“Knowing Your Population”Health System Performance

ImprovementShirl Johnson, DNP (c ) RN, MSN, CNS, MHA

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.

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.

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

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

Where Do We Go From Here?

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

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

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

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

Questions