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Patient Centered Processes Pursuing Perfection

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Title: Patient Centered Processes Pursuing Perfection


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Patient Centered ProcessesPursuing Perfection
  • Whatcom Community
  • Marc Pierson
  • Nancy Stothart

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Community-wideConnection Communicationwith
for PATIENTS who live withCHROINC CONDIDTIONS
Whatcom Community Marc Pierson Nancy Stothart
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Institute of Medicine
  • Six Aims
  • Patient centered
  • Safe
  • Timely
  • Effective
  • Efficient
  • Equitable

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IOM
  • 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.

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It Takes a Community
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P2 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

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Involving Patients in the Process
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Patient 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

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How 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

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PATIENTS EXPERIENCE
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THE DILEMMA
  • Too little connection
  • Too little communication

TWO IMPORTANT SOLUTIONS
  • Clinical care specialists
  • Shared care plan

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Changing 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

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Rebecca Brysons Conditions and Virtual Care Team
Pursuing Perfection in Whatcom CountyApril 2003
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Rebeccas Communication Burden
Pursuing Perfection in Whatcom CountyApril 2003
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Virtual Care Teams
  • Patients with multiple conditions are often
    left at the center by default
  • Resources surrounding and supporting are
    necessary

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Information
  • The focus shifts
  • from EMR
  • (organization specific business medical records)
  • to include PHR
  • (patient health records)

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Business RecordsPaper or Electrocuted
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Video InnovationsIn Chronic Care Management
  • Whatcom Community
  • Robert Wood Johnson Foundation
  • Crosskeys Media

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Simple Rules for the 21st- Century Health Care
System
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Patients 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

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The 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

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What 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

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Patient Action Committee
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www. patientpowered.org
Website serving as central information site for
patients designed by patient team with staff
support
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Patients View of Physicians Medication List
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Hospital 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

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A 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

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The 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

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