SelfManagement

1
Self-Management

• It Takes a Team

2
The Team
3
Delivery System Design

• Pharmacy creates drug profiles for patients and
  up dates with each visit. Following appointment
  the patient is directed to pharmacy for a review
  of drugs with the clinical pharmacist. One more
  opportunity to reinforce medications.
• Patients are provided to pharmacy in advance to
  streamline the process and allow pharmacist to
  schedule time accordingly

4
Self-management Support

• Both e-mail and telephone communication modes are
  used.
• Nursing Helpline information is included in the
  patient education/ resources package. We are
  using the fridge magnet and pamphlets. This has
  been tested for 3 months now to date the service
  has been used by four patients.

• Whats it look like
• Patient resource sheet
• Weight Log
• Sodium Facts
• Introduction to Heart Failure ( HFSA)
• Add on
• Know your numbers
• Activity and Exercise
• Video Understanding Heart Failure

5
Follow-up

• P- Lori will schedule a block of time (1.5
  hours) one day / week (Thursday) for telephone
  and e-mail follow-up. The call will be used to
  evaluate patient's weight, symptoms and adherence
  to self-management goal.
• D- called 4 patients each call required 5 -
  10minutes. Responded to 3 e-mails (15 minutes).
• S- the patients contacted by phone all reported
  good progress with identified goals 3 of 4 had a
  question regarding possible side effects of
  medications. 1 patient reported a weight gain of
  4lbs in 2 days and had correctly adjusted his
  diuretic.
• A- Continue with phone follow-up for patients
  adjusting diuretic and those starting beta
  blockers.

6
Self-management Support

• Benefits of e-mail
• Allows more time to review chart
• Can be done efficiently
• My response is in written form and can be printed
  and saved by patient
• Serves as documentation
• Negatives
• Patient requires computer and some skills
• Patient must able to read
• Patients need to look at
• e-mails

7
Decision Support

• Other Challenges
• As numbers grow the need to identify patients who
  would most benefit from F/U
• Who needs it most
• Patients starting beta blockers
• Patients using self-management to adjust
  diuretics

8
Self management Goals

• Using self-management support tool we hope to get
  a better sense of our success with self
  management. It seems easy to establish the goal
  the difficult part is making that change a way of
  life.

9
Self-management Goal