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Improving Chronic Disease Care in Vermont: A Community Approach

This article discusses the personal and financial costs associated with chronic conditions and the importance of proactive and informed care. It introduces the Wagner Model for Chronic Disease Care and highlights the effectiveness of the Stanford Patient Education Research Center's Self-Management Program. The article also emphasizes the role of community care teams and their connection to local public health offices. Additionally, it provides information on resources such as Vermont 2-1-1 and highlights the impact of community programs on quality healthcare and quality of life. References and resources for further information are also provided.

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Improving Chronic Disease Care in Vermont: A Community Approach

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  1. Sharon Moffatt, RN, MSN

  2. Cost of Chronic Conditions is both Personal and Financial Care for people with chronic conditions accounts for: 83% of health care spending 81% of hospital admissions 76% of all physician visits 91% of all prescriptions filled

  3. Wagner Model for Chronic Disease Care with Public Health

  4. Prepared, Proactive Practice Team Informed, Activated Patient Productive Interactions Prepared Activated Community Improved Health Outcomes –Healthier People

  5. Healthy Living Workshops Individual Focus Stanford Patient Education Research Center - Self Management Program Evidence based research to affect individual health Empowers individual and families in requesting more of health care

  6. Healthy Living ParticipantsMedical Care Visits to a health care provider’s office and the Emergency Dept decreased significantly at 6 & 12 months MD Visits ED Visits

  7. Supports individual and health care provider for improved health care Connects individual with community resources Replaces or enhances outside disease management programs Community Care Team

  8. Community Care Team Medical Social Worker Dietician Community Health Outreach Worker Behavior Specialist Public Health Prevention Specialist

  9. Community Care Team Connected with Local Public Health 12 Vermont District Health Offices Public Health Nurses Nutritionists Outreach Specialists Prevention Specialists Richford Canaan Alburg Westfield Enosburg Falls Island Pond Orleans Barton Milton South Hero Guildhall Lyndonville Winooski Hardwick Gilman Hinesburg Waterbury Vergennes Bristol Waitsfield Wells River Bradford Chelsea Randolph Rochester Bethel Thetford South Royalton Brandon Castleton Woodstock Poultney Windsor Ludlow Chester Manchester Bellows Falls District Health Offices Towshend Putney Wilmington Community Locations Stamford

  10. Vermont 2-1-1 • Call Specialists problem solve and refer callers from throughout Vermont to government programs, community-based organizations, support groups, and other local resources • A local call from anywhere in Vermont • Available 24 hours a day, 7 days a week • Live translation services for 170 languages • Access for persons who have special needs • Ability to transfer emergency calls to E 9-1-1

  11. Community Quality Health Care and Quality of Life Communities have walking programs year round for all ages Farmers’ Markets have doubled in the last 5 years

  12. Diabetes Related Hospitalizations, per 1,000 Vermonters with Diabetes

  13. Hospitalizations for Lower Extremity Amputations, per 1,000 Vermonters with Diabetes

  14. Resources/References The Chronic Care Model: Improving chronic illness care a national program of The Robert Wood Johnson Foundation, www.improvingchroniccare.org Wagner, E.H. Chronic Disease Management: What will it take to improve care for chronic illness? Effective Clinical Practice 1998; 12-4. National Estimated Cost of Obesity, CDC, BRFSS 1998-2000).

  15. Resources/References Crossing the Quality Chasm: A New Health System for the 21st Centry, Institute of Medicine, National Academy of Sciences, 2001. To Err is Human: Building a Safer Health System,Institute of Medicine, National Academy of Sciences, 2000.

  16. Resources/References The Model for Improvement by the Institute for Health Improvement www.ihi.org The Quality of Health Care Delivered to Adults in the United States. New England Journal of Medicine 2003, 348:26. Vermont Department of Health website: www.healthvermont.gov

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