WISEWOMAN: Lifestyle Medicine Provider Education Care Coordination
AMERICAN COLLEGE OF PREVENTIVE MEDICINE / WISEWOMAN PARTNERSHIP ACPM has a partnership with the Centers for Disease Control and Prevention(CDC) to create and deliver new lifestyle medicine education modules for providers in the CDC WISEWOMAN program The grant is administered through CDC's Division for Heart Disease and Stroke Prevention (DHDSP)
TODAY S MODERATORS AND PANEL MEMBERS Moderators: Ayanna Buckner, MD, MPH, FACPM Principal, Community Health Cooperative ACPM Member Shaylona Kirk, MD, MPH Health Promotion Physician (US Air Force) ACPM Member Panel: Polk County Health Department: Kari Lebeda Townsend, BA, MA WISEWOMAN Program Director Walker s Point Community Clinic: Steve Ohly, RN, NPC Program Manager Maria Perez Garcia, RN Care Management Coordinator Nicole Meirose, BA WISEWOMAN Coordinator
OVERVIEW OF WEBINARS Today: Care Coordination Patient navigation Team based care Patient selfmanagement Coming in August: Systems/Policies Cost reimbursement and value - based models Quality improvement strategies Clinic workflows Population health perspectives
SESSION REMINDERS All participants are in listen only mode We encourage questions and comments Please enter questions into the question box in the GoToMeeting panel Questions will be addressed at the end of the presentation We encourage you to type in the question as they come to mind Session is being recorded
LEARNING OBJECTIVES Participants will: Understand the patient navigation process and how this relates to the WISEWOMAN goals and objectives Be able to describe examples of team based care approaches and how this optimizes the patient experience Understand the key steps of developing a successful patient self management process
PATIENT NAVIGATION
PATIENT NAVIGATION What is patient navigation? Patient navigation improves coordination of patient care and reduces barriers to adherence to care plans
PATIENT NAVIGATION Effective patient navigation: Requires empathy Includes understanding of cultural/ socioeconomic backgrounds Promotes relationship building within healthcare team Identifies patient support resources Source: Colorado Patient Navigator Training Program
POLK COUNTY HEALTH DEPARTMENT Over 18 programs, one of which is the Healthy Women Program (HWP) In last 3 fiscal years, 40% of women diagnosed with breast cancer were younger than 50 Served 1,693 patients in 2016-2017 o 275 were WISEWOMAN participants o WISEWOMAN participants limited by funding 60-70% are Spanish speaking Over 12,000 clinic visits annually
POLK COUNTY HEALTH DEPARTMENT: PATIENT NAVIGATION The WISEWOMAN program provides heart disease and stroke risk factor screenings Those screened and found to be at risk (high blood pressure, prediabetes, diabetes, high cholesterol, etc.) are referred for clinical care and other support resources This requires effective patient navigation to ensure coordination and compliance with the patient care plan
POLK COUNTY HEALTH DEPARTMENT: PATIENT NAVIGATION How do WISEWOMAN providers address the needs associated with patient navigation to efficiently address referrals, follow-up and issue prioritization? Establish rapport with patient Complete additional risk identification as needed Explore patient s readiness to change (for prioritization) Explore barriers Complete referrals for medical needs Complete care plan document
POLK COUNTY HEALTH DEPARTMENT: PATIENT NAVIGATION What are the key components to patient s care plan? Patient specific goals and objectives Identified risk factors Medical follow up/referrals Clinical follow up Medication/Pharmacy needs Lifestyle Interventions Progress and Outcomes Handoffs between team Members (this is key!) Social determinants of health
POLK COUNTY HEALTH DEPARTMENT: CARE PLAN
TEAM-BASED CARE
TEAM-BASED CARE The collaboration of health care professionals to provide comprehensive care to patients Health care professionals collaborate with each other as well as with patients, families and community organizations Implementation of team-based care requires team member engagement, role clarification, communication enhancement, and changes in workflow Source: Naylor MD, Coburn KD, Kurtzman ET, et al. Team-Based Primary Care for Chronically Ill Adults: State of the Science. Advancing Team-Based Care. Philadelphia, PA: American Board of Internal Medicine Foundation; 2010
AURORA WALKER S POINT COMMUNITY CLINIC Clinic in area with highest percentage of uninsured and most ethnically diverse in Wisconsin Patients often have more than one job with little sick leave 40% living at or below the poverty level Clinic serves 90% born abroad 80% undocumented 22 languages spoken in clinic in 2016 75% Spanish-speaking only
AURORA WALKER S POINT COMMUNITY CLINIC Free or low-cost clinic serving low-income uninsured as well as new-arrival refugees 4 FTE FNP,.5 FTE Practice MD, 2FTE RN 12,000 annual visits 400+ WISEWOMAN patients annually Onsite Integrated care includes massage,yoga, multiple specialists (volunteers), acupuncture, mental health, Chiropractic, etc. Overall Clinic Outcomes Clinical Patient satisfaction Employee engagement
TEAM-BASED CARE: WALKER S POINT Who are the members of the Walker s Point Care Team for WISEWOMAN participants? PHYSICIAN ASSISTANTS REGISTERED NURSES HEALTH EDUCATORS NURSE PRACTITIONERS HEALTH COACHES
TEAM-BASED CARE: WALKER S POINT What are the roles and responsibilities of the Walker s Point Care Team for WISEWOMAN participants? Care Team Member Nurse Practitioner / Physician Assistant Roles and Responsibilities Cancer screenings Cardiovascular risk assessment Registered Nurse Discussion of risk factors and Health Educator need for preventive care Referrals for additional care / resources Follow up in one month post referrals Health Coach 1:1 health coaching Coordination with internal and external resources TOPS Venga de Relajese UW Extension Resources
TEAM BASED CARE: WALKER S POINT
WALKER S POINT PATIENT RESOURCES Health Coaching (phone or in person) TOPS (Taking Off Pounds Sensibly) An ongoing support group format helping individuals set goals around weight management Venga de Relajese program inviting women to learn self-care practices including mindfulness, breath work, aroma therapy, and other stress management techniques Wisconsin Extension Classes - On-site nutrition classes including cooking and shopping instructions and tasting of prepared healthy food options.
TEAM BASED CARE: WALKER S POINT How did Walker s Point identify community resources for participants? Identified what was in the community and accessible and focused on programs that were available to come to clinic (improves attendance rate). Developed win-win partnerships where everybody benefits o Mobile mammogram van comes to Walker s Point 4 times a year (very positive for patients) o Positive for the agency that owns and operates the van = 100% attendance rate Assigned a team lead from Walker s Point Dedicated to communication / coordination with partners Communicates availability of partnership to entire team and manages all aspects of the program
TEAM BASED CARE: WALKER S POINT What best practices do WISEWOMAN providers utilize to optimize team based care and develop a care plan? Appropriate risk determination / stratification Discussion of risk factors with all team members (messaging consistency) Providing multiple options for support Consistent follow up Streamlined experience for patient (critical with multiple team members involved)
WALKER S POINT: KEYS TO PATIENT ADHERENCE Establishing Readiness to Change Utilization of Motivational Interviewing across care team Setting small / achievable goals Addressing barriers Childcare Transportation resources Language / culturally appropriate Follow Up Follow up calls Individual coaching
TEAM BASED CARE What resources are utilized? Institutional resources Health educations/coaching Diabetes prevention/ management Hypertension monitoring National Resources (Community) DPRP directory Diabetes self-management Y-USA hypertension monitoring program Weight Watchers Pharmacy partnerships
PATIENT SELF-MANAGEMENT
PATIENT SELF-MANAGEMENT What is patient self-management? Patient self-management is a patient's ability to monitor and manage their own illness, making informed decisions about care and engaging in healthy behaviors. Self-management support is the care and encouragement provided to people with chronic conditions to help them understand their central role in managing their illness.
PATIENT SELF-MANAGEMENT A plan for patient selfmanagement includes referrals to internal and external programs and resources. A key objective of the WISEWOMAN program is to build or strengthen communityclinical linkages to increase access to community-based lifestyle programs and services that promote self-management of healthy behaviors.
POLK COUNTY HYPERTENSION SELF-MANAGEMENT INTERNAL PROGRAM Program is in 2 nd year Eligibility: women enrolled in WISEWOMAN newly diagnosed with high BP or with uncontrolled BP The Nurse Case Manager: Identifies patients by criteria Assesses readiness Provides education and trains the patient to use the monitor Reviews patient BP logs Conducts follow-up with the patient and incorporates the home BP monitoring into case management The patient: Completes home monitoring and completes logs
POLK COUNTY: COMMUNITY PHARMACY MTM PARTNERSHIP Medication Therapy Management (MTM) is patient-specific care by a pharmacist whose aim is to optimize drug therapy and improve therapeutic outcomes for patients. MTM is used to: Formulate medication treatment plans Help patients take medications correctly Reduce adverse events and address side effects Address safety and efficacy of medication regimens Improve medication adherence Promote cost-effective use of medications
POLK COUNTY: COMMUNITY PHARMACY MTM PARTNERSHIP MTM Process: Nurse case manager identifies and refers patients to MTM Patients receive a minimum of two face-to-face sessions with a pharmacist and two follow-up calls (majority of participants have received four sessions) Pharmacist faxes assessment tool to Nurse Case Manager after each session that includes goals, notes, progress, etc. Nurse Case Manager ensures MTM goals/info is shared with provider, health coach, team MTM is completed within 3 month period Adding MTM for diabetes patients this year
POLK COUNTY: COMMUNITY PHARMACY MTM PARTNERSHIP How was the partnership developed? Polk County identified FQHC with a community pharmacy already engaged in patient referrals Conducted initial meeting with pharmacist at FQHC to explore the program concept Following the initial meeting, Polk County included partners at the Iowa Department of Public Health. After a successful pilot, Polk County moved MTM into a standard option and the state used the pilot to replicate with other WISEWOMAN sites in other parts of Iowa
POLK COUNTY: COMMUNITY PHARMACY MTM PARTNERSHIP RESULTS 43% of patients received assistance obtaining low cost medications 30% improved medication compliance 29% had medication adjustments from MTM consultation with patient and provider 75% received 4 or more sessions
POLK COUNTY: HOW TO SUCCESSFULLY DEVELOP COMMUNITY BASED PARTNERSHIPS Look to existing partnerships for options Start small Include the patient s health care provider make sure they are on board with the referral and provide care coordination (for example, getting the information from MTM to the provider) Confirm that the patient s health coach receives the information from the pharmacist following the MTM goals/plans to reinforce messages, provide continuity of care, and add an additional layer of follow-up for changes and desired outcomes stemming from MTM
NATIONAL EXAMPLE: YMCA BLOOD PRESSURE SELF-MONITORING Participants work with trained Healthy Heart Ambassadors for the four-month program During this time, participants will be encouraged to: Self-measure their blood pressure at least two times per month using an easy-to-use, self-selected tracking tool Attend two personalized consultations per month Attend 4 nutrition education seminars during 4 month time period Additional information: www.ymca.net/bloodpressure-self-monitoring/
POLK COUNTY: PATIENT SELF-MANAGEMENT How do WISEWOMAN providers increase adherence to recommended self-management programs/activities? Understand readiness to change Relationship / rapport with program staff of external programs (how can everyone work well together?) Patient navigation / ongoing support Opportunity to identify any barriers and address quickly Consider other options if resource isn t working Make it personal understand patient specific needs and refer to appropriate resources (avoid one size fits all) Care Coordination Entire team must be aware Every touch can encourage adherence
PROGRAM DOCUMENTATION How do WISEWOMAN providers effectively address documentation needs?
QUESTIONS?
NEXT STEPS Access ACPM Lifestyle Medicine Curriculum: WISEWOMAN providers have access to ACPM s (30.0- hour/cme credit) on-line curriculum Includes 4 WISEWOMAN specific modules Clinicians will gain practical skills that can be used to modify unhealthy behaviors that place women (age 40-64) at high risk for hypertension and cardiovascular disease For access: email mhudson@acpm.org August 30 4:00-5:30 pm EDT Webinar: Systems/Policies Cost reimbursement and value- based models Quality improvement strategies Clinic/practice workflow Population health perspectives Registration at www.acpm.org/wisewoman
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