Patient Centered Processes Pursuing Perfection

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Patient Centered ProcessesPursuing Perfection

• Whatcom Community
• Marc Pierson
• Nancy Stothart

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Community-wideConnection Communicationwith
for PATIENTS who live withCHROINC CONDIDTIONS
Whatcom Community Marc Pierson Nancy Stothart
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Institute of Medicine

• Six Aims
• Patient centered
• Safe
• Timely
• Effective
• Efficient
• Equitable

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IOM

• Not an indictment of physicians, nurses, or,
  indeed any of the people who give or lead care.
• futile to seek the improvement by further
  burdening an overstressed health care workforce
  or by exhorting committed professionals to try
  harder.
• A redesigned health care system can offer the
  health care workforce what it wantsa better
  opportunity to provide high-quality care.

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It Takes a Community
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P2 Participating Orgs

• Family Care Network
• Sea Mar Community Health Clinics
• North Cascade Cardiology
• St. Joseph Center for Senior Health
• St. Joseph Hospital
• Group Health Cooperative
• Community Health Plan of Washington

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Involving Patients in the Process
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Patient Centered

• Invite patients into all planning and design work
• Increases probability of creating new value
• Adds meaning
• Gets folks close to the reason they are in health
  carepatients
• The work is understood to be helpful

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How to Invite Patients

• Simply have prospective team members ask patients
  that they or their friends know will fit the team
• Caution
• Avoid inviting patient advocates
• Forgiveness and compassion are not theirs to
  choose
• Avoid asking healthcare workers who are also
  patients

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PATIENTS EXPERIENCE
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THE DILEMMA

• Too little connection
• Too little communication

TWO IMPORTANT SOLUTIONS

• Clinical care specialists
• Shared care plan

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Changing the Experience of Patients

• Patient-centered Patient is the most important
  member of the CARE TEAM
• People with chronic conditions manage their
  illnesses 24/7. Other team members come off the
  bench.
• Build support of patients self-management
  intoour daily work
• Create tools that support patients in
  self-management
• Involve patients in all aspects of planning and
  redesign of healthcare delivery system

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Rebecca Brysons Conditions and Virtual Care Team
Pursuing Perfection in Whatcom CountyApril 2003
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Rebeccas Communication Burden
Pursuing Perfection in Whatcom CountyApril 2003
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Virtual Care Teams

• Patients with multiple conditions are often
  left at the center by default
• Resources surrounding and supporting are
  necessary

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Information

• The focus shifts
• from EMR
• (organization specific business medical records)
• to include PHR
• (patient health records)

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Business RecordsPaper or Electrocuted
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Video InnovationsIn Chronic Care Management

• Whatcom Community
• Robert Wood Johnson Foundation
• Crosskeys Media

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Simple Rules for the 21st- Century Health Care
System
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Patients as Partners in Care

• Each patient is a full member of the team a
  patients perspective and experience is
  importantlisten carefully
• Patients are the ultimate managers of their
  chronic conditions their active participation
  in making decisions and sharing information is
  critical to improving outcomes and patient
  satisfaction
• When patients ask questions, seek out
  information, or want to be involved in decisions
  about their treatment, respond thoughtfully and
  thoroughly
• Assist them in identifying what they will do to
  promote and improve their health
• Encourage them to share with care team members
  what support or resources they will need to be an
  effective member of the team

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The Clinical Care SpecialistPartnering with the
Patient

• Develop relationship
• Holistic approach .
  self-management
• Providing information and helping patients
  develop skills
• Providing support and tools
• Advocacy, navigation, and translation

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What Patients have Designed, So Far

• Role of navigator, lifeguard, coachClinical Care
  Specialist
• Patient health recordThe Shared Care Plan
• www.PatientPowered.org support for DM and CHR
• Design work flow in clinics and hospital
• Medication reconciliation
• Diabetes education
• Transition of care
• Patient Advisory Committee
• Spread of the Shared Care Plan
• Traveled to Burnaby, BC to meet with counterparts
  who have manage falls for 7 yrs
• Mapping the processes of providing self care in
  their homes
• Present to visiting communities and legislators

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Patient Action Committee
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www. patientpowered.org
Website serving as central information site for
patients designed by patient team with staff
support
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Patients View of Physicians Medication List
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Hospital CEOs Dream

• Nancy Bitting asks her team and all directors
• Have patients on all design teams, 50 of members
  if possible
• Patients on design of multidisciplinary care and
  implementation of major EMR upgrade
• Patient on Pharmacy and Therapeutic Committee

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A System Supporting the Re-Socialization of
Chronic Conditions

• With and by patients
• They have a network of supporters
• They have capacity
• They have ideas, they can lead
• A return from the over medicalization of life
• BMJ article, Too Much Medicine, suggesting
  balance is possible

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The Real Challenge

• Jointly identify win-win opportunities that
  optimize the system of care as seen from the
  patients perspective
• Across organization lines
• Manage these opportunities from invention to
  implementation
• Across organizational lines

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