10 Oct-10 Nov-10 Dec-10 Jan-1150%

55%

60%

65%

70%

75%

71.6% 71.9%71.0%

71.7% 72.1% 72.3%72.9%

72.0% 71.9%72.4% 72.7% 72.9%

68.4%

69.6%

55.8%

59.4%

COLORECTAL CA SCREEN

IMC with Colorectal Screening 90th Percentile Colo-Rectal 50th Percentile Colo-Rectal

% W

ITH

Data Source: MHSPHP Action List

Notes: 2010 benchmarks in effect starting with Apr10 data. No Data from MHS portal for Jul10-Sep10.




65%

70%

75%

80%

85%

73.9% 73.8%74.3% 74.6%

75.8% 76.0% 76.3% 76.7%75.7% 75.4% 75.3% 75.6%

78.2%78.7%

68.5%

70.0%

BREAST CA SCREENING

IMC with Mammo 90th Percentile MAMMO 50th Percentile Mammo

% W

ITH






70%

75%

80%

85%

77.3% 77.7% 77.6%78.2%

79.6% 79.9% 79.9% 80.2% 80.4% 80.6% 80.7% 80.5%

87.8%86.7%

82.0%81.4%

CERVICAL CA SCREENING

IMC with Pap 90th Percentile Cervical Exam 50th Percentile Cervical Exam

% W

ITH






80%

85%

90%

95%

90.8% 91.1% 91.1% 91.1% 91.2%92.2% 92.2% 92.2%

93.2%92.7% 92.4% 92.7%

82.0%

PNEUMOCOCCAL IMMUNIZATION

IMC with Pneumococcal Pneumococcal Target

% W

ITH

Data Source: current enrollment file for patients 65+ with most current data.




40%

45%

50%

55%

60%

65%

57.8%59.1%

58.3% 58.2% 58.6% 58.2% 57.9% 57.9%

59.6%60.6%

58.8%58.1%

52.3%

53.9%

43.9%

45.3%

DIABETIC LDL<100

IMC DM with LDL<100 90th Percentile DM LDL<100 50th Percentile DM LDL<100

% W

ITH






70%

75%

80%

85%

90%

79.4%80.4% 80.1%

79.5% 79.9% 79.8%80.5% 80.8%

81.9%

82.2%

81.0%

79.6%

81.0%81.3%

71.1%

72.2%

DIABETIC HbA1c <=9

IMC DM with HbA1c<=9.0 90th Percentile DM HbA1c<=9 50th Percentile DM HbA1c<=9

% W

ITH





Army Medical Home:Comprehensive Care Plan


Un(der)managed

Care

Specialty Care

Emergency Care

Inpatient Care

Primary Care

CPGsRGsConsultsRegistries

DischargeSummaries

Essentris ED note

Patient Care Landscape - Current



History - 2007 Joint Statement Principles

• Personal physician

• Physician directed medical practice

• Whole person orientation

• Care is coordinated and/or integrated across all elements of the complex health care system

• Quality and Safety

• Enhanced Access to Care

• Payment appropriately recognizes the added value


Communication of care

One of the best benefits of implementation of the Patient Centered Medical Home is the establishment of standard work. Everyone has an expected role and a way to document. Before the PCMH, reviewing the medical record was like dumpster diving for data

•Group Health Provider



How Do We Integrate Care?

60


Integrating Care Delivery Pathways:The Comprehensive Care Plan Concept

Slide 61


Primary Caregiver Serves as a Portal Between Specialist and the CCP

Slide 62

PCMH

CCP

Outcomes (Quadruple Aim)

• Experience of Care

• Population Health

• Readiness

• Per Capita Cost

Patient

Value Added CCP Lifecycle Activities

The Patient Centered Medical Home (PCMH) Primary Care Team manages the CCP lifecycle with co-management roles defined for the Accountable Care Organization (ACO) and the patient.

ACO

Specialist

Specialist

Specialist

All CCP activities are recognized allowing better attribution of value to MHS strategic outcome measures.


Comprehensive Care Plan (CCP) Overview

The Comprehensive Care Plan will be based on a database of organized and searchableinformation and will serve as the primary portal for each patient touch point.

Electronic Representation

Comprehensive Care Plan (CCP)

• Individualized: Contains only the information relevant to that patient

• Automated: Makes proactive requests for care activities

• Integrated: Organizes information logically from all data sources

Unhealthy behaviors/High disease burden

High utilization of resourcesLower PCMH empanelment

capability

Patient Today

Healthy behaviors/Lower disease burden

Less utilization of resourcesHigher PCMH empanelment

capability

Patient Ideal

Comprehensive, Coordinated Care

Delivery

Patient

7 of 11


Documentation Allows Provider Recognition

One of the key value propositions from the implementation of PCMH is increased patient-provider interaction and review. Increased documentation allows provider recognition.

MultipleInteractions

Face to Face VisitGroup Visits

RN VisitCase Management

Telephone

EmailWeb Visit

VTCResult ReviewSpecialty Input

Documentation Result

• Increased awareness of providers implementing the principles of PCMH within their respective

teams.• Recognition in correlation with the

value proposition of a PCMH

CCP Documentation

PCM Team

Specialist Specialist


Transforming into a PCMH:Capabilities Provided by the CCP

Slide 65


All CCP Elements copy forward from AIM to AIM within the Triservice Workflow AIM Group


Standard CCP

• 7 Condition Blocks (each ties to a CPG)1. Metabolic Syndrome (DM, HTN, HLD, Obesity)

2. Asthma/COPD

3. Low Back Pain

4. CV Disease

5. Depression/PTSD/SPMI

6. Pain Management

7. Substance Abuse

68


CCP – 7 Core Items1. Diagnosis

2. Goal of Therapy: (Generally pre-populated – example “A1C <7, BP <130/80, LDL<100, BMI <25)

3. Actionable data: (Generally pre-populated with name of data – example A1C: 8.2 on 12/16/10)

4. Co-managing Team/Consultants: (“Which cooks are in the kitchen?” - nurse/tech will ask pt the 1st time this is documented, any additions can be added by ordering provider)

5. Barriers to achieving goal: Provider-driven entry (requires judgment)

6. Timeframe for f/u: Provider-driven entry

7. Patient’s goal for next appt: Provider-driven entry, negotiated between provider and pt at today’s visit (example: cut smoking rate in ½, exercise additional 1 hr/week, lose 2 lbs, take meds as prescribed)

Ideally, provider only has to enter these 3 fields. Additional data can be added at provider discretion and copied forward. The above 7 items are the minimum standard for CCP.

69


New Patient To Your Clinic

• 36 year Old female• How do you learn of this patient?

• How should you learn of this patient?• In a PCMH Clinic what should you do when you learn of your

new patient?

70


Initial Intake

• Pro-active data gathering

71


Chart ReviewConducted Prior to Visit By Nurse

Records review• Seasonal allergies• Hyperlipidemia• BMI 30• Generalized anxiety• Family Planning OCP’s• Smoker

72


Now What?

Provider Concerns• Smoking / OCP use• Quit smoking• Lipid management• Weight loss to BMI 25

73


Intake Nurse Visit

Patient Concerns• Husband deployed• Two children under age 8 (one with ADD)• Full-time job• Worries all the time

74


Put It All Together(shared decision making)

Individualized Comprehensive Care Plan (CCP)• Pt satisfied with SAR tx if she can stop sneezing and itchy eye

and not feel tired from any medication (has a job and kids)• Pt has been thinking about quitting smoking but too much

stress right now (contemplative stage with barriers)• Willing to stop her OCP to reduce stroke risk since husband is

deployed anyway• Willing to see someone about her anxiety but doesn’t want to

start any medication that will “knock her out or get her addicted”• Wants help with her “hyper child” causing her a lot of stress and

she gets very frustrated with him.• She has tried to lose weight many times and will be stressful

right now to lose all the weight needed to get to BMI of 25 but willing to work with team to achieve 10% weight loss to reduce risk of medical complications 75


QUESTIONS ?

[email protected]

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