A Path to Self-actualization:

Maximizing Quality of Life for People with

Chronic Disease

Lisa Bujno, APRN

Associate Chief Nurse, Quality and

Performance

White River Junction VAMC

May 12, 2015

May 12, 2015

Agenda

• NH Landscape & Chronic Disease Burden

• Determinants of Health

• Maslow’s Hierarchy of Needs

• VA Programs Making a Difference

• Health Impact Pyramid

• NH State Health Improvement Plan (SHIP)

• Changing the Context

NH Landscape

• 1.3 million people • Aging population • Stagnant birth rate (9.9) • Increasing diversity • Migration: -1.2/1000 • Unemployment @3.9% • Crime rate rising • ER visits increasing • Rising healthcare costs

Growing Chronic Disease Burden

• 34.9% overweight and 25.8% obese

• 17.2% reported smoking

• 4.2% ever diagnosed with coronary heart disease

• 4.3% ever diagnosed with heart attack

• 2.3% ever diagnosed with stroke

• 9.1% ever diagnosed with diabetes; 21.3% among those aged 65 and older

• 11.0% had current asthma in 2013

The Story of Mr. H

• 64 y male

• Dx of Polymyositis

• Disabled

• Confined to wheelchair with limited use of L arm, no use of R arm

• Homebound

• Married, wife works

Determinants of Health

Maslow’s Hierarchy of Needs

Medical Center: White River Junction, VT

Community Based

Outreach Clinics

(CBOC’s): Rutland, Burlington,

Newport, Bennington and

Brattleboro, VT

Littleton and Keene, NH

VA Programs Making a Difference

• Home Based Primary Care

• Home Telehealth

• Geriatrics & Extended Care

• Recreational Therapy

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Home Based Primary Care (HBPC)

• Serves frail, chronically ill veterans with complex health care needs who require comprehensive, longitudinal home care services

HBPC Services

• Primary care visits at home by a physician, nurse practitioner or physician's assistant

• Nursing care management

• Coordination of services by a social worker

• Therapy visits from a physical, occupational, or speech therapist

• Mental health services

• Nutrition counseling

• Medication management

HBPC Outcomes

• Reduction of inpatient admissions by 43.9%

• Reduction of inpatient days by 60%

• 10% reduction in repeat falls

• 95% immunization rate for influenza; 98% for pneumoccus

• End of life protections: DNR (91%), advanced directives (100%), long-term planning (100%)

Home Telehealth

• Uses health informatics, disease management and telehealth technologies to target care and case management

• Changes the location where health care services are routinely provided

• Home telehealth, Clinical Video Telehealth, and Store-and-Forward modalities

Telehealth Services

Clinical Video Telehealth (CVT) Mental Health CVT in Home(SCI, PT, OT ) Podiatry Ear, Nose & throat (ENT) Physical Therapy (PT) Wound / Ostomy Care Occupational Therapy (OT) Neurology Speech Therapy (ST) Nursing Preop Diabetes 1:1 Visits Pain Nutrition 1:1 Visits Genomics Weight Loss Group Hearing Aid Management Weight Loss Group Women Cardiology Weight loss 1:1 Ambulatory Monitoring Spinal Cord Injury (SCI) with Boston VAMC Urology

Telehealth Services

Home Telehealth Store and Forward

Diabetes Hypertension Chronic Obstructive Pulmonary Disease Heart Failure Dementia Support for Caregivers Weight Loss Pallative Care Smoking Cessation

Dermatology Tele-Retinal Imaging

Telehealth Outcomes

• Improved access to care and quality of life

• Improved patient self-management

• 25% decrease in length of stay

• 19% reduction in hospital admissions

• 9.8% mortality rate in HT patients versus 16.58% in Non-HT patients

• High satisfaction rates among veteran patients Darkins, A. (2008) Care Coordination/Home Telehealth: The Systematic Implementation of Health Informatics, Home Telehealth, and Disease Management to Support the Care of Veteran Patients with Chronic Conditions, TELEMEDICINE and e-HEALTH

Adam Darkins et. al (2014). Reduced Cost and Mortality Using Home Telehealth to Promote Self-Management of Complex Chronic Conditions: A Retrospective Matched Cohort Study of 4,999 Veteran Patients TELEMEDICINE and e-HEALTH, 20, 50. Decreased unscheduled primary care visits

Geriatrics & Extended Care (GEC)

• Programs to maximize each Veteran’s functional independence and lessen the burden of disability on Veterans, their families, and caregivers

• Focus on shared decision making

• Institutional and non-institutional care options

GEC Services

• Skilled home care/Homemaker & Home Health Aide

• Adult Day Health Care

• Hospice/Palliative Care

• Medical Foster Home

• Respite Care: in home or hospital

• Caregiver Support

• Veteran Independence Program

GEC Outcomes

• Improved functional independence

• Reduced caregiver stress and improved family functioning

• Better coordination of care with non-VA providers

• Veterans can remain in their homes longer

• Reduced cost

Recreational Therapy

• Provide recreation activities to treat and maintain the physical, mental and emotional well-being of Veterans with disabilities, illnesses or other disabling conditions.

• Use a variety of techniques, including arts and crafts, sports, games, dance, music and community integration activities

• Assist Veterans with disabilities to integrate into the community by helping them use community resources and recreational activities

Recreational Therapy Services

• MOVE!

• Adaptive sports programs

• Greenhouse gardening

• Arts and crafts

• Music

Recreational Therapy Outcomes

• Improves physical well being such as weight management and controlling diabetes and hypertension

• Improves social functioning and help Veterans develop new leisure skills

• Enhances creative expression and break down barriers for cultural expression

The Story of Mr. H

“HBPC has made the biggest difference to me and my wife.”

• Reduced burden of time spent navigating the health system to get needed care

• Frees time to spend with family and pursue hobbies

Maslow’s Hierarchy of Needs

Health Impact Pyramid

NH SHIP: Top 10 health priorities

• Tobacco

• Obesity/Diabetes

• Cardiovascular Disease

• Misuse of alcohol and drugs

• Cancer Prevention

• Asthma

• Healthy Mothers & Babies

• Infectious Disease

• Injury Prevention

• Emergency Preparedness

Changing the Context

• Leverage Points in a System

– Information flow

– System rules and goals

– Paradigm

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Next Steps

• Integrate Maslow’s principles into everyday practice

• Help patients fulfill their needs beyond medical care & safety

• Support policy changes that promote self-actualization for people with chronic diseases

Image courtesy of Paul Martin Eldridge /FreeDigitalPhotos.net

Questions?

Lisa Bujno, MSN, APRN Associate Chief Nurse, Quality & Performance 802-295-9363 x5380 Lisa.bujno@va.gov