nicheprogram.org • 2016 Annual NICHE Conference • Care Across the Continuum 1

Professional Practice and Development Specialist-Shannon Patel, BSN, PCCN,CCRN-CMC

APN/DNP Student

Clinical Informatics Specialist-Summer Tinkcom MSN,RN

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Manage Me Model©

Improving the Self Management Practices of Patients with Chronic Conditions

“We’ve Got An App For That!”

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At the completion of the presentation participants will be able to:

• Recognize that Manage Me Model© is foundational to the delivery of all chronic condition education across transitions in care

• Identify at least 3 opportunities for improvement with your current patient education delivery system

• Describe at least 3 benefits of adding technology to the model that have empowered patients

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The Facts

• 1 of 4 adults had 2+ chronic health conditions (2012)

• 7 of the top 10 causes of death since 2010 have been related to chronic diseases

Diabetes is the leading cause of:

• kidney failure

• lower-limb amputations (other than those caused by injury)

• new cases adult blindness

• Heart disease and cancer combined accounted for approximately 48% of all deaths.

• Heart failure is the most common diagnosis in hospital patients age 65 years and older.

• The Center for Health Information and Analysis reported that CMS spent $17 Billion for avoidable readmissions in 2014

(Ward, B.W., 2014)

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What are the costs of Chronic Conditions?

Prediction: 2024 the annual healthcare costs will cost our country approx. $4.3 trillion per year

This includes direct and indirect care costs such as re-admission and other care management related penalties

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Alignment

History

• CMS, TJC and others have identified the impact that self-management practices have on health maintenance

• Agency for Health Research and Quality (AHRQ) identified the role of nurses in improving self-management practices

Manage Me Model©

• TJC have recognized the Manage Me Model© inspired Heart Failure Toolkit as best practice for nurse innovation (2010)

• Magnet commendation for innovative nursing practice (2014)

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Opportunities Within Current Self Management Education

• Multiple educators(Nurses, Physicians, Health-Coaches, etc.) all with varied levels of expertise and confidence

• Varied educational resources across continuum• Lack of standardization across the continuum- led to

inconsistent and conflicting information• Adult Literacy & Health Literacy• Cultural sensitivity• Time constraints• Missed opportunity to maximize available and

popular technological advances

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How We Broke the Cycle

• Reviewed countless educational tools

• Critiqued our own teaching practices

• Realization- We knew what to teach, we just had to figure out how to teach it!

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Theory that Underpins the Manage Me Model©

• Based upon concepts of Adult Learning Theory

• Inspired by the Self Care Theory, Goal Attainment Theory, Health Promotion Model, Health Beliefs Model

• Uses “Best Practice” and guideline information determined by the specific chronic condition

• Incorporates the “Teach Back Method” to ensure frequent knowledge assessment

• Based upon the experiences of nurses and other healthcare providers to ensure practicality

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Our Heart Failure Tool Kit (2010)

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Our Diabetes Tool Kit (2014)

Tool Kits in production for:

• COPD

• Smoking Cessation

• Anticoagulation mgt.

• Wellness Promotion

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Evidence

• 6 month inpatient pilot program (2009)

• Patients were able to verbalize understanding of self management tasks during follow-up phone calls and visits

• Readmission numbers declined during pilot and rebounded when pilot was discontinued

• Patient and educator positive testimonials

• Reproducible results have been reported

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WIFM – Patients and Caregivers

• Improves knowledge

• Eliminates overwhelming paperwork

• Encourages a proactive health routine

• Increases adherence

• Patient accountability

• Provides a mechanism for the easy transmittal of VS, S&S and weights to providers

• Engages patient + caregiver

• Frequent educational reinforcement

• Reminders for medication & self-assessments

• Changes behavior

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WIFM - Nurses

Advantages

• Improves knowledge

• Shift onus of accountability to patient

• Increases patient adhereance

• Eliminates paperwork

• Enables early intervention

• Engages caregiver

• Efficient use of resources

• Promotes collaboration between educators across continuum

Tool Kit Flip Chart, Reminder Card, App

• Scripts & standardizes education

• Progresses at patient’s pace of learning

• Integrates patient knowledge assessment via “teach-back” method

• Decreases the amount of “handouts” provided patients

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Optimizing Technology – Welcome to our Family of “Mobile ME” Apps

Through a collaborative effort between our web developers, nurses, content experts, and clinical informatics team, our first Chronic Condition Self-Management App was developed and released to the public (2012)

“WOW ME 2000”

“MEET ME @ 7”

Download these free apps on-

Apple App Store & Google Play

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A simple and effective approach to Heart Failure Self-Management

Supports heart failure patients & caregivers ability to:

• Learn/ perform daily self-management tasks

• Early recognition of heart failure decompensation

• Maximize over-all wellness

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Mobile Health (mHealth)“Medical and public health practice supported

by mobile devices”

•Ubiquitous use of mobile devices in society

•Bridge the gap between medical visits

•Inexpensive and timely

•Targets triple aim goal Improve patient

experience and health of populations while

reducing cost of healthcare

•Enhances patient engagement

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Patient Engagement

“Actions individuals must take to obtain

the greatest benefit from the health care

services available to them”

•Empowers patient

•Promotes partnership with medical care team

•Fosters individualized plan of care

•Encourages patient commitment to health goals

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What do patients want?

• Hundreds of mobile healthcare apps on the market

• Adoption increases with > 2 engagement features

• Self- monitoring & progress tracking most widely used features

• Interoperability/ Sharing of data

• Support group/ Social network

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The 5 Phases of Patient Engagement

Support My e-Community• E-Community Support

• Televisits

Partner With Me • Interoperability (Devices, EHR/Portal)

• Real-time Feedback

Empower Me• Secure messaging• Evaluation of Symptoms

• SMART goals

Engage Me• Manual health tracking/ notifications• Weight, BP, HR, I/O, Activity, Sodium

• Medication reminders

Inform Me• Patient education

• Phone directories

• How does the WOW ME 2000 app engage our patients?

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Patient Engagement

Navigating the App

• WOW ME 2000mg acronym

• Navigation Bar

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My Profile• The basic My Profile allows

patients to enter settings based on their individualized care plan

• Enter healthy weight

• Enter systolic and diastolic range

• Enter heart rate range

• Enter primary care provide & cardiologist info.: name, number, and email

• Enter pharmacy number

• Enter emergency number

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Contact list

• Stores phone numbers for key medical care team members

Smart Goals

• Allows input and tracking of individualized Care Plan goals

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Symptom Assessment and Alerts

• The tool evaluates manually entered data against Patient Profile ranges

• Triggers warning alerts if outside of desired ranges

• Instructs patient to contact care provider

• Tap on the alert to link to the phone directory

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edications

• Upon tapping into medication tracker, prompt appears to verify at least 7 days of medications

• If no, patient is prompted to Call Pharmacy

• If YES, patient can

• View and update Current Medication List

• Record medication as taken

• Set reminder alerts

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valuation of Symptoms•This Symptoms checker helps patients to log how they are feeling each day

•It helps patients to identify and take early action when they start to have signs and symptoms of heart failure decompensation

•The tool will offer guidance depending upon the patients selections

•Tap one or more symptoms and select “Evaluate”

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Zones: Green ● Yellow● Red

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Log• Displays running log with date,

measurements and zone

• Includes ability to Share a 7 day, 30 day, or 90 log via email

• Stores emails of medical team for timely and convenient sharing of data

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World Wide Downloads

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Future Plans• Continued research and Practice Improvement projects support the

validity of the apps (Capstone!)

• Ability to simulate tele-monitoring by syncing withcompatable BP cuff, scale, glucometer, etc.

• Interconnect ability with all apps - patients with multiple conditions will benefit from using just one!

If you think that our Self Management Education Toolkits may help your patients with their chronic conditions I am happy to

share this innovation and would love to hear how you have used it – Please complete the letter of interest form in your

packet and hand back to me!

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Contact

Shannon.patel@atlanticare.org

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References

• Center for Advancing Health. (2010). A new definition of patient engagement: What is engagement and why is it important? Retrieved from http://www.cfah.org/pdfs/CFAH_Engagement_Behavior_Framework_current.pdf

• CMS.gov Centers for Medicare and Medicaide Services. (2016). https://www.cms.gov/Medicare/medicare -fee-for-service-paymnets/acuteinpatientPPS/readmission-reduction-program.html

• Centers for Disease Control and Prevention-Chronic Disease Prevention and Health Promotion. (February 17,2016). www.cdc.gov/chronidisease/stats

• Do, V., Young, L., Bamason, S., & Tran,H. (2015). Relationships between activation level, knowledge, self-efficacy, and self management behaviors in heart failure patients from rural hospitals. US Library of Medicine National Institute of Health. Retrieved from http://dx.doi.org/10.12668/f100research6557.1

• Eng, D.S. & Lee, J.M. The promise and peril of mobile health applications for diabetes and endocrinology. Pediatric Diabetes, 14. doi:10.1111/pedi.12034

• Janz N., K., Becker, M.,H., (1984). The health belief model: A decade later. Health Education Quarterly, 11(1),1-47.

• Martinez-Perez, B., Torre-Diez, I., & Lopez-Coronado, M. (2013, June). Mobile health applications for the most prevalent conditions in the world health organization: Review and analysis. Journal of Medical Internet Research, 15(6). doi:10.216/jmir.2600

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References

• National eHealth Collaborative. (2012). The patient engagement framework. Retrieved from http://www.nationalehealth.org/patient-engagement-framework

• Polit, D., F., Beck, C., T., Nursing research: Principles and methods (7th ed). Retrieved from Lippincott Williams and Wilkins

• Reardon,S., (2015). Avoidable readmissions cost CMS $17 billion. RevCycle Intelligence. Retrieved from http://revcycleintelligence.com/news/preventable-readmissions-cost-cms-17-billion/

• Sama, P.R., Eapen, Z.J., Weinfurt, K.P., Shah, B.R., & Schulman, K.A. (2014, May). An evaluation of mobile health application tools. JMIR mHealth and uHealth, 2(2). doi:10.2196/mhealth.3088

• Su, Y., Knoth, J., Patel, S., (2014). Improve cardiac health and prevent avoidable heart failure readmissions: There’s an app for that! Remington Report, 24-31. Retrieved from remingtonreport.com/images/rem_nd14-Readmissions.pdf

• Ward BW, Schiller JS, Goodman RA. Multiple chronic conditions among US adults: a 2012 update. Prev Chronic Dis. 2014;11:130389. DOI: http://dx.doi.org/10.5888/pcd11.130389

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Questions?

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