Mariella Martini Coordinator of HPH Emilia Romagna Regional Network Health Promoting Hospitals...
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Transcript of Mariella Martini Coordinator of HPH Emilia Romagna Regional Network Health Promoting Hospitals...
Mariella Martini
Coordinator of HPH Emilia Romagna Regional Network
HealthPromoting Hospitals
PATHWAYS OF INTEGRATED CARE FOR PATIENTS AFFECTED BY HEART
FAILURE
(Ed Wagner, MacColl Institute for Healthcare Innovation)
Informed,ActivatedPatient
Prepared,Proactive
Practice Team
ProductiveInteractions
Community
Resourcesand Policies
Health System(Health Care Organization)
Self-ManagementSupport
Delivery SystemDesign
DecisionSupport
Clinical InformationSystems
TARGET: PATIENTS WITH- NEOPLASTIC PATHOLOGIES- RESPIRATORY FAILURE- CARDIAC DECOMPENSATION
THE PATIENT-PERSON:Decisions based on
weighted judgements(Illness Histories)
… as a method for:
- systematising ideas and actions (finding a way out of the confusion “caused
by complexity”, of the routine chaos)
- identifying measurable spaces ofefficiency (EBM) and effectiveness,
(translating the evidence into “practices”:GOOD PERFORMANCE)
- highlighting the “global” needs of the patient-person
- assigning indicators for monitoring
EFFECTIVENESSAND APPROPRIATENESS:
Decisions basedon scientific evidence(EBM-based decisions)
Evidence-based MedicineNarrative-based Medicine
PALLIATIVETREATMENT
…………………………
………………….
PRESENCE OF THE PROBLEM
IN-DEPTHDIAGNOSTICS
COMMUNICATION
DEFINITION OF PERSONALISED PROGRAMME.
SHARED (agreed)THERAPY PROGRAMME.
INTERACTIVE TREATMENT
INTERACTIVEMONITORING
* Is the diagnosis always informed?* To whom?* How and when?* Which family member is informed of the diagnosis?* Appropriate verbal (and other) language? * …………………………
* Am I the right professional figure?* Am I aware of my state of mind?* Do I possess the right resources to manage my emotions in this relationship?* …………….
* What is the structure and what are the internal relationships of the family?* Who is the reference figure within the family?* …………….
(PATIENT) PERSON
OPERATOR
FAMILY
A S S I S T A N C E P A T H as a useful model for considering not only clinical improvement but all other
dimensions as well
CURING THEDISEASE
CURING THESYSTEM
CURING THEILLNESS
Aims of the projectAims of the project
•To improve the organisation and quality of life of the patients with a more
effective and efficient integrated pathology management, preventing unnecessary hospitalisation or reducing the
length of stay
• To guarantee patient centrality To guarantee patient centrality (empowerment)
•To improve the appropriateness of To improve the appropriateness of the interventionsthe interventions
centering them on the results, in terms of improved clinical effectiveness but also closer response to patient
needs (not only E.B.M. but also patient life histories)
Working methodologyWorking methodology
Phase 1: analysis and development of diagnostic-therapeutic guidelines and organisational-
relational protocols/recommendations
Phase 2: preparation of theoretical path
Phase 3: training programmes for all professionals in the network dealing with Cardiac
Decompensation
Phase 4: start of experimentation
Phase 5: clinical audit to monitor the indicators
Working tools/1
Diagnostic-therapeutic guidelines and organisational-relational recommendations
Path flow-chart
Follow up sheet
Decompensated patient pathDecompensated patient pathPRESENCE OF SYMPTOMS 1ST
DIAGNOSIS
GENERAL PRACTITIONER
HOSPITAL
REFERRAL TO LOCAL / HOSPTIAL SPECIALIST FOR FURTHER INVESTIGATIONS
INVESTIGATIONS
DECOMPENSATIO
N
NO
NYHA I CLASS
NYHA II CLASS
NYHA III CLASS
NYHA IV CLASS
YES
GENERAL PRACTITIONER COMMUNICATES DIAGNOSIS (or repeats the information given by the
hospital/territorial doctor) AND EDUCATES THE PATIENT IN TERMS OF CORRECT LIFESTYLE, THE IMPORTANCE OF FOLLOWING THE THERAPY, AND
THE RECOGNITION OF SYMPTOMS
EARLY FOLLOW-UP
STABLE PATIENT
SENT TO GENERAL PRACTITIONER WITH DISCHARGE LETTER / SPECIALIST REPORT, COMPLETION OF
DECOMPENSATION SHEET AND INDICATION OF PROPOSED THERAPIES AND FOLLOW UP
STAYS IN CLASS I
GP and specialists
communicate by phone and internet
NYHA 1
POSSIBLE ADJUSTMENT OF
PHARMACOLOGICAL THERAPY
GP SETS THE THERAPY AND FOLLOW UP (sets the next stage at each check up and notes it on the follow up sheet)
NO YES
SPECIALIST CONSULT
SPECIALIST REPORT INDICATING ANY
MODIFICATION IN THE THERAPY AND FOLLOW UP
GENERAL PRACTITIONER COMMUNICATES
OUTCOME TO PATIENT AND ESTABLISHES
THERAPY AND FOLLOW-UP
ExampleExample
Working tools/2
Self-monitoring sheets paziente: -Weight control sheet-Blood pressure control sheet-Physical activity monitoring sheet-Pharmacological compliance monitoring sheet
Information booklet: given to patient at the time of diagnosis; strong educational impact, with little technical information
Recipe book: given to patient at the time of diagnosis. Includes recipes suited to the whole family
Making a “therapy deal” with the Making a “therapy deal” with the patient involves:patient involves:
correct communicationcorrect communication
education of patient and familyeducation of patient and family
control of the adherence to thecontrol of the adherence to thepharmacological and other pharmacological and other
types of therapytypes of therapy
Transferring clear, appropriate messages to the patient concerning his pathology and checking his level of understanding With the patient’s consent, transferring the same messages to her/his relatives and checking the level of understanding Not having inattentive, distracted or didactic attitudes Paying attention to the patient’s doubts, uncertainties and fears Understanding and managing any attitudes of resentment the patient may have towards usIT IS FUNDAMENTAL FOR ALL THE INVOLVED
PROFESSIONALS TO USE THE SAME LANGUAGE
Communicating the diagnosisCommunicating the diagnosis
Educating the patient/relatives
Initial education at the time of diagnosis (by GP or hospital doctor), with patient/relative training aimed at self-monitoring
Handing over information booklet
Handing over the recipe book
Continuous education by all the professionals involved in the path
Yearly meetings with experts (diet, physical fitness, psychological reactions to the illness and management of such reactions…)
Ask the patient if he has taken the prescribed medicines
Ask the relatives the same thing
Check the self-monitoring compliance sheet
Objectively assess the consumption of medicines
Check the expected effects of some pharmacological therapies
Investigate the low tolerance of particular medicines
Checking pharmacological compliance….
Checking the introduction
Checking the diuresis
Checking the diet in relation to any cardiovascular risk factors
Checking life style
Checking non-pharmacological
compliance means….
USEFUL TOOLS FOR MANAGING CHRONIC PATIENTS
Aspettative dell’utente Esperienza dell’utente
Selezione
Ingresso
Primo contatto
Prima risposta
Intervento
Revisione
Chiusura
Follow-up
Divisione1
Divisione3
Servizio2
Risultatiparziali
Risultato per
l’utente
Risultatiparziali
Risultatiparziali
Processo assistenziale (il percorsopercorso del cittadino all’interno dell’Azienda)
HospitalAspettative dell’utente Esperienza dell’utente
Selezione
Ingresso
Primo contatto
Prima risposta
Intervento
Revisione
Chiusura
Follow-up
Divisione1
Divisione3
Servizio2
Risultatiparziali
Risultato per
l’utente
Risultatiparziali
Risultatiparziali
Processo assistenziale (il percorsopercorso del cittadino all’interno dell’Azienda)
Territory
IN GOD WE TRUST.
ALL OTHERSMUST USE DATA.
W.E. Deming
WHERE, WHAT, WHEN, HOW… TO EVALUATE?
INDICATORSINDICATORS
• opening of opening of
educational educational
clinics managed by clinics managed by
nursesnurses
• number of patients number of patients
following the pathfollowing the path
• use of toolsuse of tools
• home access by home access by
cardiologistcardiologist
PROCESSPROCESS RESULTRESULT
• reduction in reduction in
hospitalisationhospitalisation
• increase in the increase in the
amount amount of of
Integrated Home Integrated Home
CareCare
• illness historiesillness histories
Accountability