1. Presented by Vicki M. Young, PhD October 19, 2010 1

2. Informed, Empowered Patient & Family Patient- Centered Prepared, Proactive Practice Team Improved Outcomes Delivery System Design Decision Support Clinical Information Systems Self- Management Support Health System Resources and Policies Community Health Care Organization Care Model Productive Interactions Coordinated Timely and Efficient Evidenced-based And safe 2

3.  Include measurable goals for chronic illness in the organizational plan.  Senior leaders visibly support improvement in chronic illness care.  Use effective improvement strategies aimed at comprehensive system change.  Promote good chronic illness care through benefit packages.  Encourage better chronic illness care through provider incentives. 3

4.  Identify effective programs and encourage patients to participate.  Form partnerships with community organizations to support or develop evidence- based programs. 4

5.  Emphasize the patient's central role in managing their illness.  Assess patient self-management knowledge, behaviors, confidence, and barriers.  Provide effective behavior change interventions and ongoing support with peers or professionals.  Assure collaborative care-planning and problem-solving by the team. 5

6.  Define roles and delegate tasks amongst team members.  Use planned visits to support evidence-based care.  Build “effective” case management functionality into practice.  Assure continuity by the primary care team.  Assure regular follow-up. 6

7.  Embed evidence-based guidelines which describe stepped-care into daily clinical practice.  Integrate specialist expertise into primary care.  Use proven provider education modalities to support behavior change.  Inform patients about guidelines pertinent to their care. 7

8.  Include clinically useful and timely information on all patients in a registry.  Provide reminders and feedback for providers and patients.  Identify relevant patient subgroups and provide proactive care.  Facilitate individual patient care planning through the registry. 8

9. Why National, State, and Local Measures? “How will we know that a change is an improvement?” 9

10.  Use key measures to clarify a clinic’s aim and make it tangible.  Make use of the clinic’s patient population data base (registry) for measurement.  Integrate measurement into the daily routine.  Plot data on the key measures each month during the collaborative.  The question - How will we know that a change is an improvement? usually requires more than one measure. Improvement in a balanced set of five to nine measures should ensure that the system itself is improved. 10

11.  Established Best Practices  Allowed organizations to determine the effectiveness and/or need for change  Increased Quality Improvement  In essence, measures focus on quality:  Evaluation, Evaluation, Evaluation 11

12.  National and Local Faculty developed a set of measures to:  Address major aspects of care for patients with chronic illnesses.  Translate evidenced-based guidelines into clinical practice. 12

13.  Measure aspects of individual patient care and health.  Create summary reports and graphs 13

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15.  American Academy of Pediatrics- late 1960s  Institute of Medicine- late 1990s and early 2000  Various demonstration projects- from early 2000 to date  National Committee on Quality Assurance certification- 2007 ◦ Physician Practice Connections- Patient Centered Medical Home  Development of Joint Principles- AAP, AAFP, ACP, AOA- 2007 15

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18.  Mindfulness = Openness to new ideas and different perspectives; continuous creation of new categories  Respectful Interaction = Honest, tactful, and mutually valuing interchange where each person brings meaning and value to the other  Heedful Interrelating = Interaction where individuals are especially sensitive to the way their role and others fit into the larger group and its goals 18

19.  Channel Effectiveness = Appropriate use and mix of rich (eg, face-to-face) and lean (eg, e-mail) communications where rich channels are used when messages are highly ambiguous, complicated, or emotionally charged and lean channels are used when messages are clear, simple, and emotionally neutral  Mix of Social and Task Relatedness = Social relatedness includes non–work-related conversations and activities that are often based on friendships and family, whereas task relatedness consists of work-related conversations and activities. 19

20.  Diversity = Differences in mental models and in age, sex, and ethnicity.  Trust = Belief that you can depend on the other and the associated willingness to be vulnerable to another. 20

21.  Personal physician  Physician directed medical practice  Whole person orientation  Care is coordinated or integrated  Quality and safety  Enhanced access  Payment 21

22.  Refer to handout 22

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