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

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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 -
DIABETESCenters for Disease Control and Prevention (CDC) recently announced thatnearly 26 million Americans have diabetesand an estimated 79 million U.S. adultshave prediabetes. Dr. Albright, director ofCDC’s Division of Diabetes Translation,states that “these distressing numbersshow how important it is to prevent type 2diabetes and to help those who havediabetes manage the disease toprevent serious complications suchas kidney failure and blindness”. Theinformation below describes strategies forpromoting better management ofdiabetes.The AADE7 Self-Care Behaviors fordiabetes are:• Healthy eating• Being active• Monitoring• Taking medication• Problem solving• Healthy coping• Reducing risksMore information on the AADE7 selfcarebehaviors click here.“Diabetes education, also known as diabetes self-management training (DSMT)or diabetes self-management education (DSME), is defined as a collaborativeprocess through which people with or at risk for diabetes gain the knowledge andskills needed to modify behavior and successfully self-manage the disease and itsrelated conditions. DSMT/DSME is an interactive, ongoing process involving theperson with diabetes (or the caregiver or family) and a diabetes educator(s). Theintervention aims to achieve optimal health status, better quality of life andreduce the need for costly health care” (American Association of DiabetesEducators --AADE).The ADE7 TM self-care behaviors are listed in the box above.Patient resources, which include a self-management plan for each behavior, areavailable for each of the behaviors at this link.Franz, et al., (2010) reviews the evidence and nutrition practicerecommendations presented in the American Dietetic Association NutritionPractice Guidelines for Type 1 and Type 2 Diabetics in Adults. The article shares29 key nutrition practice guidelines to support diabetics. This includes therecommendations on assessing patient needs, selecting interventions, andmonitoring and evaluating outcomes. The evidence supports medical nutritiontherapy provided by a registered dietitian (RD). Some of the keyrecommendations include:• Consistency in day-to-day carbohydrate intake for persons with type 2diabetes• Adjusting insulin dose to match carbohydrate intake for persons with type1 diabetes• Focusing on total carbohydrate intake rather than the type of carbohydrate• Cardio protective nutrition interventions• Weight management strategies• Regular physical activity• Use of self glucose monitoring data to determine if goals are being met- 15 -
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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 13: The Bottom LineLeaders must create
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
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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
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Page 53 and 54: TRACKING DATA AND MEASURING PROGRES
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Page 61 and 62: Coleman, E.A. (2003). Falling throu
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