SelfManagement

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Self-Management
Surviving the Waves of Change

• Leilani Goudeau, RN, BSN, Chronic Care
  Coordinator
• TEAM- MOTIVATORS lt 7
• Family Health Centers, WA
• lgoudeau_at_myfamilyhealth.org

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• 
  Family Health Centers
• Located in the state of Washington County of
  Okanogan. It is the
• largest county in the state. As of 2000, the
  population was 39,564..
• Total number of patients using FHC medical
  services in 2005 8,644
• THREE SITES
  DIABETES REGISTRY
• 
  To Date
• Okanogan site established 1985
  201
• Tonasket site established 1993.
  175
• Brewster site established 1994.
  279
• Routine health services include well child
  care and immunizations adult care
  includes chronic care management, annual
  physicals and health screenings
• gynecologic and womens health, obstetrics.
• Special services include minor office
  surgery, laboratory x-ray emergency
• hospital care and referrals to other
  specialists as needed.

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Aim, Measures, Goals
Family Health Centers is imbedding the Chronic
Care Model into the way we care for all patients
with chronic conditions across all sites, by all
clinicians. By doing so we will improve care and
delay and decrease complications for our initial
patient population of diabetics. We will
accomplish this over the next 13 months by
participating in WSC 5. Measure Target 1.
Percentage of patients with most recent A1clt7.0
50 2. Average A1c value for patients with A1c
7.4 3. Percentage of patients with most recent
BP lt130/80 40 4. Percentage of patients with
most recent LDL lt100 mg/dL 50 5. Average LDL
value for patients with LDL results in past year
100 mg/dL 6. Percentage of patients with
documentation of SMG 35 7. Percentage of
patients offered tobacco-cessation counseling 35
8. Neuro-sensory foot exam in the past year
50 9. ACE Inhibitors 50 10. Daily aspirin use
50
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Chronic Care Model
Health System
Community
Health Care Organization
Resources and Policies
DeliverySystem Design
ClinicalInformationSystems
Self-Management Support
Decision Support
Prepared, Proactive Practice Team
Productive Interactions
Informed, Activated Patient
Improved Outcomes
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Key Change Concepts for Diabetes Self-Management

• Set and document collaborative goals.
• Follow-up and monitor Collaborative goals.
• Group visits formatted to educate and provide
  support.
• Provide tools to patients (and staff) to assist
  with self-management.
• Train providers (and staff) to assist patients to
  set Collaborative goals
• Use culturally competent standardized educational
  materials
• Tap community resources to achieve
  self-management goals.

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Identify problems/barriers that prevent you from
reaching set goals
One Great Barrier
Several Small Barriers
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Our Barriers to Self Management Success

• Staff had little interest in explaining self
  management goals to patients some were
  uncomfortable asking patients to complete goals
  form.
• Patients showed little interest in completing
  goals form.
• Lack of or improper data entries in the Registry,
  resulted in inaccurate reports.

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Life Saving Tools to Assist in Surviving the
Waves of Change

• Provide training in use of registry and
  importance of accurate data entry.
• Provide training to staff with each new tool
  introduced.
• New or updated forms with content that address
  the measures and goals being tracked.
• Inform staff regarding community resources to
  assist patients with goal setting.
• Make the forms colorful, simple, user friendly
  and culturally competent. Use pictures when
  possible (1 picture can be worth a 1,000 words).
• Solicit ideas from the other team members and the
  List-serve.
• Provide prompts and cheat sheets.

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What Tools can be Used?

• Make the Tool specific to the barrier being
  addressed.
• Our Barrier Inaccurate registry use and data
  input.

Tool used to assist with barrier All Staff
CDEMS Training Session
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More Tools

• Barrier Staff did not feel confident in
  explaining S.M.A.R.T.
• Tool used to assist in overcoming barrier Staff
  role playing use of form with foot exam