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