“Knowing Your Population” Health System Performance Improvement Shirl Johnson, DNP (c ) RN, MSN,...
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Transcript of “Knowing Your Population” Health System Performance Improvement Shirl Johnson, DNP (c ) RN, MSN,...
![Page 1: “Knowing Your Population” Health System Performance Improvement Shirl Johnson, DNP (c ) RN, MSN, CNS, MHA.](https://reader036.fdocuments.in/reader036/viewer/2022062517/56649f2e5503460f94c4849e/html5/thumbnails/1.jpg)
“Knowing Your Population”Health System Performance
ImprovementShirl Johnson, DNP (c ) RN, MSN, CNS, MHA
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OBJECTIVES• Describe the challenges encountered, across
the continuum of care, associated with managing patients with chronic disease.
• Discuss current strategies for improving the patient’s transition from one care setting to another.
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Challenges with Managing Chronic Disease• By 2020, the number of people with
chronic disease is projected to grow to an estimated 157 million, with 81 million having multiple conditions.
• More than 75% of all health care costs are due to chronic conditions.
• The average cost of having one or more chronic conditions are 5 times greater than for someone without any chronic conditions.
• Chronic diseases causes 7 out of every 10 deaths.
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Challenges with Managing Chronic Disease
• Driving significant cost: Hospitalization, ED utilization• Who is managing care : “ Primary Care Physician or
Specialists”• Lack of disease knowledge and skills for self
management• Complicated drug regimens
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Historical Gaps in Care Transition• Historical silos between hospitals,
Rehabilitation, Skilled Nursing Facilities, Home Health Agencies
• Fragmented reimbursement• Poor hand- off to next site of care• Not including patient/family in
informed decision making
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Where Do We Go From Here?
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Population ManagementLeverage Electronic Medical Record:
– Data Mining: Predictive Analytics– Identification of patients at risk– Patient registries identify pts with
chronic diseases• Interviewing the patient and or family• Methods of patient engagement
– Motivational Interviewing• Transition to multi-disciplinary resource
to ambulatory settings– Nurse Navigators, Social workers
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PCMH (Patient Centered Medical Home)
“model of care that strengthens the clinician-patient relationship by replacing episodic care with coordinated care and a long-term healing
relationship.”
patient centerednesscoordinated care
personalized careeffective and efficient care
primary care provider led
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Personal Touch to Patient Care • Understanding the
patient and family dynamics
• Patient engagement• Advance care planning
with the patient and or family
• Sharing information with next care settings
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We must face the epidemic of chronic diseases. If we don’t, the human costs will continue to soar. We might even face a lack of available or affordable care when it is needed most.
Centers for Disease Control and Prevention. Chronic Disease Overview, 2007
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Questions