community assessment
DESCRIPTION
Community Assessment. Creating a Community Assessment Christi Robbins Community Health Practicum – NURS506 March 10, 2014 Teresa M. O’Neill. Introduction. This presentation is a windshield assessment of my community Approximately 20 slides, total 5-7 minutes in length - PowerPoint PPT PresentationTRANSCRIPT
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Community Assessment
Creating a Community Assessment Christi Robbins
Community Health Practicum – NURS506March 10, 2014
Teresa M. O’Neill
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Introduction• This presentation is a windshield assessment of my community• Approximately 20 slides, total 5-7 minutes in length• Identifying State and County and Statistical Data • Identify Government and County initiatives • Interpretation of data• A statement of a population nursing diagnosis/problem• Community Highlights • Introduce an intervention plan using evidence-based research
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Statistical Data, California
• California Medicare Beneficiaries exceed 4.5 million• Projected to double to 9 million by 2030• California Medicare Beneficiaries comprise of:
• 85% Elderly• 14% Disabled Adults• 1% ESRD
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Variables of Health Statistics, California
Poverty & Ethnicity• Poverty, 2005
• 33% beneficiary income less than $15,000• 21% have income between $15,000 to $24,000• 13% have income from $24,000 to 35,000
• Ethnicity, 2005• 79% White• 9% Asian• 6% Latino • 5% Black• 4% Other
Projected Ethnicity• By 2020 Ethnic Outlook• 50% White• 27% Latino• 15% Black• 9% Asian• 3% other
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Variable of Health Statistics• California’s Medicare reimbursements are approximately $600.00
higher per beneficiary than the national average. • Average cost per beneficiary with one chronic disease $9,025• Average cost per beneficiary with three chronic diseases are $26,707• Ethnic variations as they relate to chronic disease
• Forward thinking…Sustainability requires we reduce healthcare costs to become more cost efficient on how care is delivered and managed
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Statement of the Problem/Diagnosis
• 79% of Medicare Beneficiaries suffers from Multiple Chronic Conditions MCCs
• MCCs are defined by:• Two or more conditions at least one year or more requiring ongoing medical
attention• Physical Conditions (Arthritis, asthma, chronic respiratory conditions, diabetes, HD,
HTN, • Behavioral conditions: (Mental disorders, substance and addiction, and dementia), and• Intellectual and developmental disabilities
• Complex Medication Management
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Statistical Data, San Diego
• San Diego’s Medicare enrollment was 11.5-13% with the highest proportion in the rural areas. • Future Problem Statement: Access to care (a future assignment
should continue my practicums).
• 2011 Hospital discharges in San Diego County of aged 65 and above were 97,647
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Palomar Health District
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Financial Implications of Health• VBP
• Aligns clinical process of care measures• Patient experience measures• Outcome measures, and • Efficiency measures • Concepts of
• Better patient outcomes• Higher quality • Increased safety • Lower Medicare costs
• Hospitals are reimbursed for• High quality care• High patient satisfaction• Low incidence of:
• HAIs• Never events• Low hospital < 30 day
readmisisons
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Collaborative Initiatives
• CMS• Community-based Care Transitions Program (CCTP)
• 98 participating counties, including San Diego (SDCTP)
• 12 measures characterizing an “avoidable” readmission• Some include all-cause readmissions following
• AMI• HF• PNS• PCI
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Summary of Interview
• 30 programs for San Diego’s Elderly population • Although some readmissions are progression of disease
processes, other causes for “potentially avoidable” reasons are people don’t choose healthy lifestyles
• Declination of services • Char W. indicated that in addition to access to healthcare as a
barrier, multiple chronic conditions as well as poor medication compliance continue to be reasons for the CCTP readmissions.
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Community HighlightsEvidence-based Research
• Hospitalizations:• Heart Disease were 1,423.8 incidents per 100,000 population• Cancer at 1,319.9 incidents per 100,000• Stroke at 1,309.4 incidents per 100,000• Unintentional injury at 2,707.0 incidents per 100,000
• Falls comprise 1,1995.0 incidents per 100,000 (likely to worsen with age)
• Hip fracture 595.7 per 100,000 (likely to increase with age)
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Community HighlightsEvidence-based Research
• Hospitalizations, cont.• Arthritis at 1,400.9 incidents per 100,000• Mental illness or depression at 606.0 incidents per 100,000• COPD at 606.0 incidents per 100,000• Infectious disease
• Flu and pneumonia at 302.0 per 100,000, and • 19.3 active cases of TB per 100,000
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Goals• Build a better health system and delivery system with less fragmentation
through better transitions/coordination of care.• Pursue infrastructure changes by changing the culture from within• Advocate for policy and environmental changes• Engage patients for early intervention success• Strengthen self=management through positive support • Primary, secondary, and tertiary health promotions to “increase quality
and years of health life for individuals of all ages, and eliminate health disparities between different groups of the population
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Proposed Nursing Interventions, MCC
• Foster trust and rapport to enhance collaboration and partnership• Self-management of the whole person
• Assess for most common barriers• Lack of awareness• Physical symptoms• Transportation problems• Lack of cost/lack of insurance coverage
• Identify home-based interventions
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MCC Interventions• Assess functional debilitations caused by chronic conditions and refer
to PT, OT• Teach to develop and articulate personal care goals (visualize goals)
• Develop regimen and take steps towards personal goal• Fosters better adherence to a self-care & increased self efficacy
• Assess interested in home self-management (to promote active engagement)
• Assess and remove barriers to active self-management • Depression, isolation, and unable to socialize
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Proposed Nursing InterventionsHealth Promotions
• Primary Prevention: • Flu & PNA vaccinations (2009, only 69.4% of seniors had a flu shot)
• Secondary Prevention: • Screening for high-blood pressure, cholesterol, and BS• Mammograms & PSA
• Tertiary: smoking cessation: nearly 1 out of ever SD senior smokes• Fill gaps in knowledge about MCCs
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Proposed Nursing InterventionsHealth Promotions
• Connect patient with resources: • Care Transitions• Team San Diego• Chronic Disease Self-
Management • Diabetes Self-Management• Feeling Fit Club• Abuse, protection, advocacy
• Suicide Hotline• Caregiver Services • Fall Prevention
• Matter of Balance• Stepping on• Tai Chi Moving for Better
Balance
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Closing
• Special needs of my population are self-management of:• MCC
• Collaboration with government and counties seek cost savings initiatives• CCTP, MCC workgroup, SDCTP, Live Well San Diego all seek to carry out…
• Healthy People goals designed to increase quality of years of health life for individuals of all ages, and eliminate health disparities between different groups of the population
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References
• California Healthcare Foundation (CHF). (2010). California health care almanac: Medicare facts and figures
• Centers for Medicare & Medicaid Services (CMS). (2014). Hospital value-based purchasing
• Centers for Medicare & Medicaid Services (CMS). (2014). Community-based Care transitions program
• County of San Diego, Health and Human Services Agency (HHSA). (2013). Healthy People 2010: Health indicators for san diego county a decade of progress at-a-glance
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References• County of San Diego, Health and Human Services Agency (HHSA). (2013). San Diego
County Senior Health Report: Update and Leading Indicators
• County of San Diego, Health and Human Services Agency (HHSA). (2013). 3-4-50: Chronic Disease in San Diego County
• H-CUP. (2012). HCUP Methods Series: Overview of key readmission measures and methods
• Jerant, A. F., von Friederichs-Fitzwater, M. M., & Moore, M. (2004). Patients’ perceived barriers to active self-management of chronic conditions. Patient Education and Counseling. 57(2005), 300-307
• Palomar Health. (2014). History of palomar health• U.S. Department of Health and Human Services (HHS). (2011). Inventory of programs
, activities, and initiatives focused on improving the health of individuals with Multiple Chronic Conditions (MCC).