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

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A publication from the American Diabetes Association (ADA), Standards ofMedical Care in Diabetes--2010, gives guidance including diabetes care,prevention and management of diabetes complications, diabetes care in specificpopulations, diabetes care in specific situations, and strategies for improvingdiabetes care.COPDCOPD self-care management poses significant challenges for the patient andcaregiver. In addition to managing oral medications, patients often must manageoxygen delivery systems and various inhalers. These inhalers vary not only iningredients; but in technique for self administration. Self-care managementsupport is critical for these patients not only from a quality of life perspective, butalso from a hospital readmission perspective. Ineffective medicationadministration can cause a hospitalization. Without careful instruction atdischarge and return demonstration, one can NOT assume patient/caregiver isprepared to self administer at home. Home care nurses are in the perfectposition to ensure patients are using the device as designed. The status of patientunderstanding and demonstration of appropriate use should be part of theinformation shared between providers during a handover in care. Manyresources are available from disease-based organizations. The American LungAssociation has the COPD management tool that can be used by home carenurses for patient education and to promote patient self-management.The Global Initiative for Chronic Obstructive LungDisease (GOLD) works with health careprofessionals and public health officials to raiseawareness of Chronic Obstructive PulmonaryDisease (COPD) and to improve prevention andtreatment of this lung disease for patients aroundthe world. Guidelines and resources forprofessionals and patients can be found here:http://www.goldcopd.com/PALLIATIVE CAREClinicians need to have an understanding of palliative and hospice care forpatients with advanced disease and recognize when to enlist the help of palliativeand hospice providers. Palliative and hospice care can be a part of diseasemanagement—and unfortunately many people with advanced disease do notreceive this type of care. “Improving care for people with advanced illness meansensuring that they get the appropriate care, at the right time, in the rightplace, in a way they can rely on. This often requires a shift in focus from cure andprevention to alleviating symptoms, making thoughtful decisions, supportingfamilies, and providing ongoing care in the appropriate setting” IHI. Severalresources can be found at the National Hospice and Palliative Care Organization.- 16 -
SELF-MANAGEMENT: EMPOWERING THE PATIENT AND THEIRCAREGIVER“Good self-management support involves collaboration between patient and theircare provider, one in which the provider is a coach as well as clinician and thepatient and family are managers of daily care. Through collaboration patients,family, and providers share information, understand a patient’s goals, and createa plan that all can use to guide care at home and in the clinical setting” IHI.Healthy People 2020On December 2, 2010, the U.S.Department of Health and HumanServices unveiled Healthy People 2020.The Healthy People objective is to“improve the quality of our Nation’shealth by producing a framework forpublic health prevention priorities andactions.” The impact of chronic diseasesis addressed and the goal formeasureable improvement is stated.“Ultimately, patients are the largest healthcare work force available. Investing inpatients to give them the knowledge,confidence, and tools that enable them tobecome an effective and reliable workforcewill be essential to maintain, and hopefullyimprove, the quality of care for most longtermillnesses.”Cleland and Eckman, 2010, p. 1383.Self-management is integrated in some of the objectives for Healthy People 2020.Here are two of the objectives for older adults (the complete list of Older Adult–OA-objectives can be found here:http://www.healthypeople.gov/2020/topicsobjectives2020/objectiveslist.aspx?topicid=31)• OA-3 Increase the proportion of older adults with one or more chronichealth conditions who report confidence in managing their conditions• OA-4 Increase the proportion of older adults who receive Diabetes Self-Management BenefitsHealth care providers must actively understand theeffective interventions that promote self-management:self-management, self-management support, selfmanagementeducation, patient activation, and actionplanning.Self-management is the “individual’s ability to managethe symptoms, treatment, physical, and psychosocialconsequences and lifestyle changes inherent in living witha chronic condition. Efficacious self-managementencompasses ability to monitor one’s condition and affectcognitive behavioral and emotional responses necessaryto maintain a satisfactory quality of life” (Barlow, Wright,Sheasby, Turner, and Hainsworth, 2002, p. 178).- 17 -“Patients are more likelyto succeed with a healthbehavior change when thechange can be related to amatter that is importantto them and when they areconfident that they canachieve the change.”Simmons, Baker,Schaefer, Miller, andAnders, 2009, p. 18.
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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 and 14: The Bottom LineLeaders must create
Page 15: DIABETESCenters for Disease Control
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
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
Page 61 and 62: Coleman, E.A. (2003). Falling throu
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