Making Community Connections: Chronic Disease Self-Management Education in FQHCs

Christine KatzenmeyerExecutive Director

Consortium for Older Adult WellnessLakewood, Colorado

Lynnzy McIntosh, Vice President/Implementation Director

Consortium for Older Adult WellnessLakewood, Colorado

Learning Objectives

• To assist you in initiating, or further developing, a chronic disease self-management program within a Federally Qualified Health Center.

• To discuss the connection between chronic disease self-management education and patient centered medical home recognition.

• To improve the quality of health care by fostering a collaborative interaction between patients, providers, and community-based organizations.

• To discuss COAW’s statewide initiative with FQHCs and patient-centered medical homes and success stories.

Who Are We?

• COAW: A 501(c)(3) non-profit organization founded in 2001 by Colorado Gerontologist, Christine Katzenmeyer.

• A statewide consortium with 90+ partnering organizations/agencies across Colorado.

• Expertise focusing on healthy aging of the older adult; provision of evidence-based training to health professionals and lay leaders on Falls Prevention and Self-Management.

• Expertise in practice transformation and the art and science of Self-Management Support.

• Evidence-based offerings include: 1) Healthier Living Colorado™ (CDSMP), 2) N’Balance™, 3) Tai Chi for Falls Prevention, 4) Matter of Balance ™, and 5)Stepping On ™.

What is Self-Management?

The tasks that individuals must undertake to live well with one or more chronic conditions. These tasks

include having the confidence to deal with medical management, role management and emotional

management of their conditions.Institute of Medicine 2004

How does Self-Management work within Healthcare Transformation, Patient Centered Medical Home (PCMH), Patient Activation, any YOUR organization?

Self-Management and PCMH Recognition

• 2011 Version Reinforces the critical role of patient Self-Management and practice Self-Management Support

• Document Self-Management capabilities• Document Self-Management goals; provide tools

and resources• Counsel on healthy behaviors• Assess/provide/arrange for mental

health/substance abuse treatment • Provide community resources

Engaging the patient is the ONLY way to successfully impact clinical

outcomes… as opposed to process measures.

7A nonprofit service and advocacy organization © 2012 National Council on Aging

CDSMP as a Key Component of NCQA

PCMH StandardsPCMHI: Access and ContinuityD. Use of Data for Population ManagementF. Culturally and Linguistically Appropriate Services

PCMH4: Provide Self-Care Support and Community Resources (Must Pass)A. Support Self-Care ProcessB. Document Goals, Ability, Self-

Management Tools, Referrals to Community Resources

PCMH2: Identify and Manage Patient PopulationsC. Patient Panels, Comprehensive Health Assessment

PCMH5: Track and Coordinate CareB. Referral Tracking and Follow-UpC. Coordinate with Facilities/Care Transitions

PCMH3: Plan and Manage CareB. Identify High-Risk PatientsC. Care Management, Pre-Visit Planning,

Treatment Plan and Goals, Identify Barriers

D. Manage Medications

PCMH6: Measure and Improve PerformanceB. Measure Patient/Family ExperienceE. Report Performance

What makes a self-management program work for you…and your patient?

• Designed to enhance medical treatment.

• Evidence-based: a tested model-intervention that has demonstrated, replicable results.

• Use multiple strategies and interventions.

• Empower (activate) patients to increase control.

• Promote collaboration among providers, organizations, individuals, families, caregivers and community.

• Resources need to have a fidelity component to ensure that programs are being delivered to achieve the proven outcomes.

Why CDSME?

Over 20 years of proven impact‘Gold standard’ of evidence-based programmingOffered locally and worldwideAvailable in 21 languagesPremise – people with ongoing health conditionsHave similar concerns and problemsDeal not only with their condition, but its impact

on their lives and emotionsLay Leaders teach the workshop as effectively as health professionals

CDSMP 6 Week Class Series

Exercise and nutrition Medication usage Stress management Talking with your doctor Dealing with emotions and depression Action Planning!

CDSMP Benefits to the Practice

•External resource •No need to re-create the wheel•Reinforces communication “feedback loop”•Documents self-management in PCMH terms•Documents the shift in patient interaction•Quality measures•Delivery of data to practice•Patient activation and patient engagement•Increase in patient confidence levels

Results- Federally Qualified Health Centers

•10 new FQ sites in collaboration with the CCHN. •6 FQs now active, 4 in winter of 2012.•Range from large multi-site, to small one-site clinics.•8 of the 10 practices will have classes in English and Spanish.•5 of 10 now offering classes on site with provider referrals.•5 of 10 now have at least one CDSMP trained staff member.•Clinical and front office involvement in referrals.•Transportation is an issue.

Referral Results

•26 % of all COAW attendees in CDSMP are referred by physicians•Recent project started with 10 new internal medicine clinics in Denver’s Front Range•Practices ranged from single provider, to single location to a large multi-site FQ practice•Practices requested classes in Spanish•All classes are on their sites•Roughly 52% of referrals attended first available CDSMP class.•Additional % enrolled in the next class•Referrals continuing, no one has said “no”•Transportation is a major issue, 40% of practices•Communication within the practice is an issue.

The Process and the Details

COAW and Clinic meet to discuss self-management.Clinician introduces

CDSMP opportunity to

patient.

Patient agrees and signs referral form.

Referral form faxed to COAW.

COAW Coordinator contacts referred patient

and enrolls in class.Patient attends CDSMP.

COAW communicates with practice weekly

regarding patients who decline scheduling for

class.

As part of the CDSMP program, patient writes a

letter to provider describing what he/she

has learned.

Leader mails week six letters to providers.

Provider uses letter in follow-up with patient in

goal-setting.

Feedback Form

Referral Form

Feedback Form

My Name___ Ma ry Smi th_____________ Today’s Date__ J a n ua ry 8, 2012_____

Dear Health Care Providers,

I wanted to let you know that I have been attending the Healthier Living Colorado™ class to help me better manage my own health. Today we are in our final class of the 6 weekly sessions and we are sending you our thoughts about our chronic conditions, taking care of ourselves, and what we want our Health Care Providers to know about what we are learning and doing. What I have learned about my health is: Thi s i sn ’t goi n g to go a wa y just beca use I ta ke a pi l l three ti mes a d a y. I ca n ma ke some cha n ges i n how I d ea l wi th the pa i n . Ea tin g a few more fru i ts ha s helped my d igesti on . I didn’t know that my chronic condition was affected by: Worryin g a bout wha t I ca n ’t d o won ’t help me a n y. I n eed to fi x my si ghts on wha t I en joy doi n g. I a m worki n g on bei n g more posi ti ve. I t ha s been n i ce to ta lk wi th others wi th si mi la r con cern s.

The things that have helped me the most to manage my chronic conditions are: Exerci si n g a l i ttle more ha s helped my kn ees. I a m goi n g to keep wi th i t a n d ma ybe ta ke a wa ter exerci se cla ss. I ’ve been usi n g a pi l l box so I keep tra ck of when I a m ta ki ng the pi l ls better —I d id n ’t kn ow i t wou ld hu rt me to ski p some.

My Action Plan for the next six months is: Long term goal: Thi s i s my l i fe a n d I wa n t to sta y a s hea lthy a s I ca n for a s lon g a s I ca n . I wa n t to lower my blood pressure so I ca n be here to see my gran d kid s gra d u a te from col lege Specific action step: Wa lk wi th a n ei ghbor to the l i bra ry a n d ba ck.

How much/often? 3 ti mes a week When? Mon da y, Wed nesd a y a nd Sa turda y

Confidence Level (0-10): 9

COAW will forward this letter to your provider listed below: My health care provider’s name and address is: Dr. Smart 1234 Main St. Denver 80202

Consortium for Older Adult Wellness 2575 S. Wadsworth Blvd. Lakewood, CO 80227 888-900-COAW(2629) Fax: 303-984-5962 info@COAW.org

Christine Katzenmeyer, Executive DirectorChris@COAW.org

Lynnzy McIntosh, Vice President/ImplementationDirector Lynnzy@COAW.org

303-984-1845, 888-900-2629www.COAW.orginfo@COAW.org

Thank You!