Improving Disease Management: Project 3bi and 4bii Updates

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Care Compass Network’s Project 3bi – Cardiovascular Disease Management and Project 4bii – Chronic Disease Management/ Prevention COPD both work to improve disease management for patients through self-management. The projects are interconnected in a number of ways as patients with chronic obstructive pulmonary disease (COPD) have a higher incidence of and mortality from cardiovascular disease.

The core function of the projects is developing and implementing self-management goals with the patient. With Project 3bi, partner organizations create a panel or registry of patients within the cardiovascular disease cohort. The criteria for the registry and selected interventions are defined by each organization with a goal to have an office visit within the year where the individual will create a self-management goal with their healthcare professional. The self-management goals are specific to the individual and does not need to be directly related to the disease.

Typically, in healthcare, patients are accustomed to visiting their primary care provider and being prescribed a list of changes to their lifestyle. People can become overwhelmed by this list as it often involves major lifestyle modifications. Because of this, the list is often times abandoned completely with no progress being made. With self-management goals, the person is involved in the process, allowing for both the caregiver and the person to collaborate to determine what the specific goal that they are ready to commit to will be. Motivational Interviewing is used to understand the person’s confidence level ensuring that the goal will be reachable. “For someone it may not be appropriate to try to exercise for 30 minutes every day, it may be more appropriate to set a goal of walking for 10 minutes on your lunch break every other day. The theory is that it’s better to be doing something different today than nothing different today,” says Rachael Haller, Project Manager for 3bi and 4bii at Care Compass Network. “Achievable goals build patient confidence and that’s really important.”

Partner organizations record the patient’s visits and goals in their electronic health record (EHR), then report back to Care Compass Network monthly how many of those patients have either established or reviewed their self-management goals. Use of the EHR ensures that there is a record of the goal and what progress has been made towards achieving the goal. It also allows the partner organizations to easily generate a list of patients that need to schedule a follow-up visit to assess their self-management goals.

Project 3bi also includes a guideline and workflow adoption which highlights best practices for cardiovascular disease management. These include many practices which have generally been in place in practices such as standardized hypertension and hyperlipidemia protocols, blood pressure checks without copay or appointment, and making sure there is a process to make medication adherence easier. As well, since smoking is one of the leading causes of cardiovascular disease, the 5As of tobacco cessation are also implemented into the workflow.

The 5As are ask, assess, advise, assist, and arrange. During an office visit the person is asked to describe their smoking status, such as, never smoked, stopped recently over a year ago, or smokes regularly. The caregiver then assesses the person’s willingness to quit over the next 30-days and advises them with clear and strong advice to quit, assisting the person with recommended pharmacotherapy and community resources. Follow-up contact is arranged through phone calls or visits to continue assessing the smoking status.

This is one of the intersections of 3bi and 4bii. Both the Cardiovascular Disease Management program and the Chronic Disease Management/ Prevention COPD project are asking healthcare professionals to adopt standardized treatment plans for disease specific populations. Each project uses the 5As of tobacco cessation as smoking can lead to both cardiovascular disease and COPD. Both projects also target patient-driven self-management goals with the Chronic Disease Self-Management Program (CDSMP) and Nurse Navigators.

CDSMP is an evidence-based strategy that is meant to help individuals and their caregivers take control of their chronic condition rather than the condition taking control of them. These small, peer-led classes work with individuals to empower them to learn more about their disease, how to manage it and to understand that they are not alone in their diagnosis.

During the first session of CDSMP each person creates an action plan, using smart goals to decide what they want to attain and then create short term, measureable steps to get there. Throughout the six weeks of sessions participants build relationships with group leaders and with one another. Peer Leaders model behaviors for participants and call them outside of calls to check in on the progress with their action plans.

Pam Guth, Director of Community Health Services for Rural Health Network and CDSMP Regional Program Coordinator and Peer Leader, recalls one person who came in to the first session of CDSMP an unwilling participant. He sat separately from the rest of the group and did not speak to anyone. “When he came in his kidneys were in their end state,” Guth remembers. During a session where participants where paired together for an activity, he sat with another gentlemen, and during their one-on-one time he started to open up. By the end, he became a willing participant, laughing and smiling. It was through the peer support that he was able to gain confidence in sharing, which led him to change his attitude about life. Since concluding the CDSMP over a year ago, he is no longer jaundiced due to his failing kidneys, rides his bike 3 times a week, and has not been readmitted to the hospital.

Nurse Navigators, who are care managers located onsite at a provider’s facility, work one-on-one with patient self-management goals. They are another integral piece of both projects. If a provider sees a patient that needs someone to go over a health care concern more in depth, such as strategies for maintaining blood pressure, the Nurse Navigator is onsite to have a conversation that day without having to make a second appointment.

“The focus of our cardiovascular work is around blood pressure control and things that could essentially end up developing into cardiovascular disease like high cholesterol and obesity,” says Robin Mosher, RN Community Navigator with Lourdes. Nurse Navigators receive weekly registry lists created from EHRs and other data sources that look at criteria for blood pressure control. The list indicates patients that need follow-up and will be coming in to the office for appointments with their provider. While those patients are in the office the Nurse Navigators touch base with as many as possible, prioritizing anyone who has uncontrolled blood pressure or additional diagnoses to help set self-management goals to bring their condition into check.

Through Motivational Interviewing, using open-ended questions such as “Tell me about your wellness,” Nurse Navigators encourage them to discuss their current health goals nd circumstances. “When I meet with the patients, I am trying to tease out where they are in their health and wellness goals, what they want to do, their reasoning behind it and how motivated they are,” Mosher explains. “I’m just meeting some of these patients so they need to develop some kind of relationship or trust with me before they open up about everything.”

Once that trust is established, it can be easier to understand the social determinants that effect them, helping the Nurse Navigator to know what first steps need to be taken to achieve a positive health outcome. Mosher uses the example of smoking. While the obvious step for a current smoker might be to set goals to quit smoking there might be social determinants that need to be considered. Perhaps there are stressful situations that they need to work through before they are ready quit. “Maybe our first focus isn’t quitting smoking but making sure they have enough money and resources to meet some of their basic needs,” shares Mosher. Setting small goals helps set the patient up for success if they do decide to quit smoking.

Motivational Interviewing also assists Nurse Navigators in determining if a person is ready to begin the quitting process. “If a patient says something like ‘I smoke and I know I probably shouldn’t’ then I can build on that and say ‘tell me a little bit about your smoking’ or ‘how willing are you to quit’, says Mosher. Nurse Navigators help the patient put strategies in place and work with the care team to achieve their goals and in turn improve the management of their chronic conditions.

“It’s easy to do and say the right thing when your doctor is right there,” says Rachael Haller. “Its more difficult to do it when you’re on your own. That’s really what self-management is about, it’s about being able to walk away and continue to make the decisions that you know you want to make when faced with a doctor’s office visit. [Through these projects] patients can set a goal and learn what it’s like to succeed, and learn what it’s like to fail and have someone there, be it the CDSMP program or the Nurse Navigators, who has been trained to coach them through it.”