Marcus Pierson, MD: Diabetes

The Surprising Shared Care Plan, and what patients and families are doing with it

Sun, 21 Mar 2004 21:50:40 GMT

A few days ago a group of patients and their families talked to Ed Wagner about their experiences in Pursuing Perfection in Whatcom county. Each of these patients had a clinical care specialists and a shared care plan. What I heard changed my thinking.

They described the role of the shared care plan differently than I had expected. As I listened I came to see that for them it was a cultural artifact, an object around which improved conversations can occur. In the doctor's office, a paper copy is used to help the physician or nurse understand where the patient is in their goals and understanding. Likewise this piece of paper helps the patient learn from physician or nurse. They can write down and discuss medical concepts, diagnoses, medications, goals and plans. I heard that without this piece of paper the 15 minutes of an office visit is often confusing and less valuable. I heard over and over that this piece of paper help create a relationship between the doctor and patient that is more like a partnership than a trip to the principles office. One patient's daughter made the cute comment, "Dad is getting kind of uppity. He uses big medical words now." The point I took away is that now he understands the meaning of important medical concepts and that he, with his family and care team, can do a better job of managing his situation with diabetes.

Even more surprising was the story of a family. Before the shared care plan, "Dad, did not want to bother us with his diabetes." Little communication about his needs for special diet, exercise, and medications occurred, due to his desire not to be a burden. Since the daughters and wife have access to his shared care plan, they now print it out and talk together about what they can do to help. They have all changed their diets as they learned to change the cooking for their father. They understand more about what they can do to reduce the chances that they and their children will develop type II diabetes. This simple piece of paper has become the focus of new family conversations that help everyone. It has obviously added meaningfully to the lives of this family.

Something important is happening here. We are discovering with patients how to move beyond business medical records (which help physicians and nurses get the information they need and help insure that they get paid for what they did) toward a shared document about which learning and planning for improved self-care and partnerships can develop.

You can download a Microsoft Word version of the Shared Care Plan from https://www.patientpowered.org/PatientSite/Login.asp and you can look at the on-line electronic version which prints out for those who have assess to it. In Whatcom county, Washington, we are opening up use of the electronic version to patients and their families and caregivers.

For those of you who what to know more about the best thinking for how communities can support their citizens with chronic medical conditions, I recommend the Improving Chronic Illness Care site http://www.improvingchroniccare.org/index.html

"...program is so simple, it's brilliant, "Bellingham Herald editorial board

Tue, 15 Jul 2003 15:52:41 GMT

Link to Bellingham Herald Editorial

Link to more about program

Helping chronically ill manage care improves lives, cuts costs
HEALTH CARE: "Pursuing Perfection" program is so simple, it's brilliant.

The whole point of "managed care" started out, at least in theory, as an attempt to contain health-care costs through prevention. It's no secret that's not what happened. In fact, navigating the medical maze has become more difficult than ever, it seems.

But there is a solid movement afoot to change that and Whatcom County is one of the ground-zero sites for a program called "Pursuing Perfection: Raising the Bar for Healthcare Performance." Its method isn't complicated. It seeks to help people manage their own health care, sometimes by doing something as simple as regular telephone calls to check up on patients and answer their questions. By heading off potential problems, extensive and pricey hospital visits can often be avoided and a patient's health better maintained. It's so simple, it's brilliant.

The Whatcom Community Health Improvement Consortium last year was one of seven groups in the nation to win a $20.9 million grant from Robert Wood Johnson Foundation and the Institute for Healthcare Improvement that funds the program. It's not just some kind of feel-good program, either. The foundation wants to document measurable results in improvement of patients' access to care, patients' self-management and satisfaction, and a decrease in medical errors.

Caring for chronically ill people consumes as much as 70 percent of the nation's health-care dollars, so it makes sense that helping them manage their own conditions would reduce those costs and help those people lead more productive and less frustrating lives.

In Whatcom County, two of the most common chronic illnesses are diabetes and congestive heart failure. In 2000, St. Joseph Hospital had almost 700 admissions related to diabetes and almost 900 related to congestive heart failure.

Empowering patients with better information and better access to people who monitor their progress and can quickly answer questions can help keep many from becoming dangerously ill and compromising their health further. Medical advances happen quickly as new drugs are developed, more information is discovered about drug interactions and new technologies help people monitor their blood sugar. Keeping patients active in helping to make their own decisions will result in better outcomes. After all, who better to "manage" the care than the person living with the illness?

Screening: Diabetes Mellitus, Adult Type II

Sun, 02 Mar 2003 18:20:34 GMT

Screening: Diabe http://www.ahrq.gov/clinic/uspstf/uspsdiab.htm tes Mellitus, Adult Type II.
The U.S. Preventive Services Task Force recommended yesterday that adults with high blood pressure or high cholesterol be screened for type 2 diabetes. It concluded that further research is needed on whether widespread screening of the general adult population would improve health outcomes. The task force also found insufficient evidence to recommend for or against routine screening for gestational diabetes in asymptomatic pregnant women.
[Family Medicine Notes]

Diabetes has been an area of focus for over two years.

Wed, 26 Jun 2002 03:26:21 GMT

Evidence based guidelines and information systems help providers improve patient outcomes.