Best Practice Intervention Package - Kansas Foundation for Medical ...

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Cross Settings II BPIP Resource TableAgency Goals First Steps BPIP ResourcesTo effectively educateclinicians to care for patientswith advanced diseaseInvest in educationalresources for staff.Look to community expertsto provide assistance andup-to-date information.BPIP offers success stories to showhow agencies educated staffBPIP recommends Agency forHealthcare Research and QualityClinician GuidesBPIP recommends standards andguidelines from national diseasebasedorganizations (e.g., AHA, ADA)To effectively utilizetelemonitoring andtelephone supportTo encourage patients tobegin self-management onday one of admissionTo work effectively withother health care providersExamine patterns of useand protocols for assigningservices.Evaluate hospitalizationrate for target populationbefore and after telemonitoruse.Drive home importance ofassigning scarce resourceswith inspiring real lifestories where technologymade a difference.Educate staff about theimportance of patient selfmanagement.Distribute resources topatients to foster selfmanagement.Take the lead to improvecare transitions in yourcommunity.BPIP offers experts’ telemonitoringadviceBPIP recommends Using TelephoneSupport to Manage Chronic DiseaseBPIP offers Home Telehealth DiseaseManagement Series featuring PatientSelection Criteria: Home Telehealthfor Heart FailureBPIP recommends Partnering inSelf-Management Support: A Toolkitfor CliniciansBPIP offers Self Hospitalization RiskAssessmentBPIP Focus section offers PalliativeCare Track: Focus on CareTransitionsBPIP Focus section outlinesadvantages of working together inWhat’s In It For Me?
The Bottom LineLeaders must create an operational environment that ensures availablity ofevidence-based practice standards. Review current evidence throughliterature reviews and organization sites devoted to specific diseases (e.g.,American DiabetesAssociation). Refer to theTools/Resources availablethrough Web links (page 33-36) for quick links to severalweb sites that offer evidencebasedresources andguidelines.“Health care is changing and chronic diseases areamong the biggest threats to health worldwide andaccount for over 75% of health care spending. In thisnew health care environment a broader applicationof evidence-based care standards is the best hopefor promoting consumer health, independence andresource management.” Health Sciences InstituteSuggestions on ways to incorporate and apply evidence-based practice include:• Revise agency education guidelines and protocols to make certain they arecurrent with the most recently published treatment guidelines• Integrate the standards into orientation/annual competencies• Reach out to community providers to share/gain knowledge and establishcross settings/provider protocols for the handover of patients living withchronic disease• Ensure that equipment is available and being used to support evidencebasedpractice (e.g., telemonitors)Disease management, patient self-management, and telehealth are essentialinterventions to reduce readmissions and improve quality of life for chronic carepatients. Some specific recommendations on each of these interventions are onthe next few pages—but remember-- effective quality improvement programs willmerge facets from all three interventions.• Disease Management (page 14-16)• Self-Management (page 17-20)• Telehealth (page 21-22)“Chronic diseases, such as heart disease, cancer anddiabetes, are responsible for seven out of every 10 deathsamong Americans each year and account for 75 percent ofthe nation’s health spending. Many of the risk factors thatcontribute to the development of these diseases arepreventable.”Healthy People 2020 News ReleaseU.S. Department of Health and Human Services- 13 -
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Page 5 and 6: Quick Start GuideQUICK START GUIDE:
Page 7 and 8: Source: Wu, Shin-Yi and Green, Anth
Page 9: CHRONIC CAREIt may assist leadershi
Page 15 and 16: DIABETESCenters for Disease Control
Page 17 and 18: SELF-MANAGEMENT: EMPOWERING THE PAT
Page 19 and 20: What is Patient Activation? How Doe
Page 21 and 22: TELEHEALTHTelehealth encompasses a
Page 23 and 24: Focus Section: Improving Care Trans
Page 25 and 26: Checklist for Agency LeadershipHow
Page 27 and 28: CHECKLIST FOR AGENCY LEADERSHIPASSI
Page 29 and 30: CHECKLIST FOR AGENCY LEADERSHIPASSI
Page 31 and 32: Motivational Interventions (CMI) Pa
Page 33 and 34: Tools/Resources available through W
Page 35 and 36: The four conceptual areas (referred
Page 37 and 38: and steps toward them.Self-Efficacy
Page 39 and 40: 1. Goals: Something you WANT to do:
Page 41 and 42: Conviction Ruler0 1 2 3 4 5 6 7 8 9
Page 43 and 44: Partnering with Patients and Famili
Page 45 and 46: Are You at Risk for Going to the Ho
Page 47 and 48: Call Me First!Stay safe and well at
Page 49 and 50: SUCCESS STORIESThere are three succ
Page 51 and 52: Promoting Telehealth as part of a C
Page 53 and 54: TRACKING DATA AND MEASURING PROGRES
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Page 57 and 58: Therapy Track: Focus on Improving C
Page 59 and 60: Home Health Aide Track: Focus on Im
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Coleman, E.A. (2003). Falling throu
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http://www.fda.gov/downloads/Medica
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