evidence-based interventions for chronic conditions ... · evidence based self-management programs...
TRANSCRIPT
Evidence-Based Interventions for Chronic Conditions:
Chronic Disease Self-Management Program Supports
September 25, 2017 2
Introductions• Celeste Harp: NYSDOH Arthritis Program
• Jan Kaelin-Kee: NYSDOH Mohawk Valley CDSME
• Dr. John May: Mohawk Valley PHIP
• Aletha Sprague: Mohawk Valley PHIP
Part of the team and speaking next month:
• Nancy Katagiri: NYSDOH Arthritis Program
September 25, 2017 3
Agenda
• Primary Care Physician Education About CDSMP
• Electronic Health Record (EHR) Success Stories: Experiences From a Closed-loop System
• Ideas to Work with Independent Clinicians
• Questions and Discussion
September 25, 2017 4
Primary Care Physician Education
Communicating what self-management programs can offer:
• Provider Outreach
• Public Outreach
• Non-pharmacological Interventions
September 25, 2017 5
1.2.3 Approach to Provider Outreach
Improved Communication
• Marketing to Providers &
Patients
o CDC 123 Program
o 3 C’s
o Effective Promotion
September 25, 2017 6
Evidence Based Self-Management
Programs & PHIPS• Non-pharmacological Interventions
o Self-Management = Self Efficacy
o Focus on well-care, not sick care
September 25, 2017 7
Primary Care Clinicians
• Inclined to refer these patients to
community resources
– Recognition of shortcomings of the
medical model
– Open to use of inexpensive , community-
based resources
– No insurance prior approval, etc, etc, etc,
September 25, 2017 8
Primary Care Clinicians - Considerations
• Evidence of impact
– Fewer ER visits; fewer hospitalizations
– Also:• Increased management self-efficacy
• Increased energy levels
• Better communication with care-givers
• Improved cognitive symptom management
• Improved aerobic and strength exercise
September 25, 2017 9
Primary Care Clinicians - Motivators
• Ease of referral
• Notification of participation / completion
• Feedback from patients and family care-
givers
September 25, 2017 10
EHR Success Stories & Clinician Education
• Bassett Healthcare Network
– Closed provider system; Bassett Medical Group
– Epic EHR order added
– Clinician education and awareness
– Referral to the Bassett Research Institute
– Follow up with patient and clinician
September 25, 2017 11
EHR Success Stories & Clinician Education
• Nathan Littauer Hospital
– Bi-directional referral capability through
HealthLink Littauer “The Great Connection”
September 25, 2017 12
Working With Independent Clinicians
• Reaching out to
Performing
Provider Systems
(PPS)
• Grand Rounds
September 25, 2017 13
Performing Provider Systems (PPSs)
• Performing
Provider System
(PPS) selection
of Preventing
Chronic
Diseases within
Domain 4
(4.b.ii)
September 25, 2017 14
Performing Provider Systems (PPS) continuedCapital Region ● Albany Medical Center
Finger Lakes ● Finger Lakes PPS
Long Island ● Stony Brook University Hospital
Southern Tier ● United Health Systems and Cortland Regional
North Country ● Adirondack Health Institute
Tug Hill ● Samaritan Medical Center
Mid-Hudson ● Montefiore Medical Center
● Westchester
New York City ● Mount Sinai Hospitals Group
● Advocate
● Staten Island Univ. Hosp. & Richmond Univ. Medical Center
September 25, 2017 15
Grand Rounds• Hospitals offer a regularly scheduled teaching time for
attending physicians as well as residents and students
• CDSMP is a pertinent topic to present providing medical staff with a disease management alternative to pharmacological interventions
September 25, 2017 16
Opportunities for Partnerships
• Local Departments of Health
• Area Offices on Aging
– Referrals
– Promotion
– Other programmatic support
• Quality and Technical Assistance Center of New York – Register workshops as open through Compass
September 25, 2017 17
QUESTIONS AND DISCUSSION
September 25, 2017 18
THANK YOU
September 25, 2017 19
Contact Information
New York State Department of Health
Celeste Roeller Harp, MRP Intervention CoordinatorNYS Arthritis Program518-408-5142 [email protected]
Nancy Katagiri, MPH, CPH NYS Arthritis Program Coordinator518-408-5142 [email protected]
Jan Kaelin-Kee, MSW, MS Ed Senior Health Program CoordinatorCDSME in the Mohawk Valley Initiative518-408-5142 [email protected]
Aletha Sprague Mohawk Valley PHIP Supervisor 607-547-7639 [email protected]
John May, MD Mohawk Valley PHIP Program Lead and Primary [email protected]