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

DISEASE MANAGEMENTDisease ManagementDisease management is a system of coordinated health care interventions andcommunications for populations with conditions in which patient self-careefforts are significant.http://www.carecontinuum.org/dm_definition.aspThe chronic disease list is long, but cardiovascular disease, diabetes, and COPDfigure significantly in home care admissions.CARDIOVASCULAR DISEASEWhat can an agency do to ensure the best possible is provided to theirpatients? First, make certain you have received all necessary patient-centeredinformation from the upstream provider/setting. Additionally, the use ofevidence-based practices and guidelines which are delivered by competent staffsupports an agency of excellence. Here are three foci for evidence-based practicestandardization and improvement for easy access and potential implementationrelated to the management of those patients with cardiovascular disease:• American Heart Association / American Stroke Association provides a“Learning Library” with current evidence-based standards / guidelinesand webinars as well as electronic patient education tools for the moretechnology-savvy patient / caregiver.• Heart Failure Nursing Certification will be offered for the first time inJune, 2011 by the American Association of Heart Failure Nurses (AAHFN).This certification is for those wishing to remain competitive in the marketplace by demonstrating responsibility for providing the best possible heartfailure care. “The purpose of this certification is to promote the higheststandards of practice within the specialty, to validate attainment of acommon knowledge base required for practice, and to encourage andpromote continued educational growth”(AAHFN Media Release).• Hospital to Home (H2H) is organized by the American College ofCardiology (ACC) and the Institute for Healthcare Improvement (IHI) andseeks to improve patient care during transitions from inpatient tooutpatient setting for patients with cardiovascular disease. The overallgoal is to reduce rehospitalizations. H2H provides resource toolkits, bestpractices, and shares tactics from experts and other health care providersall free of charge. H2H incorporates the viewpoints of patients and familycaregivers, clinicians across the continuum of care, integrated healthsystems, communities, policy-makers and payers.- 14 -