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

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(Available in English, Spanish, andaudio for the hearing impaired.)American Diabetes AssociationAmerican Heart AssociationAmerican Lung AssociationAmerican Telemedicine AssociationOrganization that is a resource and advocate promotingthe use of advanced remote medical technologies.American Thoracic SocietyAssociation dedicated to advance clinical and scientificunderstanding of pulmonary diseases, critical illnessesand sleep-related breathing disorders.Ask Me 3Ask Me 3 is a patient education program designed topromote communication between health care providersand patients in order to improve health outcomes.Care Continuum AlliancePromotes and aligns population health improvementthrough a patient centric focus on care continuum anddisease management.Care Transitions SMWeb site for the Care Transitions Intervention.- 34 -Includes resources for healthprofessionals: clinical practiceguidelines and researchProvides resources for health careprofessionals: statements, guidelinesand clinical updates.Provides evidence-based clinicalinformation/resources for COPD.Patient resource includes COPDManagement ToolProvides current news /informationand standards/ guidance fortelemedicine.Provides guidance on treatment ofpulmonary diseases and breathingdisorders.Encourages patients to understandthe answers to three questions:1. What is my main problem?2. What do I need to do?3. Why is it important for me todo this?Patients should be encouraged to asktheir providers (doctors, nurses,pharmacists, therapists) these threesimple but essential questions inevery health care interaction.Likewise, providers should alwaysencourage their patients tounderstand the answers to thesethree questions.Resources and guidance for healthcare professionals.Resources include:• Personal Health Record• Patient Activation Assessment• Link to the Four Pillars
The four conceptual areas (referredto as The Four Pillars TM ):• Medication Self-Management• Use of a Dynamic Patient-Centered Record• Primary Care and SpecialistFollow-Up• Knowledge of Red FlagsCenters for Disease Control and PreventionThe CHAMP programThe first national initiative to improve home carequality for older persons.Chronic Care: Making the Case for Ongoing CareGlobal Initiative for Chronic Obstructive LungDisease(GOLD)The GOLD works with health care professionals andpublic health officials to raise awareness COPD and toimprove prevention and treatment for patients aroundthe world.HealthSciences InstituteThe HealthSciences Institute is a multidisciplinarycollaborative and health care certification, development,and resource organization founded in 2003.- 35 -Provides two easy ways to find outabout diseases and conditionsthrough an A-Z Index or thorough theTop Requested Diseases &Conditions. Information is availableon chronic and acute diseases.Provides programs & learningdesigned specifically for home healthmanagers and staff, and freeevidence-based resources (includingtools) for transitions, carecoordination, rehospitalization, andother topics to assist in managinghome care patients with chronicdiseases.A 2010 update of the Robert WoodJohnson Foundation’s 2002chartbook, examines the impact ofchronic conditions on individuals andtheir caregivers, as well as theinadequacies of the U.S. health caresystem to meet their needs.GOLD 2010 Pocket Guide (for healthcare professionals)Patient GuideHealthSciences prepares health careorganizations and professionals for anew health care environment inwhich chronic, not episodic,conditions are the biggest threats tohealth. HealthSciences developed theChronic Care ProfessionalCertification Program—review theirWeb site for current chronic careinformation.
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 and 28: CHECKLIST FOR AGENCY LEADERSHIPASSI
Page 29 and 30: CHECKLIST FOR AGENCY LEADERSHIPASSI
Page 31 and 32: Motivational Interventions (CMI) Pa
Page 33: Tools/Resources available through W
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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