San Diego Long Term Care Integration Project

LTCIP Planning Committee

September 23, 2008

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

“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!

LTCIP Strategies Developed to Support “Vision”

• Communication Strategy (Aging & Disability Resource Connection)

• Physician Strategy (TEAM SAN DIEGO)

• Fully Integrated Health Care Strategy

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

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

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

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

For more information:

• See website for background & info: www.sdltcip.org

– Call or e-mail: brenda.schmitthenner@sdcounty.ca.gov

858-495-5853

TEAM SAN DIEGO

Highlights from: Review and Discussion of

On-line Modules

– 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

Medical & social service coordination for chronic care needs to improve:

13

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

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 doctor’s office visit.

Improves systems to serve complicated and costly patients and improve satisfaction and outcomes.

Helps the physician’s office deal more efficiently with the complexity of using social supports along with medical services.

Results in efficiencies in practice management and patient safety.

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

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

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 tomeet at the same time and place

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

Informed,Activated

Patient

ProductiveInteractions

Prepared,Proactive

Practice Team

DeliverySystemDesign

DecisionSupport

ClinicalInformation

SystemsSelf-

Management Support

Health System

Resources and Policies

Community

Health Care Organization

Chronic Care ModelChronic Care Model

Improved OutcomesFigure 1 from Wagner, E.H. Chronic Disease Management: What Will It Take to Improve Care for Chronic Illness? Effective Clinical Practice, 1998; 1:2-4

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

21

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 individual’s own pace; cannot be given, BUT can be helped by providing information, tools, and skills.

22

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

23

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

24

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

25

The Four Pillars

Dr. Coleman’s 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

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

Working with Diverse Patients

28

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

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

30

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?

31

Teach Back Method of Communication

Well documented patient-provider communication strategy

Health literacy approach: “Communication loop” that supports patient understanding of provider instructions

Provider determines

if the patient understands

the instructions or info

communicated

Provider clarifies and rephrases so

that patient can understand it

Provider asks patient to

restate information in his or her words

32

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

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

Response to Red Flags

• Define level of urgency

• Speak with individual’s primary care physician or office staff based on urgency

• Speak with individual’s caregiver about your observation

• Offer assistance in finding resources for assessment and treatment/services

• Document your activities

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.

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

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…

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 don’t have to be perfect—don’t stress over developing a relationship

– Make no assumptions!!

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 one’s needs met, and to adapt to stressors

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

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

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 organization’s “Notice of Privacy Practice”

– File a complaint if they believe their rights are denied or their info is not protected

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

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

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

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