San Diego Long Term Care Integration Project

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San Diego Long Term Care Integration Project

• LTCIP Planning Committee
• September 23, 2008

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LTCIP Vision Today

• Improve care for elderly and disabled persons in
  San Diego
• Utilize existing funding better, more effectively
• Change culture of care from symptom response to
  whole person care
• Organize health and social service providers to
  support effort

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Stakeholders

• Health social service providers, consumers,
  caregivers, advocates
• With interest in promoting and supporting the
  vision
• Have informed the process with 30,000 hours over
  10 years!
• Input needed today!

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LTCIP Strategies Developed to Support Vision

• Communication Strategy (Aging Disability
  Resource Connection)
• Physician Strategy (TEAM SAN DIEGO)
• Fully Integrated Health Care Strategy

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TEAM SAN DIEGO!

• Building supports for better chronic care across
  providers, settings, and funding by
• Community development of team dynamic through
  education practice
• Empowerment of patients to better manage their
  own care
• Formal feedback loops to close the circle for
  improved patient outcomes

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TEAM SAN DIEGO TODAY

• 8 on-line modules developed
• With experts/Advisory Group
• Loaded onto UCSD Blackboard
• Combined with resources
• Serving as basis for development of virtual
  teams
• To be followed by in-class training

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TSD In-Class Training

• Focus is review and team-building
• 5 hours to include working lunch
• Aiming for geographic focus
• Demo of Network of Care
• Exhibit of tools for patient empowerment
• Development of basis for formal feedback loops

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Now

• Highlights from on-line modules
• Discussion, questions
• Stakeholder groups to simulate teams
• Teams to discuss case scenario
• Teams to report out on development of feedback
  loop in groups

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For more information

• See website for background info
  www.sdltcip.org
• Call or e-mail brenda.schmitthenner_at_sdcounty.ca.g
  ov
• 858-495-5853

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TEAM SAN DIEGO

• Highlights from Review and Discussion of
• On-line Modules

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Medical social service coordination for chronic
care needs to improve

• Chronic care is now the major reason for care
• 1 in 2 Americans have 1 or more chronic illnesses
• Increased diversity challenges medical practice
• Physicians were not trained in chronic care
• Systems are currently filled w/gaps overlaps

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San Diego Physicians Perspective Key Issues
in Caring for the Chronically Ill

• Multiple chronic problems
• Drug-drug interactions
• Physical disability
• Functional Impairment
• Environmental / Cultural Diversity
• Economic Stressors

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TEAM SAN DIEGO Solutions

• Helps physicians and their patients other
  providers do a better job.
• Provides array of after office support services
  that go beyond the immediate doctors office
  visit.
• Improves systems to serve complicated and costly
  patients and improve satisfaction and outcomes.
• Helps the physicians office deal more
  efficiently with the complexity of using social
  supports along with medical services.
• Results in efficiencies in practice management
  and patient safety.

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Why Change?

• Risk Management (improved patient safety)
• More efficient patient visits due to patient
  activation
• Fewer missed appointments through planned visits
  facilitated by community supports
• More effective office staff support for patient
  access to and use of after office supportive
  services
• Improved patient outcomes and satisfaction

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How Do We Change?

• Learn evidence-based models teaming
• Learn tools and techniques to activate patients
• Learn to respond to the needs and preferences of
  the whole patient
• Learn about aging and disability
• Learn the basics of legal-ethical issues
• Learn how to find resources for your mutual
  patients
• Apply on a day-to-day basis

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The Importance of Interdisciplinary Teaming

• Primary care for chronic illness requires team
  approach
• Primary care offices do not often work as teams
• Lack of communication with other disciplines
  involved in patient care is the norm
• Even if a team existed, it would be impractical
  to
• meet at the same time and place

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How to Implement Virtual Team Care Strategies

• Practice management self assessment
• Identify current community partners
• Identify possible improvements
• Implement workable improvements
• Measure progress, adjust
• Feedback loop with partners
• Repeat this sequence

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Chronic Care Model
Health System
Community
Health Care Organization
Resources and Policies
ClinicalInformationSystems
DeliverySystem Design
Self-Management Support
Decision Support
Prepared, Proactive Practice Team
Informed, Activated Patient
Productive Interactions
Improved Outcomes
Figure 1 from Wagner, E.H. Chronic Disease
Management What Will It Take to Improve Care for
Chronic Illness? Effective Clinical Practice,
1998 12-4
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Remember the Feedback Loop!

1. Keep in touch regularly (phone, FAX, e-mail)
2. Alert the others of specific mutual patient
   problems
3. Educate patients on self-care management
4. Encourage patients to follow treatment plan
5. Assist patients in linking with support services

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What is Patient Empowerment?

• Empowerment as described by June Isaacson
  Kailes
• is self-perceived, personal power
• occurs on an internal, psychological level
• is a state of mind and a belief system
• is a developmental and ongoing process occurs
  at each individuals own pace
• cannot be given, BUT can be helped by
  providing information, tools, and skills.

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Better Patients Better Care

• Encourage patient to bring current medical
  history and medication list to appointments
• Encourage patient to bring list of issues to
  discuss, acknowledging some may have to be dealt
  with later
• Encourage patients to ask questions, seek
  clarification, offer preferences and feedback

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How TSD Can Empower Patients

• Listening to the patient
• Offering opportunities to choose
• Involving patients as partners in their own care
  by encouraging them to prepare for the visit.
• Providing information and support in finding
  services.
• Providing education in skills for self-management
• Providing tools to support self-management, such
  as a personal health record, discharge checklist

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Patients as Team Members

• By default, patients and caregivers sometimes
  function as their own care coordinators
• Patients are the first line of defense for
  transition related errors
• In TEAM SAN DIEGO, patient is in central role as
  educated, activated, empowered team member

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The Four Pillars
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Dr. Colemans Four Pillars

• 1. Medication self-management
• a) reinforcing knowing each medication when,
  why, and how to take it
• b) developing an effective medication management
  system
• 2. Personal Health Record
• a) providing healthcare management guide
• b) patient tracks own care plan and goals

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Four Pillars (continued)

• 3. Primary Care Provider/Specialist Follow-Up
• a) involving patient in scheduling
  appointments
• b) scheduling ASAP post discharge/transition
• 4. Knowledge of Red Flags
• a) teaching patient indicators that
  condition is worsening
• b) teaching patient how to respond

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Working with Diverse Patients
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Diversity Enriches Us All

• Need to recognize the values and strengths of
  ethnic persons and their communities
• Understand and respect their cultures
• Question personal stereotypes, attitudes and
  behaviors
• Move beyond fear to find value in improving
  current situations and benefit from the richness
  of diversity

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Communication Is The Key

• Good communication, the key to good medicine
• recognizes the individual as unique,
• helps prevent medical errors,
• strengthens the patient-physician relationship,
• makes the most of limited interaction time
• leads to improved health outcomes
• assists in discovering additional health-related
  concerns

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Communication Approaches

• What do you think caused the problem?
• What have you done to deal with this problem?
• Have you asked anyone to help you?
• Do you have traditional ways of treating this?
• What do you want the treatment/service to do for
  you?
• How does your faith/religion help you to be well?

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Teach Back Method of Communication

• Well documented patient-provider communication
  strategy
• Health literacy approach Communication loop
  that supports patient understanding of provider
  instructions

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Different Types of Seniors

• The oldest-old 85 year olds
• The old-old 75 to 84 year olds
• The young-old 65 to 74 year olds
• The Baby Boomers born between 1946 and 1964
  (44 to 62 year olds today)
• Boomers create the age wave estimated to triple
  percentage of seniors by 2020

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Normal Change vs. Red Flags

• Normal aging of major physical systems can be
  reviewed in the on-line training
• A red flag is a sign or symptom of a new or
  worsening condition
• Red flags are important for all members of the
  team to observe and report
• Red flags are important to teach your patient to
  help manage chronic care

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Response to Red Flags

• Define level of urgency
• Speak with individuals primary care physician or
  office staff based on urgency
• Speak with individuals caregiver about your
  observation
• Offer assistance in finding resources for
  assessment and treatment/services
• Document your activities

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What We Can Do Everyday with TEAM SAN DIEGO

• Prevention routine visits, reminders to patients
• Patient education on self-care, healthy choices
• Referrals for support services and equipment
• housing, public programs, transportation,
  personal assistance, home adaptation, etc.

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TSD Can Promote Healthy Aging

• Staying engaged and having social contact
• Being active and keeping a healthy weight
• Having activities that are mentally stimulating
• Volunteering to have significance in life
• Engaging in caregiving with family and/or friends
  or on a paid basis

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In the Video from the World Institute on
Disability, You Heard

• That individuals in the video want providers to
  know
• They want quality in their life
• They are doing what they need to do with
  assistance
• They are not sick and in need of a cure
• They want you to talk with/to them, not their
  assistant
• That health is not their main occupation or
  concern
• ADA accommodations can be hard to find but anyone
  can call a rehab center for help, and

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Persons in the Video Said

• What they want most is for the provider to listen
  to them
• They are often experts on the care of their
  disability and a resource to you and others
• They have diverse needs within the same group
  (deaf example)
• You dont have to be perfectdont stress over
  developing a relationship
• Make no assumptions!!

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We Need to Look Beyond Disability

• Health is not the absence of disability or
  disease
• Health is maximizing our potential physical,
  social, emotional, spiritual, and intellectual
  wellbeing
• Health and disability can and do co-exist
• Health is the ability to function effectively in
  different environs, to get ones needs met, and
  to adapt to stressors

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Independent Living

• Independent living is not doing things by
  yourself it is being in control of how things
  are done.
• Independent living is the conscious choice that
  individuals make to be responsible for managing
  significant issues in their lives.
• From June Isaacson-Kailes

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Privacy and Confidentiality HIPAA

• Health Insurance Portability Accountability
  Act
• Establishes safeguards to protect the privacy and
  security of protected health information (PHI)
• Improves efficiency and effectiveness of health
  care systems by standardizing electronic
  transactions
• Gives consumers more control over their health
  information, use and disclosure

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HIPAA Patients Rights

• To see and obtain copies of their health records
• Have corrections or amendments added to their
  health info
• Be notified of how their health info may be
  shared or disclosed
• Decide to give permission before used or shared
  for certain purposes, such as for marketing
• Get a report on when and why it was shared
• Have a copy of the organizations Notice of
  Privacy Practice
• File a complaint if they believe their rights are
  denied or their info is not protected

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What HIPAA Means for You

• Protect patient info as if it were your own
• Have patient as team member agree to referrals
• Have patient sign Consent for Release of PHI
• Provide minimum necessary limited info for
  success of referral and continuum of care
• Develop feedback loop with referral agency and
  get approval of patient
• Document referrals and appointments

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Major Ethical Principles

• Self determination respect patient right to make
  informed decisions
• Duty to benefit others educate patient so
  decision can be informed
• Duty to protect others from harm
• Justice and fairness to all parties regardless
  of who they are or ability to pay
• Honesty and trustworthiness

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Patient Self-Determination Act of 1990

• Highlights of the law include
• Providing all adult patients with written
  information concerning care decisions
• Asking patients whether they have an Advanced
  Directive (AD) where to find it in emergency
• Maintaining policies regarding discussions of an
  AD
• Honoring Advanced Directives
• Educating patients about Advanced Directives

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Finding Resources

• Aging and Disability Resource Connection
• Network of Care
• AIS Call Center
• a2i Independent Living Center
• Document referrals
• Implement feedback loop as virtual team
• Improve patient outcomes