Presentation to Rural Wisconsin Health Cooperative Board of Directors

Transcription

1 Presentation to Rural Wisconsin Health Cooperative Board of Directors Gina Dennik-Champion RN, MS, MSHA WNA Executive Director and Grant Project Director September 9, 2016 Grant Deliverable Wisconsin s health care delivery systems will be aware of the tools and resources available to implement patient-centered team-based care populations with chronic disease hypertension and diabetes hiding in plain sight diagnosed not in control diagnosed in control Team-based care is the provision of health services to individuals, families, and/or their communities by at least two health providers who work collaboratively with patients and their care givers to the extent preferred by each patient to accomplish shared goals within and across settings to achieve coordinated high-quality care. Source: Naylor, Coburn, Kurtzman (2010)

2 A starting point Redesign strategy Review of the literature Interdisciplinary support and advice Antecedent conditions needed for development Roles and responsibilities of key stakeholders Patient is the central focus. Care to me Care with me Care by me Relationship to the other elements (team, parentorganization and workforce) Self-management activity

3 Organizational Leadership Provide infrastructure and support the team to assure: -Proactive work -Sustainable action -Shared culture -Shared vision -Shared values -Services connect to community resources to improve and protect health The team functions as the microsystem of the parent organization. It functions as a prepared, proactive team. It has its own set of adopted principles, team-based processes, and actions. Full array of both licensed and assigned team members working interprofessionally. Diversity reflects community demographics. Interprofessional members are needed to practice to the full extent of their education, training and experience (top of license) Preparation in Interprofessional Education Demonstrate team values of honesty, discipline, creativity, humility and curiosity Supply and Demand

4 Guide action, behavior, and performance: -Shared goals -Clear goals -Mutual trust -Effective communication -Measurable processes & outcomes High functioning team Partnerships with patients Patient engagement Safe, competent & evidencedbased care Community connections Population health Share same core values Care is facilitated by registries (IT) Increase access to care and services Improving patient experience of care (including quality and satisfaction). Improving the health of populations. Reducing per capita costs of health care. Proposing a new aim: Provider satisfaction (Quadruple Aim)

5 Sampling the Extent of Patient-Centered Team-Based Care Delivery in Wisconsin To learn, how patient-centered team-based care is being delivered in Wisconsin. Nine semi-structured interviews with Wisconsin Health System leaders. Survey report will include quantitative and qualitative data on a host of grant-related performance measures with an emphasis on hypertension and diabetes. Pre-tested survey instrument Description of the health system including role/responsibilities of interviewee; Readiness, organizational support, and context for team-based care in the health system; Extent of patient self-management for hypertension and diabetes; Staffing; and Challenges, successes, and advice. Timeframe May 27, 2016 June 12, 2016 Face-to-face up to 90 minute interview One to two interviewees per system Interviewer: An advanced practice registered nurse with extensive experience in teambased care and national board certification as a diabetes educator. Report will be presented at WNA October 21, 2016 Conference

6 Aurora Health Care, Inc., Milwaukee Oneida Tribal Clinic, Webster Froedtert and Medical College of Wisconsin, Wauwatosa Sauk Prarie Healthcare, Prairie Du Sac Group Health of Wisconsin, Madison ThedaCare, Appleton Gundersen Health Care, LaCrosse, WI UW Health, Madison Ministry Health Care Beyond the 50%: It Starts with Blood Pressure Measurement Less than 50% of the US population diagnosed with hypertension are in control Errors in measuring BP are prevalent Utilize the M.A.P. Framework which has been developed by the American Medical Association. MAP stands for: Measure; Act; Partner. MAP was developed in response to recommendations from Million Hearts. Increase the number of nurses and assistive clinic staff in gaining knowledge related to proper blood pressure measurement. Providing opportunity for train-the-trainer Created an on-line, on-demand educational offering that provides justification, the skills and techniques for measuring Blood Pressure. Offer CNE and/or Certificate of Attendance. 115 participants since July 10, 2016 We need help in spreading the word

7 1. Apply the patient-centered team-based care conceptual model against the condition of hypertension. 2. Identify evidence-based processes and practical strategies used by the three core elements of the conceptual model: a. Health care teams in primary health care settings. b. Parent organization that houses the team. c. Diverse, interprofessional workforce. 3. Refine, present, and disseminate this document for health care and public health improvement in October 2016 and include as a practical appendix to the forthcoming collaboratively-developed conceptual model of patientcentered team-based care in Wisconsin. Clinical and Interprofessional Education Considerations for Patient-Centered Team- Based Care Friday, October 21, :30 am 4:15 pm Marriott West Hotel, Middleton, WI