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

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CHECKLIST FOR AGENCY LEADERSHIPASSIGNEDNOTESDATESUGGESTED ACTIVITIES:TO:COMPLETE:preventing pressure ulcers and chronic disease maintenance.Confirm how your patients are made aware of their risk forhospitalization and how staff is documenting this.Incorporate the Self HRA for patient use to promoteunderstanding of their risk.Use the Personal Health Record for patients to takeownership of their health record—and provide acommunication tool that can be used between all settingsInclude a caregiver or patient representation to youragency’s teams (board, quality team, etc.).Use the Partnering with Patients and Families toAccelerate Improvement Readiness Assessment(page 43-44) to assess organizational readiness.Incorporate / expand your agency’s telehealth program(telephonic support and / or telemonitors).• Evaluate if protocols current.• Evaluate if all monitors are in use—if not set goals toincrease monitor usage until 100% are utilized.• Confirm your patients at high risk for hospitalizationreceive a monitor or phone support. (see PatientSelection Criteria: Home Telehealth for Heart Failure,page 48; Flow Chart for High-Risk Patient - AssociatedResources )Explore patient care alternatives for when you may not havethe staff to implement telehealth or if a patient continues torequire care but is no longer homebound. This couldinclude coordinating vendor service providing telehealth to
CHECKLIST FOR AGENCY LEADERSHIPASSIGNEDNOTESDATESUGGESTED ACTIVITIES:TO:COMPLETE:the patient with or without agency input.Read and share journal articles and BPIP success storieswith staff and use as an example to develop/enhance youragency chronic disease management and telemonitoringprogram. Hall and Morris (2010) share their agency’s storyto develop an evidence-based disease management andtelemonitoring program. This is in the November/December2010 issue of Home Healthcare Nurse.Post mini-posters from some pages in this BPIP• Page 9—The Chronic Care Model• Page 20- Patient-Clinician Interaction Level TipsUse the parts of this BPIP (e.g., Focus Section--individual orall excerpts) to share with board of directors, owners, othercare settings.
Page 1: Best PracticeIntervention PackageCr
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 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: 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
Page 55 and 56: Best Practice Intervention Package
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
Page 63: http://www.fda.gov/downloads/Medica

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