what is pcrs? - ncoa · secrets to success ... staff training on self management key concepts...
TRANSCRIPT
© 2010. National Council on Aging A non-profit service and advocacy organization
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Improving the lives of older Americans
Secrets to Success – How to Partner with Healthcare Organizations
AoA Resource Center Webinar November 16 and 17, 2010
© 2010. National Council on Aging A non-profit service and advocacy organization
Agenda
Welcome
West Virginia – Strategies for Working with Federally Qualified
Health Centers
• Sally Hurst, Self Management Outreach Coordinator, Marshall Center
for Rural Health
Minnesota – Winning Over HMOs (Health Maintenance
Organizations), Healthcare Providers, and Healthcare Systems
• Mary Hertel, Central Minnesota Council on Aging
• Debra Laine, Arrowhead Area Agency on Aging
• Peter Spuit, Minnesota Board on Aging
Iowa – Linking Up with Medical Homes, the Chronic Care
Collaborative, Hospitals and VAs
• Kay Corriere, Iowa Department on Aging
Q &A
MARSHALL CENTER FOR RURAL HEALTH
SALLY HURST, SELF MANAGEMENT OUTREACH
COORDINATOR
N C O A G ra n t e e C o n f e r e n c e C a l l
S E C R E T S TO S U C C E S S – H O W TO PA RT N E R W I T H
H E A LT H C A R E O R G A N I Z AT I O N S
N o v e m b e r 2 0 1 0
West Virginia Strategies for Working with
Federally Qualified Health Centers
CDSMP/DSSMP leader
training
Workshop leaderships and
support
Staff training on self
management key
concepts
Promoting Self Management with FQHC Partners
Since 2003
Social marketing
materials
Assist with self
management QI
Assist with self
management integration
strategies
Resources and Support We Offer
WHY?
Patient Outcomes
Staff Wellness
EMR Documentation
Medical Home application
Chronic Disease Collaborative
Health Improvement Initiatives
Quality Improvement
Staff need common language and
know how
Senior
Management
Buy-in
Develop and
support
champions
Create a
buzz
Make it easy
Build Support from Within
Identify Coordinator(s)
Recruit participants
Promote from within
Brainstorm
Purpose
Marketing
Recruitment/Referral
Partnerships
Logistics
Silver platter support
Marketing/Materials/Supplies
Referral/Registration
Data Collection/Reports
Who
and What?
Always Model Self Management
Key Concepts and Skills
● Everyone can contribute and benefit
● Don’t judge
● Figure out who’s ready
● Begin by taking small steps
● Use the problem solving process
● Build on and celebrate success
● Be patient…change takes time
HOW DO PRIMARY CARE
ORGANIZATIONS
INTEGRATE SELF MANAGEMENT
INTO THEIR DAY-TO- DAY
DELIVERY OF PATIENT CARE?
Challenge
Primary Care Resources and Supports
PCRS Assessment
http://improveselfmanagement.org
A self assessment tool for patient care teams in
primary care settings
Based on the Chronic Care Model it “drills down” to
defines the support components of self
management
A quality improvement tool
Purpose of the PCRS
To help patient care teams in primary care settings focus
on actions that can be taken to support self management
by patients
Specifically, the PCRS helps:
Define/ describe optimal performance
Identify gaps in resources, services and supports for self
management
Facilitate communication among team members; build
consensus for change
Provide a mechanism to monitor progress
Patient Organization
1. Individualized assessment of
self management educational
needs
2. Self management education
3. Goal setting/ action planning
4. Problem solving
5. Emotional health
6. Patient involvement in
decision making
7. Social support
8. Links to community resources
1. Continuity of care
2. Coordination of referrals
3. Ongoing quality improvement
4. Documentation of SM support
services
5. Patient participation and input
6. Integration of SM support
7. Patient care team/ team
approach
8. Staff education and training
Components of Self Management Support
A Success Story at
a WV Primary Care Center
•Success with offering Stanford CDSMP
•Success with incorporating Self Management in Medical Group Visits
•Interest in system change for Self Management Integration- Self Management QI Team
•Standardize a “user friendly” process for self management goal setting
•Need to establish self management baseline for Rural Quality Grant and Medical Home Application
What we’ve learned….
Understanding about self management support
widely varies
Not everyone had basic self management skills and
understanding of key concepts
Staff are resistant to change and overwhelmed
Individuals and teams need support to begin from
where they are
Changing the culture of care will take time and
require an investment
Staff self-management skills training
Four lunch time sessions over 4 weeks with a healthy
lunch provided
Patient schedules altered to ensure that staff would be
able to attend
Sessions spaced out by one week so that staff can set
their own goals and report on them at the next meeting
Training agenda focus on staff setting personal self
management goals and then on how to properly interact
with patients using a defined method of self management
action planning and motivational interviewing
Build Excitement
about Self
Management
• Personal
letter of
invitation
• Flyers
• Reminders
Beginning a Cultural Shift
• Involve everyone
• Model the process
• Documentation of ongoing QI
Organization
• Common language
• “Know how” to promote self management skills
• Employee wellness
Staff • Workshop offerings
• Action planning at every visit
• More active and informed
Patient
Thank you!
PCRS http://improveselfmanagement.org
Marshall Self Management Website
http://selfmanagementonline.org
Sally Hurst
304-574-3384 [email protected]
This presentation was supported by Grant/Cooperative Agreement Number U32/CCU322734 from the CDC.
Its contents are solely the responsibility of the authors and do not
necessarily represent the official views of the CDC.
Winning over HMOs, Healthcare Providers, and
Healthcare Systems
National Council on Aging
ARRA Grantee Webinar
November 16 and 17, 2010
Mary Hertel, Central Minnesota Council on Aging
Debra Laine, Arrowhead Area Agency on Aging
Peter Spuit, Minnesota Board on Aging
Minnesota: CDSMP Snapshot
CDSMP ARRA Grant Partners
• Minnesota Department of Health
• Minnesota Board on Aging
– Minnesota’s seven Area Agencies on Aging
Stanford CDSMP License-holders serving Minnesota
• Minnesota Department of Health
• MeritCare Health System
• HealthEast Care System
• Native American Community Clinic
• Veterans Affairs – Midwest Health Care Network
Minnesota: CDSMP Snapshot State and Regional-Level relations with health system
State
• Meetings with Minnesota HMOs
• Minnesota Academy of Family Physicians
• VA Health Care System
Regional
• Twin Cities CDSMP Consortium (metro region)
• MeritCare Health System (northwest region)
• SMDC Health System (northeast region)
• Minnesota Academy of Family Physicians (central and metro
regions)
Collaboration with the Minnesota
Academy of Family Physicians
• Partners
– Central Minnesota Council on Aging (CMCA)
– Minnesota Department of Health (MDH)
– Minnesota Academy of Family Physicians (MAFP)
• Executive director of MAFP had interest in CDSMP
– She identified possible champions for the program at the clinic level
• Dialogue between MAFP and MDH opened door
• CMCOA was able to offer the 1st class offered by trained
leaders through Catholic Charities
CMCOA
• Offers training and technical assistance (materials, marketing tools, and
other assistance)for potential partners
• If project does not have “ready leaders” works to create collaboration
with other partners that have trained leaders
• Collaboration with other projects such as OAA Title III
Collaboration with the Minnesota
Academy of Family Physicians
MAFP
• Offers information to possible champions
• Work in conjunction with MDH and AAA
• Offers connection to clinics/health systems
• Potential for outreach to many communities across Minnesota
Collaboration with the Minnesota
Academy of Family Physicians
Lessons Learned
• Being able to offer a “trial” workshop with proven leaders made for a
successful workshop with positive outcomes
• 2 lay leaders stepped forward to be trained in addition to 1 person from
the clinic staff. They are now trained and offering CDSMP workshops
through the clinic
• Having “ready leaders” is an opportunity to “open the door” for
clinics/health orgs who have interest but may not want to commit
staff/volunteers immediately
• The challenge is to find champion who believes in CDSMP and is
willing to start the conversation
Collaboration with the Minnesota
Academy of Family Physicians
Partnership Development
• Used contacts and networks to find the right person or department within the large organization
• If necessary educate on the program
• Then begin a dialogue as to how we can cooperate Develop a team of champions with in the organization
• Developed a plan that met both organizations needs
Collaboration with SMDC Health
System
AAA
• Provide tools for education of providers
• Provide tools for recruiting patients
• Train leaders
• Provide leaders with instructional materials
• Provide leaders on going support
• Help with ongoing organization efforts
What the partnership looks like…
Collaboration with SMDC Health
System
SMDC
• Educate providers
• Establish a system for referring patients to classes
• Designate persons to be leaders
• Recruit patients as workshop participants
• Provide workshop space
• Participant registration
What the partnership looks like…
Collaboration with SMDC Health
System
Challenges
• Bring providers up to speed on the program
• Referrals to the program
• Length of time it takes to build a class
• Finding the right niche to recruit participants in
Collaboration with SMDC Health
System
Successes
• Support staff understanding & endorsing the program
• Finding leaders
• Multiple ways of getting the word out
• System Support
• Workshop and Training space
• Multi departments working together
Collaboration with SMDC Health
System
For more information
Minnesota Healthy Aging Website http://www.mnhealthyaging.org/
Twin Cities CDSMP Consortium http://www.health.state.mn.us/divs/hpcd/arthritis/cdsmpconsortium/index.html
For more information
Peter Spuit | Minnesota Board on Aging
[email protected] | 651-431-2359
Pam Van Zyl York | Minnesota Department of Health
[email protected] | 651-201-3616
Mary Hertel | Central Minnesota Council on Aging
[email protected] | 320-253-9349
Debra Laine | Arrowhead Area Agency on Aging
[email protected] | 218-529-7534
Evidence Based
Stanford Chronic Disease Self Management Program
Iowa Healthy Links
Umbrella of Five Evidence-Based
Programs
Chronic Disease Self Management Program (Marketed as Better Choices/Better Health Community-Based Program)
Tomando Control de su Salud
Better Choices, Better Health Online Program
Matter of Balance-Fear of Falling
(Exercise/Flexibility Program)
Enhance Fitness (Exercise Program)
Better Choices/Better Health Community
Workshop Coverage
Indicates one or more workshop being held in a
county per grant guidelines
Funding Since Inception (2006)
U.S. Administration on Aging: $1.6M
National Council on Aging/Atlantic Philanthropies: $300K
CDC/IDPH Iowans Fit for Life (To projects): $7.5K
CDC/IDPH Arthritis Initiative (To projects): $15K
NACDD/IDPH Diabetes Funding (To projects): $15K
The Wellmark Foundation $144K
Key Partnerships (42+)
State Level Iowa Department on Aging Iowa Department of Public
Health Iowa Civil Rights Division
Local Level Area Agencies on Aging Local Public Health Health Care Providers Faith Based Communities Non Profit Organizations YMCA’s Assisted Living and Retirement
Collaborations
Prevention and Chronic Care Advisory Committee
Iowa Health Collaborative
Iowa Chronic Care Consortium
Iowa Medical Home Advisory Council
Veterans Administration
Hy-Vee
University of IA Hospitals and Clinics
Des Moines University
Proven Outcomes/Self Reported at
6 months and 1 year Reduces health care utilization (Iowa) Emergency room admissions Repetitive physician visits Hospital readmissions Skilled nursing home length of stay
Validates Stanford University control research data (Iowa)
These outcomes have been shared with Iowa Congressional delegations and partners both in writing and in numerous presentations to local, state, and national organizations. These are of particular interest to health care providers.
Hint: Be sure to share the Stanford bibliography of peer reviewed articles with the providers for reference and validation.
Health Reform Provision Opportunities
Language Language
Center for Medicare & Medicaid Innovation Title III, Subtitle A, Part 3, Sec.
3021
Reducing Hospital Readmissions & Promoting Effective Transitional Care Title III, Subtitle A, Part 3, Sec.
3026
Medicare Wellness Visit Title IV, Subtitle B, Sec. 4013
Healthy Aging Evaluations & Recommendations Title IV, Subtitle C, Sec. 4202
Education & Outreach Campaign
Regarding Preventative Benefits
Title IV, Subtitle A, Sec. 4003
Prevention & Public Health Fund
Title IV, Subtitle A, Sec. 4002
Community Transformation Grants
Title IV, Subtitle C, Sec. 4201
CDC & Employer-Based
Wellness Programs
Title IV, Subtitle D, Sec. 4303
Ways of Working with Providers Providers Large/Regional Hospitals
Mercy Medical
Family Clinics
Iowa Health System
Diabetes Education Program
Clarinda Regional Medical
Jones Regional Medical
County Hospitals
Cass County Hospital
Visiting Nurses
Iowa Veterans Home
Affiliations:
Veterans Administration
U of Iowa Hospitals and Clinics
St. Luke’s Hospital
Role for Community Projects in Rural Iowa:
Community part of the Chronic Care Model
Medical Home concept as it develops
Kay S. Corriere, MS, RD
Iowa Healthy Links Project Director
Iowa Department on Aging
515/725-3306
www.iowahealthylinks.org
Questions and Answers