1. “Knowing Your Population” Health System Performance Improvement Shirl Johnson, DNP (c ) RN, MSN, CNS, MHA

2. O BJECTIVES Describe the challenges encountered, across the continuum of care, associated with managing patients with chronic disease. Discuss current strategies for improving the patient’s transition from one care setting to another.

3. Challenges with Managing Chronic Disease By 2020, the number of people with chronic disease is projected to grow to an estimated 157 million, with 81 million having multiple conditions. More than 75% of all health care costs are due to chronic conditions. The average cost of having one or more chronic conditions are 5 times greater than for someone without any chronic conditions. Chronic diseases causes 7 out of every 10 deaths.

4. Challenges with Managing Chronic Disease Driving significant cost: Hospitalization, ED utilization Who is managing care : “ Primary Care Physician or Specialists” Lack of disease knowledge and skills for self management Complicated drug regimens

5. Historical Gaps in Care Transition Historical silos between hospitals, Rehabilitation, Skilled Nursing Facilities, Home Health Agencies Fragmented reimbursement Poor hand- off to next site of care Not including patient/family in informed decision making

6. Where Do We Go From Here?

7. Population Management Leverage Electronic Medical Record: – Data Mining: Predictive Analytics – Identification of patients at risk – Patient registries identify pts with chronic diseases Interviewing the patient and or family Methods of patient engagement – Motivational Interviewing Transition to multi-disciplinary resource to ambulatory settings – Nurse Navigators, Social workers Predictive Modeling Chart Reviews Risk Stratification EHRRx Claims Interviewing patients

8. PCMH (Patient Centered Medical Home) “model of care that strengthens the clinician-patient relationship by replacing episodic care with coordinated care and a long-term healing relationship.” patient centeredness coordinated care personalized care effective and efficient care primary care provider led

9. 1 Interdisciplinary health care - a high degree of collaboration and communication 2 Handoff of patients between Acute and Post-Acute that involves more than just the exchange of paperwork but physician to physician communication 3 No Gaps in Care – no longer working in silos but instead as true partners in the entire care continuum 4 PARTNERSHIP – driven by Health Systems, to help patients/ families make decision 5 Medication Management- implement meds to bed program 6 Patient/Family- assessment and engagement, plan of care, proactive decision making

10. Personal Touch to Patient Care Understanding the patient and family dynamics Patient engagement Advance care planning with the patient and or family Sharing information with next care settings

11. We must face the epidemic of chronic diseases. If we don’t, the human costs will continue to soar. We might even face a lack of available or affordable care when it is needed most. Centers for Disease Control and Prevention. Chronic Disease Overview, 2007

12. Questions