INCORPORATING THE CHRONIC CARE MODEL TO IMPROVE ACTIVATION, ENGAGEMENT, SATISFACTION, AND HEALTH OUTCOMES

Transcription

1 INCORPORATING THE CHRONIC CARE MODEL TO IMPROVE ACTIVATION, ENGAGEMENT, SATISFACTION, AND HEALTH OUTCOMES Marcia A. Potter, Col, USAF, NC, DNP, FNP-BC Master Clinician FNP FNP Consultant to the AF/SG

2 Identify how elements of the Chronic Care Model can be used to create a planned, proactive visit Explain how clinical leaders can use the Chronic Care Model to improve staff activation, engagement, and satisfaction Describe how clinical teams can use the Chronic Care Model can be used to foster patient activation, engagement, and satisfaction OBJECTIVES

3 The Military Health System has a unique mission to provide care for a diverse population while maintaining mission readiness to meet the United States national security needs. Similar to the American healthcare system, the MHS is designed for episodic rather than longitudinal care The result is fragmented care, stressed healthcare teams, frustrated patients, sub-optimal health outcomes, and excessive expenditure Longitudinal care is designed to address chronic health conditions and assist patients to become activated and engaged INTRODUCTION

4 Fragmentation Stress Purpose Meaning Outcomes BACKGROUND

5 The purpose of this project is to effectively incorporate elements of the Chronic Care Model into daily practice, creating activation and engagement as evidenced by: Staff Confidence/Conviction Ruler Staff Satisfaction Surveys Patient satisfaction Confidence/Conviction Ruler Exit surveys Patient health outcomes Hemoglobin A1C levels PURPOSE

6 Ray s Theory of Bureaucratic Caring The integration of humanistic, social, ethical, religious/spiritual, political, economic, technological, and legal caring. (Davidson, Ray & Turkel, 2011, p xxxii). Chaos Theory Small events cause changes many orders of magnitude greater than the originating event; all events lead either to increasing order or disorder (Fractal Foundation, 2015). The Chronic Care Model Using the planned, proactive visit to create longitudinal, therapeutic relationships that foster activation and engagement to improve health outcomes (IHI, 2006). THEORY & CONCEPTUAL FRAMEWORK

7 "For patients with diabetes, does the implementation of the Chronic Care Model lead to increased patient satisfaction, staff satisfaction, and improved self-management skills as evidenced by decreased Hemoglobin A1Cs (HbA1C) within three months? PICO-T

8 Employ all staff at the top of their skillsets Activation Engagement Satisfaction Allot time specifically to address chronic health issues separately from acute health concerns Create time-based schedule templates Establish longitudinal relationship Incorporate shared decision-making with patients Activation Engagement Satisfaction Health Outcomes PROJECT DESCRIPTION

9 For patients with no healthcare encounters in past 6 months and for patients who called in for refills Apply the Nursing Process Assess Plan Self-Management, glucose testing, results, medication adherence, barriers & successes Do they need supplies, labs, meds, preventive care, appointment? Implement Evaluate Enter order for the items identified Understanding of plan of care, when/where to pick up supplies/meds; when/where to get labs done, next appointment; BRING ANY QUESTIONS DOCUMENT IN AHLTA NURSING

10 For patients scheduled for a clinic visit within the next 2 weeks Review record: Contact patient and remind them to get labs done Remind to pick up supplies and/or bridge medications Enter orders for any primary preventive services (mammo, CRC screening, etc) DOCUMENT IN AHLTA (Open Not Checked In) Normal screening process at the visit Ensure patient enrolls in Micare Remind to complete primary prevention- including IMMUNIZATIONS! MEDICAL TECHNICIANS

11 At the healthcare encounter: Review all pertinent lab and screening data with patient Review nursing information with patient Conduct necessary exam Propose plan of care Tailor plan to patient s needs, goals, desires CLINICIANS

12 Formative Data Peer Review Summative Data Confidence (Engagement) Non-parametric analysis: Mann-Whitney Patients-t=5.7, p <.001 Staff- t= 2.36, p <.005 Conviction (Activation) Non-parametric analysis: Mann-Whitney U test Patients-t=0.24, p <.004 Staff- no change Satisfaction: Thematic analysis Patients: Appreciation and praise for the staff s CARING Staff: shift in locus of control from external to TEAM-BASED problem-solving Glycosylated hemoglobin (HbA1C) levels Paired t-test; t= 3.32, p<.003; 14% decrease EVALUATION

13 OUTCOME MEASURES Patient Confidence Patient Conviction Patient Satisfaction Staff Confidence Staff Conviction Hemoglobin A1C Pre Post OUTCOMES

14 The essence of healthcare is the relational bond of caring; the choice to care is the magnetic appeal that will keep the universe of nursing, medicine, and health care emerging, unfolding, and enfolding together into a new vision of relational selforganization. (Ray, 2011, p. 105). Incorporating elements of the Chronic Care Model can create activation, engagement, and satisfaction without increasing the need for staffing or financial resources This project innovatively leveraged the power of nursing to create better healthcare, better health, best value, and readiness. IMPLICATIONS FOR NURSING

15 When providers did not have time allotted to address chronic issues, patients simply had to make more appointments Calculating the impact to providers revealed that this author was able to provide better health care and help patients achieve better health while needing 50% fewer appointments. Healthier patients use fewer resources, are more productive, make greater contribution to society Financially, this also represents a projected annual cost savings of $ per patient per year in direct patient care costs (IHI, 2003). IMPLICATIONS FOR HEALTHCARE

16 Create planned, proactive visits, Employ each healthcare team member to the top of their skillset, Allot time specifically to address the chronic health issue separately from acute health care issues, Incorporate shared decision-making with patients in order to create activation and engagement. RECOMMENDATIONS

17 Incorporating the Chronic Care Model can improve activation, engagement, satisfaction, and health outcomes Offers opportunities to expand to other teams and more broadly throughout the AFMS CONCLUSION

18 HEALTHCARE HAPPENS IN A CLINIC HEALTH HAPPENS AT HOME The patient is the expert in their health experience; the clinical team members are the experts in healthcare Intentionally linking meaning and purpose to achieve desired outcomes in true partnership with our patients fosters activation and engagement, creating better healthcare, better health, and undeniable value.

19 Identify how elements of the Chronic Care Model can be used to create a planned, proactive visit Explain how clinical leaders can use the Chronic Care Model to improve staff activation, engagement, and satisfaction Describe how clinical teams can use the Chronic Care Model to foster patient activation, engagement, and satisfaction WRAP-UP

20 QUESTIONS?

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