With the task of transforming the health care system in Whatcom county and beyond, it is not often when the Pursuing Perfection core team can pause long enough to be in the same place at the same time thought or location wise. We have staff meetings on a regular basis, but occasionally we need a longer period of time together as a team to update, reflect and dream. This last week we had a wonderful team retreat where one of the team activities was to share our dreams for the future. Here are our dreams for one year and beyond… dreams, goals, sustainability and success.
Patient involvement – patient initiates, clinic follows
Website: more info to the right person at the right time – patients control info that goes to them
Education process through community - electronic, standardized, color printed
Inter-team communication through web or tool such as groove
Primary docs routinely meet to discuss patient needs
All clinical staff fill out shared care plans as primary priority
Spread patient centered care as norm beyond county
Bulleto used for migrant community as focus of their care
Ease in access to electronic information
Support groups across community
Any healthcare professional will know how to define/use SCP and P2
Process established to support creation of SCP for anyone in community
SCP easily connected across organizations without duplicated effort and automatically
National healthcare program, like Sweden, or transformed healthcare
Reimbursement for email, group visits to prove economic sustainability for chronic care
Motivational interviewing takes hold among all clinicians
Electronic guidelines, always current, user friendly and always available
Healthcare professionals feel balanced in their practice, with patient centeredness and sufficient time to work
Patients experience is empowered, feeling like part of collaborative team
Awareness of need for transformation and belief in our approach among total community – spreading the awareness
Sustainable, automated system to continue data collection/analysis
All FCN clinics, Lummi, Interfaith and Mt Baker family as P2 sites
More CCS’s
Patient outreach coordinator
More diseases that are better managed
Network of 13 P2 sites all following P2 community model
Integrated SAFE electronic med list
System is patient driven
Management of chronic conditions resemble one another to ease provider adoption
Forum for patient and others involved to discuss complex issues
Options for care located in a place called Chronic Urgent Care
Include all who share work on patient care in the center – not just patient-centered
Support and sustained balanced lives for heath care transformers
P2 patients being advocates of transformation among providers and other patients
Other fundamental aspects of healthcare, IE profit, are examined for transformation
Examine incentives in system to reinforce those that benefit patient
Spread beyond Whatcom county
Improvements so apparent and recognized that people demand them
Cross clinic team on going
More efficient change through systems dynamics modeling
Bi-directional, transparent med list
Clinicians and patients work together, caring for entire patient care team integrated into excellent, satisfying care
Sense of alone-ness, of being a disease rather than a whole person, disappears
More prevention and support for behavior change
Patients with chronic diseases support one another in prevention
Whatcom community knows what health indicators are and uses them and existing assets to support P2 and pool resources for prevention
Community takes responsibility for sustainability
Spread to OR, WA and non peace heath communities through leaders connecting and learning how to transform chronic care
More CCS’s, solid value-added, lean, effective structure
Patients advocating effectively to promote and sustain change at local, state and national levels
Patients feel strong and effective
World Peace
Computer in every exam room
All payors pay for P2 aspects and assure that healthcare pays for itself
Have Olympic take over Medicare payment for P2
Immediate feedback (money) for providers/payors doing the right thing
P2 at center of international transformation
P2 Whatcom county as case study of sociology of collaborative community
Company that does P2 as a service in any community
Physicians will want to stay in our brand of healthcare
All medical records tied together and patient can access through shared care plan all info on the condition
All Whatcom county patients supported by P2 process
E-SCP available nation –wide
Patients continue central role in design
Communities will use web-logs; stated personal values, to form virtual communities with free, easy access to information
Local systems dynamics modelers
Pharmaceutical companies fund electronic updates and spread to more communities
Patients show increased relationships, self-management and communication
Idealized design of clinic process solves all access problems in Whatcom county
Models expand to 5 diseases
Communities learn that they can transform their own health care
