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

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LeadershipThe Cross Settings II BPIP will provide direction to leaders initiating orenhancing care transition processes and practices for chronic care patients.Approaching chronic care management within the framework of a continuum ofcare provides the leadership with the ability to view the problem from acommunity perspective. Key practices/interventions that may assistleadership with this include: Disease Management, Self-careManagement Support, and Home Telehealth. These practices arefeatured in BPIP. To further support these topics, the agency success stories focuson:• Working in a care transition community to provide care across thecontinuum with multiple settings and multiple providers• Improving the skills of the nursing clinical staff to maximize the effect of adisease management/telemonitoring program• Using telemonitoring toimprove chronic diseasemanagement and decreaserehospitalizationsInsights are also providedthroughout the BPIP with practicalideas on applying selected bestpractices within an agency. Tools“Rehospitalization may be better viewed as a healthcare system problem than a hospital problem,because care fragmentation is a property ofthe whole system.”“Almost every institution and individualinvolved in a patient’s care can contribute topreventing rehospitalization.” Jencks, 2010, p.757.and resources are abundant in this BPIP, either through embedded links or aspart of this BPIP. Leaders should use the BPIP as a guide to either adopt newtools and/or revise existing tools. Leaders must ensure all agency resources areevidence-based.Rehospitalizations and fragmentation of care delivery are two of the many illsand challenges that plague our health care system. Solutions to overcoming thesechallenges are presented in this BPIP. The BPIP and tools can be used by allhealth care providers in all provider settings based upon the results of their ownneeds’ assessments. Often thesmallest change can make a bigdifference.For example:• Brief Action PlanningChecklist (page 42)• Partnering with Patientsand Families to AccelerateImprovement: ReadinessAssessment (page 43-44)• Tools available through theWeb Links (page 33-37)Using the BPIP across settings:“We have reviewed the fall prevention (BPIP) content ina brief PI meeting held recently with the administrator inattendance. We did not go into great detail at the time;the committee was informed as to the nature of thecontent, some of the tools available to assist the staff, andhow to involve the local PI and Case Management nursesat our local hospital (continuity of care/ transitions ofcare). We plan to incorporate the Best Practicesinto a bi-partisan (Hospital-Home Health)program. Their patients are ours and vice versa. Wehave already contacted the responsible person at thehospital and she is excited about working together.” GailBatson, RN, MSN. QA/PI Coordinator, Harmony HomeHealth, Inc. Natchitoches, LA- 8 -
CHRONIC CAREIt may assist leadership to approach chronic care management across thecontinuum as a framework from which to view the problem from a communityperspective. A close look at a model for chronic care may provide participantsfrom all health care settings with a lens to better view the spectrum andunderstand the challenges and solutions for caring for the chronically ill.“The Chronic Care Model (CCM) identifies the essential elements of a healthcare system that encourage high-quality chronic disease care. These elementsare the community, the health system, self-management support,delivery system design, decision support and clinical informationsystems. Evidence-based change concepts under each element, in combination,foster productive interactions between informed patients who take an active partin their care and providers with resources and expertise. The model can beapplied to a variety of chronic illnesses, health care settings and targetpopulations. The bottom line is healthier patients, more satisfied providers, andcost savings”. The Chronic Care Model"Copyright 1996-2010 The MacColl Institute. The Improving Chronic Illness Care program issupported by The Robert Wood Johnson Foundation, with direction and technical assistanceprovided by Group Health's MacColl Institute for Healthcare Innovation".- 9 -
Page 1: Best PracticeIntervention PackageCr
Page 5 and 6: Quick Start GuideQUICK START GUIDE:
Page 7: Source: Wu, Shin-Yi and Green, Anth
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 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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