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Using the Web to Advance Practice: VNAA s Chronic Care Clearinghouse A Tool for Disease Management chronicconditions

2. What is Disease Management. Disease Management (DM) is an approach to the strategic management of high cost, high frequency diseases using inter-disciplinary clinical teams, continuous analysis of relevant data, and cost-effective technology to improve health outcomes.DiabetesHeart FailureChro

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Using the Web to Advance Practice: VNAA s Chronic Care Clearinghouse A Tool for Disease Management chronicconditions

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    1. Using the Web to Advance Practice: VNAA’s Chronic Care Clearinghouse A Tool for Disease Management www.chronicconditions.org Shelley Ludwick, Director of Clinical Programs AHQA Conference February 14, 2007 B2 – Home Health

    2. 2 What is Disease Management Disease Management (DM) is an approach to the strategic management of high cost, high frequency diseases using inter-disciplinary clinical teams, continuous analysis of relevant data, and cost-effective technology to improve health outcomes. Diabetes Heart Failure Chronic Obstructive Pulmonary Disease Asthma Others

    3. 3 Components of Disease Management Identify specific population(s) Use of evidence-based practice guidelines Collaboration among physicians, care providers, and support-service providers Patient/family self=management education Utilizing clinical data to refine care practices Outcome measurement, evaluation and management Source: Disease Management Associations of America, 2003

    4. 4 Why Use Disease Management? Best care for the best cost Patient empowerment Clients’ rights to choice Enhanced quality outcomes Better “adherence” to plan of care Prevention of variable complications Better clinical and financial outcomes

    5. 5 Why – a VNAA Chronic Conditions Clearinghouse A number of agencies had implemented innovative care management models for their home care clients. Home care industry was ready to embrace best-practices clearinghouse There were (2) national clearinghouses available as resources but only 4-6% of the focus was on homecare.

    6. 6 Up until now there has been NO SINGLE or COMPREHENSIVE SOURCE Of INFORMATION about Best Practices in Home Care

    7. 7 Goal for the Online Clearinghouse To develop a single “Go To” Resource of Evidence-Based Best Practices Related to Caring for Individuals and Families experiencing Chronic Illness

    8. Where to Start????

    9. 9 Funding Creation of the site was supported by a federal appropriation/grant of $ 200,000 through the Department of HHS/Center for Disease Control and Prevention ( beginning July 2005 )

    10. 10 VNAA Project Staff Carolyn Markey, Pres. & CEO Shelley Ludwick, Director of Clinical Programs/Project Leader Pat Bernard, VP of Finance Linda Pearce, RN,C, BSN, MEd.,CDE Diabetes Clinical Consultant Tim Duffy, Web, IT & Communications Specialist Emma McMahon, Education Program Assistant

    11. 11 Expert Panel Geralyn Spollett, RN, C-ANP, CDE, Associate Director,YaleUniversity , Diabetes Center/Endocrinology, New Haven, CT. Adele Pike, RN, Ed.D, Dir. of Center for Excellence in Home Care Practice and Education at Boston College/VNA of Boston Terri Peterson RN, BSN, MS, VP of Clinical Services, Home Health United, Madison, WI Linda Baker RN, MSN, MBA, Dir. of Clinical Education, VNA Care Network, Worcester, MA. Susan Hollander, MPH, CPHQ, Asst. Dir. Health Care Quality Improvement Program, IPRO, Lake Success, NY.

    12. 12 Process of Creating the Clearinghouse Research and collect information about existing best home care practices for diabetes from home care agencies Review this information Expert Panel prioritizes this material for inclusion in Clearinghouse Develop and populate the site

    13. 13 Best Practice in Homecare What do we mean by best practice? What do we mean by evidence- based practice?

    14. 14 How Do We Find the Evidence? How Do We Find Best Practices? University Connections Medical Center Affiliations QIOs Journal Articles Conferences Literature Searches CQI projects and research activities Other

    15. 15 Best Practices include Guidelines Recommendations Resources Tools Ideas To help home care clinicians work with patients and families on the slow, but progressive process of learning how to manage a chronic illness

    16. 16 Focus Areas Best practices were grouped into 7 areas of focus Nutrition Exercise Monitoring Medications Problem solving Coping Risk Reduction

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    19. 19 Choice of Diabetes Among top 5 most prevalent dx of home care patients – VNAs care for approximately 600,000 patients with diabetes yearly. 18% of Medicare beneficiaries have diabetes; these individuals account for 32% of Medicare funding Sufficient number of care management models available for evaluation as best practices

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    21. 21 At the beginning of each Focus Area there are Best Practice Guidelines for the Home Care Setting

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    23. 23 The Problem Oriented Approach to Planning Care Each of the 7 Focus areas are Divided into the 4 Elements of the Nursing Process Assess Plan Implement Evaluate

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    25. 25 Tour of the Site www.vnaa.org

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    29. ….Another Example

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    33. Examples of How You Might Use the Online Clearinghouse “on Monday morning”….

    34. 34 Situation A

    35. 35 Situation B

    36. 36 Situation C

    37. 37 Situation D

    38. 38 Opportunities and Challenges in Distance Learning in Home Care Improved Patient Care and Outcomes Individualized Clinician Learning Time Availability Staff Satisfaction Cost Savings Increased Patient/Family Self-care

    39. 39 Next Chronic Condition – Heart failure 14% of Medicare beneficiaries have CHF and account for 43% of Medicare spending CHF prevalence 5 million in U.S. 53.6% percent of respondents to initial VNAA survey have CHF program material 42% of CHF patients were readmitted to hospitals within 90 days of discharge (IOM study) 62% of all CHF patients visit ERs (IOM) 90% CHF discharges had NO home care services (IOM)

    40. 40 Future Plans Ongoing development and updating of Diabetes Content Series of teleconferences to enhance educational opportunities and recognition and utilization of the VNAA Chronic Conditions Clearinghouse Continue to identify funding opportunities Evaluation tool sent out to 400 VNAs across the country Congestive Heart Failure (due up on the site in Summer 2007) Chronic Lung Disease (to follow) Ongoing support of Clearinghouse is provided by Lantus, a division of Sanofi Pasteur

    41. 41 Tying It All Together for Successful Outcomes Effective use of technology Improved use of evidence-based best practices Integration of disease management Promoting patient and family self-management Improved financial and management outcomes Consumer/patient satisfaction Collaboration amongst provider Staff satisfaction and retention Decrease in re-hospitalization

    42. 42 For more information Contact Shelley Ludwick SLudwick@VNAA.org

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