Deb Barnett, RN, MS, FNP (HealthTeamWorks, Lakewood, Colorado) Lynnzy McIntosh, BA (Consortium for Older Adult Wellness, Lakewood, Colorado)

On completion of this session the participants should be able to:  Compare and contrast patient SMS with patient education  Identify at least six key features of CDSMP which make it valuable to access for those primary care practices working on becoming medical homes.  Identify the basic steps involved with assessing patient readiness for engagement in CDSMP; also follow-through with engagement in action planning.

Insert Photos

 All people self- manage, everyday. The question is… “..in what direction?”

 Engaging the patient is the ONLY way to successfully impact clinical outcomes (as opposed to process measures)

 In this case, patient- centered culture change follows the mechanics

“But the mechanics take too much time!!” “….and who really has it?”

 Centers for Medicare and Medicaid  Ex: Recent Medicare Advanced Primary Care Pilot  Department of Health and Human Services  Ex: $27m ARRA award to states for implementation of CDSMP  State Medicaid agencies  Ex: Colorado HCPF Regional Care Collaborative RFP  NCQA in medical home recognition

2007 Version2011 Version  Element 2E: Identification of  Most frequently seen diagnoses  Most important risk factors in practice’s population  Three clinically important diagnoses (3 CID)  Element 3A: Adoption and implementation of EBG for 3 CID  Element 3D: Care management for 3 CID (11 choices- documentation of 4)  Element 4B: Self-management support (7 different activities— documentation of 3)  Assess self-management abilities  Document self-care plan; provide tools and resources  Counsel on healthy behaviors  Assess/provide/arrange for mental health/substance abuse treatment  Provide community resources  Meaningful use

SMS  Patient driven  Identifies barriers  Patient is the expert  Minimal staff time/materials  Promotes problem solving Patient Education Provider /care team driven Didactic content about illness Expertise lies with provider/staff Staff time/Cost for materials

 Stanford University’s Chronic Disease Self Management curriculum  CDSMP is offered in 48 states and 26 countries  6 week series, 2 ½ hours per week  Text and relaxation CD accompany class  Research  Mixed diagnosis  Facilitated by trained lay-leaders  COAW provides fidelity statewide  COAW has 300 leaders and 32 master trainers statewide  Translated into Spanish as Tomando Control Colorado™ and also taught in Chinese, Japanese, Thai, Hmong, Laotian, Vietnamese, Korean, and Nepalese.

 Symptom management  Physical activity and exercise  Medication regimens and treatment evaluations  Depression management and positive thinking  Communication skills  Healthy Eating  ACTION PLANNING  and PROBLEM SOLVING

14

Healthier Living Colorado™ 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

Healthier Living Colorado™ Benefits to the Patient Evidence-based curriculum Reinforces the active role of the patient Not a medical program Light bulb moments Power in the plan Wisdom in the room Reinforces communication “feedback loop” Creates higher-level communication with providers

17

Linking PCMH Practices Total Practices= 35Linking rate= 1 practice every 1.5 weeks 18

 “Feedback loop” findings  What chronic condition?  Moving does help.  Who knew being cranky made it worse.  Planning my doctor visits might help.  Talking with my family/friends/providers helps.  This way is harder and I feel better about it all.  Understanding practice-wide implementation  Practice-wide messaging  Continuing the conversation… This is easier than you may think. This is harder than you may think.

Breakthroughs  Creation of an introductory presentation that is a facilitated discussion around the practice’s definition of patient self- management, patient education and how working on practice changes in this area supports medical home transformation.  QIC support in helping the practice learn basic skills in assessing patient readiness for participation.  Establishment of protocol for number of times COAW outreaches to referred patients before reporting back to referring practice. 20

Breakthroughs (cont.)  Production of “scripts” for providers and practice staff to use in messaging about the resources to patients.  Clarification and improved timing regarding feedback provided to the practices regarding outcomes of COAW outreach to patients.  Mutual understanding of both organizations’ realities faced in terms of what is involved in being successful with this at the practice level.  New mechanism for reaching participants that otherwise would not be accessed. 21

dsites.html#USA  Contact HealthTeamWorks or COAW  Identify practice champions  Identify patients with chronic conditions  Referral system established  Provider messaging  Host or refer to CDSMP classes  Continue “feedback loop”

Deb Barnett, Coordinator Grants Management and Program Development HealthTeamWorks 274 Union Blvd, Suite 310 Lakewood, CO w c f Lynnzy McIntosh, Director of Implementation 2575 S. Wadsworth Blvd. Lakewood CO Direct Line (COAW)