Title: Patient Centered Processes Pursuing Perfection
1(No Transcript)
2Patient Centered ProcessesPursuing Perfection
- Whatcom Community
- Marc Pierson
- Nancy Stothart
3Community-wideConnection Communicationwith
for PATIENTS who live withCHROINC CONDIDTIONS
Whatcom Community Marc Pierson Nancy Stothart
4(No Transcript)
5Institute of Medicine
- Six Aims
- Patient centered
- Safe
- Timely
- Effective
- Efficient
- Equitable
6IOM
- Not an indictment of physicians, nurses, or,
indeed any of the people who give or lead care. - futile to seek the improvement by further
burdening an overstressed health care workforce
or by exhorting committed professionals to try
harder. - A redesigned health care system can offer the
health care workforce what it wantsa better
opportunity to provide high-quality care.
7It Takes a Community
8P2 Participating Orgs
- Family Care Network
- Sea Mar Community Health Clinics
- North Cascade Cardiology
- St. Joseph Center for Senior Health
- St. Joseph Hospital
- Group Health Cooperative
- Community Health Plan of Washington
9(No Transcript)
10(No Transcript)
11Involving Patients in the Process
12Patient Centered
- Invite patients into all planning and design work
- Increases probability of creating new value
- Adds meaning
- Gets folks close to the reason they are in health
carepatients - The work is understood to be helpful
13How to Invite Patients
- Simply have prospective team members ask patients
that they or their friends know will fit the team - Caution
- Avoid inviting patient advocates
- Forgiveness and compassion are not theirs to
choose - Avoid asking healthcare workers who are also
patients
14PATIENTS EXPERIENCE
15THE DILEMMA
- Too little connection
- Too little communication
TWO IMPORTANT SOLUTIONS
- Clinical care specialists
- Shared care plan
16Changing the Experience of Patients
- Patient-centered Patient is the most important
member of the CARE TEAM - People with chronic conditions manage their
illnesses 24/7. Other team members come off the
bench. - Build support of patients self-management
intoour daily work - Create tools that support patients in
self-management - Involve patients in all aspects of planning and
redesign of healthcare delivery system
17Rebecca Brysons Conditions and Virtual Care Team
Pursuing Perfection in Whatcom CountyApril 2003
18Rebeccas Communication Burden
Pursuing Perfection in Whatcom CountyApril 2003
19Virtual Care Teams
- Patients with multiple conditions are often
left at the center by default - Resources surrounding and supporting are
necessary
20Information
- The focus shifts
- from EMR
- (organization specific business medical records)
- to include PHR
- (patient health records)
21Business RecordsPaper or Electrocuted
22Video InnovationsIn Chronic Care Management
- Whatcom Community
-
- Robert Wood Johnson Foundation
- Crosskeys Media
23Simple Rules for the 21st- Century Health Care
System
24Patients as Partners in Care
- Each patient is a full member of the team a
patients perspective and experience is
importantlisten carefully - Patients are the ultimate managers of their
chronic conditions their active participation
in making decisions and sharing information is
critical to improving outcomes and patient
satisfaction - When patients ask questions, seek out
information, or want to be involved in decisions
about their treatment, respond thoughtfully and
thoroughly - Assist them in identifying what they will do to
promote and improve their health - Encourage them to share with care team members
what support or resources they will need to be an
effective member of the team
25(No Transcript)
26(No Transcript)
27The Clinical Care SpecialistPartnering with the
Patient
- Develop relationship
- Holistic approach .
self-management - Providing information and helping patients
develop skills - Providing support and tools
- Advocacy, navigation, and translation
28What Patients have Designed, So Far
- Role of navigator, lifeguard, coachClinical Care
Specialist - Patient health recordThe Shared Care Plan
- www.PatientPowered.org support for DM and CHR
- Design work flow in clinics and hospital
- Medication reconciliation
- Diabetes education
- Transition of care
- Patient Advisory Committee
- Spread of the Shared Care Plan
- Traveled to Burnaby, BC to meet with counterparts
who have manage falls for 7 yrs - Mapping the processes of providing self care in
their homes - Present to visiting communities and legislators
29Patient Action Committee
30(No Transcript)
31www. patientpowered.org
Website serving as central information site for
patients designed by patient team with staff
support
32(No Transcript)
33(No Transcript)
34(No Transcript)
35Patients View of Physicians Medication List
36Hospital CEOs Dream
- Nancy Bitting asks her team and all directors
- Have patients on all design teams, 50 of members
if possible - Patients on design of multidisciplinary care and
implementation of major EMR upgrade - Patient on Pharmacy and Therapeutic Committee
37(No Transcript)
38A System Supporting the Re-Socialization of
Chronic Conditions
- With and by patients
- They have a network of supporters
- They have capacity
- They have ideas, they can lead
- A return from the over medicalization of life
- BMJ article, Too Much Medicine, suggesting
balance is possible
39The Real Challenge
- Jointly identify win-win opportunities that
optimize the system of care as seen from the
patients perspective - Across organization lines
- Manage these opportunities from invention to
implementation - Across organizational lines
40(No Transcript)