I have been a delinquent weblog writer. And tonight I would like to catch you up. Since my last entry in October, I have turned 50 year old; hosted the IHI Technical Assistance Site Visit Team of Maureen Bisgnano, Jim Reinersten and Andrea Kabcnell. They brought along Alan Goldstein, a Group Health Cooperative cardiologist as well. We have applied for a grant through Connecting Communities: an E-Health Initiative, and we are in the process of speaking with patients who receive the services of a Clinical Care Specialist about ways they think we can sustain and spread the services without additional positions/funding.
Additionally we have talked with patients/community members about what patient-centered care is and how they yearn to be a full partner in their care and what aspects of connection with their doctors and clinic staff invite them into the process. As a result of their feedback, we are improving the patient centered care experience survey for the clinics. This includes feedback from the clinics, too...so that the information is meaningful and they can take action to improve it.
Data to prove our work has value and is making a difference is not easily available as we have such disconnected data systems across the community...however, we have identified the % of patients receiving the services of a clinical care specialist that prevented hospitalizations, an office visit, ER visit and found and corrected medication errors. We used conservative estimates of these cost avoidance efforts and estimate we have possibly saved $368,215. And that was for 69 patients only.
We are being asked by community members when they can have a shared care plan...we are connecting with the Volunteer Resources in the community who are interested in providing people to help support others in starting their own shared care plan. We have connected with community assets such as the Technical College to begin dialogue about including training for nursing staff on the patient-centered model and use of the shared care plan as well as conversations with the University Wellness Program. The City of Bellingham and Ferndale School District is interested in spreading the use of the shared care plan to employees and students. A small trial is underway.
At times progress seems slow..there is no big bang in transformation, subtle shifts occur that are the result of conversations occuring on the local, regional and national levels. There is a yearning for a new way and an impatience and despair with the old. Change is sought and resisted in the same moment within the same individual...much as a person with a chronic condition bargains and denies there is a need to change, yet knows change must come to move toward a healthier outcome. Others read about what we do, call for information and amid the many questions- I hear an unspoken question...does it work...will it make a difference....what proof do we have this is the "right" way.
I wonder did the pioneers, pilgrams, native americans moving to new lands or embracing new ways to respond to changes in the environment want to see proof before moving toward a desired state or destination...did they wait for all the maps to have specific roads drawn, miles calculated, gas stations/way stations identified before they began the journey? I think not, I think they had a vision, they created teams/partnerships that worked and were forgiving and forged ahead. Sometimes supplies ran low...both in terms of resources and resilience....yet they moved on...adjusted their course with new information and insights...sometimes they had to partner with others different from themselves to move to a new understanding.
The other thing they did is look around at those on the journey, and stop to be grateful for how far they had come and to celebrate those who came along. I had the opportunity to celebrate with patients who have come along with us by listening to their stories. I heard through their own experiences how they were enriched by the experience, more self-confident and willing to pitch in and assist not only in their own health but to connect with others. The community assets are people: they have many titles, they come from many walks of life...but they are resourceful, dedicated, connected and caring. Together within a community, the change will occur...outside of the clinics, hospitals and inside.the walls of institutions- everywhere..we must notice the value and riches that are right here and cultivate the will to continue learning and exploring the roles and contributions each one of us will make to build a new way of providing and being in service to each other.
I am grateful to have the opportunity to participate in this journey.
