Interesting site from someone pondering, actually figuring much out, about relationships.  http://thinksmart.typepad.com/

10:13:59 AM     comment []   Google It!  

Weblogs and the links to other folks are wonderful.  One finds interesting people and contexts that mirror one's own situation.    One of the bloggers I subscribe to had a link to a post http://urlgreyhot.com/drupal/node/view/1612  on children's readiness to learn. 

This isn't only true of children, it is the human condition.  We are talking about this very same thing  in the context of heatlhcare, and patient's readiness to change things about themselves, their habits and behaviors to improve their health.  We are talking about physician's readiness to engage in real dialogue and relationships with their patients, and their readiness to accept the patient where they are.

3:59:12 PM     comment []   Google It!  

At last we have been able to expand rollout of the Shared Care Plan, still for now within pilot sites, the two Family Care Network clinics and the hospital.  Online registration has simplified what has been a somewhat onerous manual process.  Now motivated and computer literate individuals can self register.  Within days of rolling out to St Joseph Hospital employees, 38 had used the online process to create their own plans.  Awesome!  Thanks to Dawn and Jonathan for their work to set this up.

Soon a marketing plan will be finalized to more make the Shared Care Plan more widely known and available to the broader community.  More to come.

12:21:56 PM     comment []   Google It!  

A story of grassroots spread of the Shared Care Plan - courtesy of Dawn Gauthier~

Patient spreads awareness of the Shared Care Plan.

I've always suspected that usage of the Shared Care Plan will spread among healthcare professionals mainly by patients asking them to use it. Here's a story from a nurse showing how this kind of spread can happen:

My name is Ida Richards, and I am one of the pre-op nurses at Pacific Rim Surgery Center.  I was interviewing a patient by phone on Friday afternoon in preparation for surgery tomorrow.  He asked me to access his Shared Care Plan for the information.  I had to tell him that it was a new concept for me, but I was willing to look into it and learn about how to do this.

I called Jone Hoag and asked her, and she asked me to contact you on the protocol for this process.   I am assuming I would have to get a password set up, and clearance, and then the patient would have to give me their password.  I did not obtain his password – I wanted to see how to proceed first.  He is very willing for me to do this, so let me know if it is something that can be set up.     

Thank you.  I think this has great potential for the patients, when we get this set up.

This is an excellent example of an empowered patient realizing that he didn't necessarily have to fill out yet another admission form asking for all the same information as the last one he filled out: "All that information can be found accurate and up-to-date online in my Shared Care Plan!"

When I called Ida to orient her, she was very impressed at how easy it was for her to login (using her existing NT login) and use the application. In a follow up email, she added:

I did access the Shared Care Plan and found it to be wonderful!  The gentleman ended up not having the surgery at our Center, but it was nice to learn the process and to save him the effort of retelling all of his history.   I will look forward to having more patients have this option available to them as they gain knowledge and comfort in this new techno age!   Thank you,  Ida

As a result of this story, we started seeing more clearly the opportunities that might be possible with the Shared Care Plan. For example, our community has already agreed to standardize the "Patient Health History Questionnaire" that all patients have to fill out every time they need to have a procedure done. Wouldn't it be nice if this long and involved questionnaire could be automatically extracted from the Shared Care Plan when needed instead of asking patients to fill it out time and time again?

How many of the multiple forms used in our healthcare community could be supplemented with information from the Shared Care Plan? Imagine if patients only had to fill out forms that asked for information not already available in the Shared Care Plan: how much time, aggravation and guesswork would be saved if patients didn't have to write out their medication lists and diagnoses every time they had an encounter with system? Aiming toward having fewer and standardized forms throughout our healthcare community and having fewer data sources from which to fill them out is crucial for everyone's sanity, both patient and healthcare professionals, in this age of being overloaded by inaccurate, out-of-date, and isolated silos of information.

Thank you to the patient who was willing to ask a healthcare professional to try something new, and to Ida for being so willing to try it!

3:01:51 PM     comment []   Google It!  

Terrifc news and recognition for terrific work, Thanks to Annie Gort, Dawn Gauthier, Jayson Olson, and Jonathan King for their most excellent efforts in developing patienpowered.org and Shared Care Plan web resources.  So nice to get confirmation that we are on the right track!

Please see Dawn's post below for more on the recent award and her weblog for more info on the design principles that led to this honor...

PatientPowered.org wins award!.

PatientPowered.org was recently recognized by receiving a silver eHealthcare Leadership Award in the category "Best Care/Disease Management Site". This award was presented by eHealthcare Strategy and Trends at their annual "Leveraging Technology and the Internet" conference that I attended earlier this month in Phoenix. At the awards ceremony I was impressed to learn that PatientPowered was selected to receive an award from almost 1200 entries reviewed by 104 judges!

PatientPowered excelled in the following features for this category: medical management tools and news and information available online to help consumers manage a chronic condition, two-way communication between patient and health practitioners, and opportunities to monitor clinical care. These points are exactly what the PatientPowered website, coupled with the Shared Care Plan, was designed to do and it's great to be recognized for this.

A big shout-out to Annie Gort (missing from photo), who did incredible work with patients putting together the bulk of the site. Left to right: Jonathan King (Web application developer), Dawn Gauthier (Web development analyst), and Jayson Olson (Web application developer).

9:57:27 AM     comment []   Google It!  

Due to an expressed interest by a local school district and a desire to spread the chronic disease model to a population that could start early on managing life long chronic disease states, a couple of us met with a Special Needs Coordinator and three school nurses to discuss their potential use of the Shared Care Plan.  This session was an eye opener which confirmed the value and need for truly coordinated Virtual Care Teams. 

Communication is sketchy between local healthcare providers, parents, out of area specialty providers and school officials trying to manage the daily education and healthcare needs of students with diabetes and other conditions.  The school district has an impressive set of tools and guidelines for handling variations in blood sugar levels, but much better coordination is needed among all who are involved in the care.  In addition to monitoring status and creating care plans for the students, the school nurses really end up supporting these kids as they learn to manage their own conditions. 

The Shared Care Plan, and the Virtual Care Team concept being tested here in Whatcom County have promise for bridging the communication gap for these students, their healthcare providers, and families.  We need to further explore how to make the other tools, such as the state's individual health plan more readily available to other care team members. 

Our encounter reminded me of the system in Jonkoping Sweden that Marc Pierson described after the recent visit by Pursuing Perfection Project Leaders and executives.  In that county,  children receive the majority of their primary care in the schools.  It makes so much sense.  How can we get there, or at least build a system to support the care and communication needs?  I believe we are on the right track.

1:44:58 PM     comment []   Google It!  

We use the term 'patient-centered' frequently, but often it is more of a philosophical ideal that is referenced rather than a practical application.  Mary Minniti shared the following definitions of four models which were presented at the recent Family Centered Care conference she attended with our patient representative Hal Peterson.

How does your practice view and act on the relationship between patients and health care professionals?  Consider how you'd like it to be, and what it actually is now...Think about how you  might realign your practice flow, and language to move you closer to your vision. 

• Proponents of professional-centered models view professionals as experts who determine patient's needs from their own, as opposed to a patient's and family's, perspective.  Interventions are implemented by professionals with patients and families being passive participants in the intervention process.
• In patient or family-allied models, patients are seen as the agents of professionals, and are enlisted to implement interventions that professionals deem important and necessary for optimal functioning.  Professionals enlists patients and families to implement intervention under the guidance and tutelage of the professionals.
• Advocates of patient-focused models view patients and families as consumers of professional services, and assist patients and families in choosing among options that professionals consider necessary for best meeting patient and family needs.  Interventions focus on monitoring patient use of professionally valued services.
• Proponents of patient-centered models view professionals as instruments of patients and familiies, and intervene in ways that (a) are individualized, flexible, and responsive, adn (b) support and strengthen patient and family functioning (see Dunst, Trivette, & Deal, 1994; Dunst, Trivette, & Thompson, 1990).  Interventions emphasize capacity building and resource and support mobilization by patients and families.

These models refer frequently to families because they have been defined through studies focused on pediatric practices, however they are applicable for all patients and their support networks, whether they are based in family, friends, or other support environments.

3:54:03 PM     comment []   Google It!  

Having just posted updates by pilot site, here now are the remaining updates by activity and staff member that didn't fit into site specific categories:

Project Coordinator Heather is returned from her conference and is planning for the transition to a new administrative support staffer to replace Zachorelli Frescobaldi, whose last day was this week.  There will be a gap in coverage, and as a result, some things, such as the communication committee, are on hold, or may be progressing more slowly than first anticipated. 

Our grantwriter, Cat, is using a Groove website info in her application for a Medication safety grant.  She is also exploring the possibility of funds from Microsoft.  Sterling/Olympic Health Care are submitting a demonstration project to CMS.  The Kellogg grant application is still in the queue to go to their board, now scheduled for September.  A donor database is finally complete and proving a great tool in her efforts.

Mary, Project Manager, is working on:

• Patient representative guidelines
• Connecting with Patient rep Hal regarding a Boston presentation
• P2 Report to the leadership board includes statistics on patient centeredness assessment
• Pursuing Perfection Leadership board reports now have 'green, yellow, red light' designation to signify which items are progressing as planned, needing attention, or have hit a barrier the board needs to address.
• Whatcom Pursuing Perfection effort has been nominated for an E-health award
• AHA highlighted P2 as 'best practice'
• Eric Coleman also wrote up the P2 project in an artcle to be published in January.
• Focus is on 'results' for pilot sites.

Our Data Analyst Duo, Christine and Brian reported that:

• Graphic tutorial of Patient Satisfaction Survey results is complete and ready for deployment to the pilot sites.  This will be a screen saver for the touchscreen pcs, and will display the specific results for site.
• This month's leadership board report is ready.
• Both are working on the Chronic Disease Datamart to support reporting on all chronic disease states.
• Revamping the reports to IHI and pilot sites
• Evaluation Team Survey is coming, will be sent to all pilot site staff and half of hospital staff.  1000 responses needed for statistically significant sample.  Will go out on paper after consideration of electronic option.
• Patient activation scores are going down for reasons that are currently not clear.  Will be meeting with Clinical Care Specialists and Psychomatrician Bill Mahoney. 
• Patient activation surveys online still pending.
• Working to streamline data reporting processes and select a core set of tools with Measurements Outcomes and Methods (MOMs) Team. 
• Enthusiastic about Groove as a tool for collaboration.
• Pulled data for presentation by Nancy Stothart and Cindy Brinn.
• Assorted other 'ad hoc' report requests

Clinical Care Specialists - Connie and Nancy shared:

• Though at the limit, they are still taking new patients as referred.
• Major concern re the types of patients referred, focus should be on
• Complex issues
• Newly diagnosed diabetics
• Finding incompatible problem lists - need to design better referral form/process
• Question about whether or when to 'discharge' or reduce contacts for patients who do not want to be involved with Clinical Care Specialist - readiness.
• Very important to have PCPs and Specialists consult with each other..
• Maintaining SCPs continues to be a challenge.
• Receiving positive patient feedback
• Patients liked the picnic
• Patients like the opportunity to share
• Diabetes classes well received, they want more.
• Capacity affected by patients with multiple diagnoses, working with whole patient, not just their diabetes...
• Carol Boston-Fleischauer of PeaceHealth is researching and reporting on similar case managers in the US.  Report will be presented to the Leadership Board and Medical Directors.

And finally, our Project's Executive Sponsor, Marc Pierson, MD told us of his activities and findings:

• Idealized Design for Office Practice is critical for improved results
• Advocacy Concept
• CMS demonstration project
• Appropriations bill (Congressman Rick Larsen to visit in August  - efforts also in Ketchikan)
• eHealth Initiative - (Janet Marchibroda with eHealth Initiative and Carol Diamond of Markle Foundation to visit in August with IDX and GE representatives)
• Has met with representatives of large pharmaceutical companies, Johnson & Johnson, Pfizer, AstraZeneca...
• Patient Safety Institute
• Spread and Sustainability assurance
• Congressional and Senate representatives, Sen Patty Murray, (aide Mary Conway)
• Dennis Wagner, John Scanlon - Spread concept to 600 communities
• Spread beyond Whatcom
• Additional chronic disease states managed
• Community of Innovation necessary to spread wider
• Communicates to PeaceHealth & beyond
• Immunization registry work also spreading

4:24:35 PM     comment []   Google It!  

The Whatcom Pursuing Perfection staff are tackling healthcare transformation on so many fronts that they are infrequently in the same place at the same time.  One day last week provided a happy exception with the staff gathering to share status of their various efforts and visions for the future.  Christine posted the hopes and dreams for a year and beyond in her weblog, here's what is going on right now at the pilot sites:

Family Health Associates

• 4 teams have been established to address transformation activities: 
• Communication - dubbed "Culture Club"
• Process Flow
• Planned Care
• Access
• Staff are overcoming historic barriers
• Not being listened to (Improved listening/Action)
• Communication issues
• Completed work includes
• Data Collection regarding Supply/Demand
• Changing appointment timing to simplify scheduling and increase flexibility
• Using the Patient Activity Report (PAR) to make decisions for change
• Defined Population for Heart Failure registry

Ferndale Family Medicine

• Reorganizing Teams - Next level of Evolution
•  Patient Outcomes Team
• Flow Team - Collaborating with outcomes Team to support improved outcomes
• Group Visits are going very well
• Good outcomes for patients
• 3 out of 4 docs are doing group visits
• Implementing electronic Shared Care Plans with patients
• Office Relocation postponed for as long as a year
• Trialing patient e-mail system 'In Touch' - Berdie Safford and Dave Lynch - Patients pay for svc.
• Collected data on Supply/Demand - will start redesign in October
• Restructured patient panels

SeaMar

• Continued implementation of Diabetes Registry
• Medical Student establishing Shared Care Plans for spanish speakers
• One physician to trial RxPad use for his patients _PCs installed in two additional exam rooms
• Reconnecting leadership communication pathways due to changes in organizational structure
• Data being pulled from billing system to ID HF patients for registry entry
• Superusers trained on electronic Shared Care Plan entry

Center for Senior Health

• Completed Supply/Demand data collection
• Working on the Delay data collection
• Re-affirming sponsorship
• Completed a 6 week intensive trial of small tests of change for Shared Care Plan utilization models with Erin Baumgart, ARNP
• Lots of learning about patient readiness/communication/medication list accuracy/encounter design

North Cascade Cardiology

• 2 Data entry clerks hired
• Entering information info Heart Failure registry, verifying through retrospective chart review
• Improving Anti-Coagulation Therapy registry process
• Nicole's interview results have been shared with followup action steps and continued assistance
• Experiencing leadership change - Roland Trenouth to retire and pass baton to Don McAffee
• Hiring two new cardiologists
• Developing processes for Implementing electronic Shared Care Plan
• Planning remodel and relocation of practice to consolidate from two floors to one

St Joseph Hospital

• Patient Centricity
• Launched Sensory 101 program
• Project Teams for P2 - completed
• Cardiovascular Center Staff - completed
• 2nd Med/Surg Unit (new teams) - completed
• Expect about 200 clinical staff will have been exposed by end of Summer (25% of clinical staff)
• Innovative Patient Education (IDEA team)
• Heart Failure and Diabetes
• Developing Info Packets for patients (to be available paper and web)
• Type I & Type II Diabetes assessment tool, critical skills, and additional patient selected learnings
• Heart Failure adapting materials developed by Clinical Care Specialists
• Developing screen in LastWord (EMR) for patient education and documentation
• Enhancing the Nursing Care Plans with Patient Education Information
• Developing protocol for staff to follow for patient education
• Includes scripts for clinical staff to use
• Staff Development
• Teach new process
• Computerized training module - will be mandatory module across organization
• Working on ideas for how to engage pysicians in these opportunities for learning
• Initial planning for community wide full day workshops
• Evidence Based Practice Guidelines
• Terry Wagner-Conner taking lead
• Heart Failure order sets being revisited -  ETA soon
• CABG order sets also being revisited
• Inpatient Diabetes order set will be reviewed next
• Implementing the Electronic Shared Care Plan and Medication Safety
• Pop up message in LastWord will turn on August 4th.  Notice visible to anyone activating a patient who has an electronic Shared Care Plan.
• Cross functional flow chart for updating roles in each department completed
• Updating existing shared care plans only at this time
• RX Pad meds display in Shared Care Plan and can be added to Shared Med List one at a time (future add all in design)
• Hospital will use RxPad for discharge medications for all patients
• Agreement among pilot units to update as they touch the SCP.  Social services staff to have ultimate update responsibility for goals etc.
• All patients will have a Shared Med List

8:32:57 PM     comment []   Google It!  

A question continues to surface...Who should have a Shared Care Plan? 

Our natural tendency and focus as caregivers has so far been to go for the most complicated patients first...the multi-diagnoses, poly-med folks, who are frail and least able to accurately and consistently communicate their mass of information to their horde of health care professionals.  Indeed, for one of our clinics here in the Pursuing Perfection Project, almost their entire population fits this description.  Another clinic has an abundance of patients who are non-English speaking and, in many cases not literate in any language, so communication around healthcare issues is a special challenge.  

Shared care plans for these folks are clearly necessary, and require one on one conversation and explanation to complete and maintain.  These patients and their caregivers can see the value, appreciate the interaction, and can feel the safety the document creates.  However, this also presents a challenge of resources, the manpower, time and reimbursement for a care model which allows these conversations to occur.

As we strive to encourage self-management for the 'walking well' folks with earlier stages of chronic disease, and pre-cursor conditions to those diseases, we face a different challenge. Articulating the value of the conversations, goal-setting, and documentation of the much smaller number of conditions and medications is essential.  Yet both caregivers and patients can feel it 'isn't necessary'. 

I know I need a shared care plan. I consider myself a healthy person, and an activated patient with inside knowledge and comfort with the medical 'system'.  I only have three meds, two for hypertension and one for mild asthma.  I have tried other meds for the hypertension which cause reactions.  My chart reflected that I was still on one of those discontinued meds though I stopped it after a single dose.   I like most everyone else, have a Primary Care Doc, a Specialist, a Dentist, and Opthalmologist, and a Pharmacist.  They can all prescribe things that could have an interaction with the others, or healthcare conditions.  I've been in the Emergency Department and forgotten to mention the inhaler.  I might someday be hospitalized for a car accident and need my ongoing maintenance meds.  So, I carry my paper shared care plan with me.

4:54:22 PM     comment []   Google It!  

v    Patient Satisfaction Survey in place at all pilot sites     

?         Results shared regularly with P2 sites and RWJ      

?         Implementation team adds meaningful measures of progress toward goal

v    PatientPowered.org site developed  

?         Grant information       

?         Documents, Teams, Calendar       

?         Shared Care Plan access      

?        Links to medical reference resources for patients and clinicians 

v    Shared Care Plan application developed and in  use

?         Clinical Care Specialists' have ~50 patients with Electronic Shared Care Plans

?         Phased rollout of Shared Care Plan use in progress by P2 sites 

?         Download of demographic data for 3400 patients done to faciliate SCP creation    

?         Links from Diagnoses to HealthWise database

?         RxPad display activated

?         Patients Love It 

?         Non P2 health care professionals enthusiastic upon encountering SCP

?         Identified LW screens for expert rule to display notice re existence of SCP   

6:13:51 PM     comment []   Google It!  

SHARED CARE PLAN

Implementation Status, Successes, Learnings

Sites Start on Schedule

v     Ferndale  Family Medicine 

o       Primarily updating existing electronic plans    

§         Using paper process at time of visit      

§         Have process to identify Shared Care Plan on Charts, in Practice Mgmt System             

§         Tested and timed creation of a Shared Care Plan    

§         Medical student will work on plans during internship

v     Center for Senior Health    

o       Multiple small tests of change      

§         Group visit with 2 patients  

§         Updating existing Shared Care Plan(s) during visit  

§         Group visit with 6 patients  - sent paper version in advance     

§         Timing entry of data   

v     SeaMar     

o       Preparing for use now 

§         Planning to pilot RxPad (prescription writer in LastWord Electronic Medical Record)

§         Need to identify their Heart Failure patients   

v     SJH  

o       Implementation meetings now happening      

§         Have seem demo of Shared Care Plan and received operational definitions 

§         Team to identify where Shared Care Plan would be of most benefit during hospitalization

§         Patient team members will complete Shared Care Plans on paper during meeting      

v     Operational Challenges  

o       Information Technology resources to make needed changes/maintenance       

o       List of application adjustments/maintenance issues ranging from small to larger scale            

o       Server Performance - Application Performance     

o       Time required for completion of a Shared Care Plan     

·        minimum 45-90 minutes each  (5000 patients = 5000 hours - 2.4 Full Time Eqivalents working for one year)

o       Patients who 'need Shared Care Plan most' are least computer savvy - have most info to enter - need 1:1 assistance HF patients not readily identfied in all sites   

o       Lack of Staff in clinics to register patients, enter Shared Care Plan data 

o       Need to identify reimbursement mechanism for Shared Care Plan visits  

o       PCs in exam rooms still not prevalent

v     Strategies     

o       Prepopulate as much data from existing sources as possible

o       Send paper plan out to patients in advance for completion and interim use    

o       Secure Community resources to assist in interview/data entry, i.e. Whatcom Community College Medical Assistant program students, nursing students, libraries

o       Create Value added functionality to encourage Shared Care Plan use (i.e. Med Flow sheet for paper charts)    

o       Explore feasibility of donated Personcal Computers to expedite use       

·        Cost to upgrade and configure approaches cost of new pc       

6:13:42 PM     comment []   Google It!