Geneva Health Forum Archive

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Collaborative Patient Care Pathway Model: Comprehensive Care Coordination for Geriatric Population

Author(s): Alakananda Mohanty1
Affiliation(s): 1Kissito Healthcare, Roanoke, United States
1st country of focus: United States
Relevant to the conference theme: Redesigning health services
Summary (max 100 words): Current trends in healthcare reform include penalties for high readmission rates that put providers at risk if patients are rehospitalized within 30 days. The goal of recent incentives under healthcare reform is to promote increased attention to chronic disease self-management competencies of patients, alter healthcare delivery systems to have increased responsibility for preventable readmissions and enhance quality care while using resources wisely. Kissito Healthcare has designed an unique collaborative model, the Collaborative Patient Care Pathway (CPCP)TM Model, which aims to deliver quality patient-centered care, greater continuity of care and improved patient outcomes at a reduced cost. The Model primarily focuses on chronic illnesses such as Congestive Heart Failure (CHF), Pneumonia, Acute Myocardial Infarction (AMI), Diabetes, Orthopedic Conditions, Depression and COPD/Asthma
Background (max 200 words): While traditional post-acute care in skilled nursing facilities focuses primarily on treatment, recuperation and short-term rehabilitation, Kissito Healthcare’s CPCP Model has chronic disease self-management as the fourth component, which is unique. The Model is currently being implemented at three Post Acute Care sites in the states of Arizona, Texas and Virginia.  The Model is based on three tenets: 1. Four Domains of Self-Management Competence 2. Patient-Centered Communication 3. Family-centered Approach to Self-Management
Objectives (max 100 words): At the patient and family (individual) level, outcomes include: Increased awareness/ knowledge of their disease, change in motivation (adherence), increased competency in recognizing red flags and responding with appropriate action and increased confidence in communicating with the health care provider. At the program and systems level, outcomes include: reduction in preventable hospital readmissions, reduction in hospital readmission rates and appropriate use of primary and community-based care options
Methodology (max 400 words): As indicated earlier, the model is based on three tenets.  1. Four Domains of Self-Management Competence. These domains are based on recent evidence in chronic disease management and outcomes: Disease Awareness - Patients are taught the disease etiology and progression, and to recognize “red flags” as a call to action.  Adherence Attitudes - patients are educated to overcome personal challenges related to the disease through  a structured assessment.  Treatment and Medication Management Competence -  patients are taught how to take their medications and adhere to their medication regimen at home. MedAction PlanTM - a web-based user-friendly software that continues to guide patients at home on their medications, and also includes powerful information to support continued health literacy of patients and families.  Healthcare Communication - patients are coached to improve their ability to communicate with their care providers.  2. Patient-Centered Communication which is “ask – tell – ask”. This unique patient-centered tool, based on adult learning theory, is used to bring the patient’s experience, perspective and concerns into a dialog, promoting shared decision making with his/her care providers, and is essential to self-management education and competence.  3. Family-centered Approach to Self-Management -  strengths, weaknesses, availability and willingness of family members (who play an important  role in the patient’s self-management team) are evaluated through structured assessment tools such as Beliefs about Medicine Questionnaire (BMQ), Patient Activation Measure (PAM) and Care Transitions Measure (CTM) Tools. Upon admission  to a Kissito Post  Acute Care Facility an assessments of the four domains of self-management competence was conducted.  An individualized care plan was designed by the Interdisciplinary Team (IDT) for attainment of optimal, patient-centered outcomes based on the assessments. The patient was educated for enhanced communication with his/her care providers. The patient was educated to perform a range of routine duties that he/she hoped to perform  at home under the self-management competence program. Medication reconciliation was carried out based on the patient’s current and planned discharge medications. In-home safety assessment was conducted prior to patient’s discharge to ensure that the home environment was safe for the patient.  Prior to the patient’s discharge, the same assessments conducted upon admission were repeated to assess progress and identify areas for continued attention.  Post Discharge calls were made between 24-48 hours,  in 2-3 weeks, after 30 days, and as often as needed in between, to ensure adherence to medication, diet, self-monitoring and physician visits.
Results (max 400 words): The following preliminary results indicate the percentage increase in patients’ understanding and behavior about self-management (compared to pre-intervention baseline data):• There was a 20% increase in disease awareness (n=50)• There was a 18% increase in signs & symptoms (n=50)• There was a 31% increase in motivating concerns (n=50)• There was a 26% increase in current status awareness (n=50)• There was a 33% increase in reflags awareness (n=50)• There was a 22% increase in understanding of RX  (n=50)• There was a 18% increase in meal preparation (n=50)• There was a 31% increase in disease self management (n=50)• There was a 19% increase in exercise activity (n=50)
Conclusion (max 400 words): The CPCP model is in its early implementation stage therefore evidence of the Model’s effectiveness remains inconclusive, although based on intermediate results there are positive outcomes.  Preliminary results demonstrate reduction in hospital readmissions within 30 days of post acute care discharge and successful transition to home among geriatric patients. We are in the process of establishing collaborative relationships with hospitals, Managed Care Organizations, Home Health Agencies, Physician (Community) Practices and other key stakeholders to improve the flow of patient information, prevent readmissions and develop systems and processes to ease and manage care transitions for patients and their families. The components of the Model are constantly being refined to establish best practices, benchmarks, databanks, and setting standards to ensure that national standards  are met and exceeded. The goal is to improve patient outcomes at a reduced cost through the CPCP Model that can be widely implemented and ultimately translated into a national standard.

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Needs for People with Type 1 Diabetes: Guidelines versus Patient Requirements

Author(s): David Beran1,2
Affiliation(s): 1Advisor to the Board, International Insulin Foundation, London, United Kingdom, 2Researcher and Lecturer, University of Geneva, Geneva, Switzerland
1st country of focus: Switzerland
Additional countries of focus: Argentina, Indonesia, Kyrgyzstan, Mozambique, Nicaragua, Singapore, South Africa, Tanzania, Thailand, UK, USA and Vietnam
Relevant to the conference theme: Redesigning health services
Summary (max 100 words): For the management of Type 1 diabetes guidelines exist and therefore international standards for care are defined. Yet people in most countries face challenges in managing their diabetes. Why does this occur? Do guidelines meet the needs of people with Type 1 diabetes?
Background (max 200 words): Type 1 diabetes is the most common paediatric endocrine disorder and the second most common Chronic Non Communicable Disease to affect children after asthma. Type 1 diabetes is characterised with the need for life-long care including daily insulin injections, management of diet and lifestyle as well as regular check-ups. For the management of Type 1 diabetes many guidelines exist and therefore international standards for care for people with Type 1 diabetes are clearly defined. In addition the Diabetes Control and Complications Trial showed that given the optimal conditions diabetes complications could be averted.
Objectives (max 100 words): To identify the needs of people with Type 1 diabetes and compare these to what the international guidance describes as the needs of people with diabetes.
Methodology (max 400 words): In order to identify the needs as defined by people with Type 1 diabetes, semi-structured interviews with 101 people from 13 different countries were carried out. Grounded Theory was used as a framework for collecting and analysing the data. Content analysis found that there was a difference between what guidelines stated and what people wanted.
Results (max 400 words): From the guidelines a varying level of importance was placed on some of the needs. For example identification, although stressed by the guidance, was not viewed as important by people with diabetes. The guidelines seemed to focus more on tangible health system aspects of care whereas the needs of people were more outside the health system. For example the importance of peer support and being open about their diabetes.
Conclusion (max 400 words): Although the Diabetes Control and Complications Trial (DCCT) found ways of decresing complications in Type 1 diabetes in reality people still face many challenges. This research highlights that there is a difference between the guidelines proposed by experts and what individuals with diabetes require.

Is Assessing Diabetic Distress An Efficient Pathway To Tailor More Effective Intervention Programs?

Author(s): Davoud Shojaeezadeh1, Azar Tol2, Golamreza Sharifirad2, Ahmadali Eslami2
Affiliation(s): 1Department of Health Education and Promotion, School of Public Health, Tehran University of Medical Sciences, Iran, 2Department of Education and promotion, School of Public Health, Isfahan University of Medical Sciences
1st country of focus: Iran
Relevant to the conference theme: Non-communicable chronic diseases
Summary (max 100 words): Type 2 diabetes is one of the most important health concerns worldwide. Many studies revealed that distress can significantly affect diabetes-related health outcomes, especially patients’ self-management. It is necessary that health experts and professionals take steps to better understand the nature of diabetes distress and its effects on health outcomes. Distress and its manner of management are powerful predictors of adopting self-management behaviors and affect the achievement rate of diabetes control. This study aims to assess the diabetes distress score and its related factors among patients with diabetes. The study can help decision- makers tailor appropriate and timely interventions.
Background (max 200 words): This study was performed to assess diabetes distress score and its related factors among type 2 diabetic patients. Considering the fact that different variables affect diabetes control in diabetic patients, this study tried to determine and analyze related effective variables. Identification and focusing of the modifiable determinants of diabetes distress plays a key role in appropriate intervention planning programs to achieve the best possible outcomes.
Objectives (max 100 words): The purpose of this study was to assess the diabetes distress score and its related factors among type 2 diabetic patients in order to tailor more effective intervention planning.
Methodology (max 400 words): A descriptive – correlation study was conducted for a period of six months in 2011. The study population was type 2 diabetic patients referring to Omolbanin, an outpatient diabetic center in Isfahan. 140 diabetic patients met the inclusion criteria and all participated in the study. A patient's diabetes distress was measured by DDS( Diabetes Distress Scale ) self-report scale with subscales reflecting four domains including Emotional Burden (5 items), Physician Distress (4 items) ,Regimen Distress (5 items) and Interpersonal Distress(3 items). Collected data was analyzed by using SPSS software version 11.5.
Results (max 400 words): The response rate was 100%. Participants were between the ages of 37 and 75 with a mean of 53.23 years (SD=7.82).  54.3% were female, 97.1% were married, and 57.1% had education levels  lower than diploma. Mean of duration of diabetes was 7.1 (SD=5.63) years. 69.3% of participants had borderline metabolic control according to World Health Organization criteria (Table 1).  The average score of total diabetes distress was 2.96 ± 0.83. The average score of each domain was (3.40 ± 1.18), (2.57 ± 0.88), (2.97 ± 0.90), (2.76 ± 0.91) respectively. ‘Emotional Burden’ was considered as the most important domain in measuring diabetes distress. Total diabetes distress revealed a significant relationship between variables such as age (p=0.02), duration of diabetes (p<0.001), marital status, comorbidity, and complications (p<0.001), and history of diabetes (p=0.01). The relationship between each domains and sociodemographic and health related factors has been shown in Table 2. With the intention of tailoring more effective intervention planning, we decided to distinguish which item in each domain had more weight on the score. Table 3 revealed the domains and more frequent response rate in each domain. Furthermore, the Pearson correlation coefficient also revealed that diabetes distress of type 2 diabetic patients had a direct relationship with HgbAlc (r = 0.63, p<0.001). This means that by increasing diabetes distress score, HgbAlc is increased and diabetes control becomes worse.
Conclusion (max 400 words): As outlined in our research it seems some keywords have a pivotal role in diabetes distress, such as emotional support, communication with patient and physician, self-efficacy and social support. All of these points are achievable through an empowerment approach to a diabetes care plan

Prevalence of Depression among the Elderly Population in Rizal Province Using the Geriatric Depression Scale

Author(s): Cheridine Oro- Josef1, Ma. Cristina dela Cruz1, Teofilo Salandanan Jr.1
Affiliation(s): 1Home Health Care, Quezon City, Philippines
1st country of focus: Philippines
Relevant to the conference theme: Vulnerable groups
Summary (max 100 words): The rate of depression (6.6%)  noted in this study was consistent with local studies done by Filipino authors. This prevalence rate among the elderly in the most populated province of the Philippines shows that depression can be present in Filipino healthy communities. However, it is considerable to note that a fourth (26.5%) of the population have scores suggestive of depression. This is a window for early intervention in the community level. Depression has been found to be associated with poorer prognosis, longer recovery times from illness, and increased health care utilization. Screening the elderly population for possible depression is important to decrease health care utilization and increase wellness for this age group. It is necessary for primary care physicians, geriatricians and caregivers to identify symptoms of depression in patients with scores suggestive of depression to avoid the development of outright depression. The Geriatric Depression Scale Short Form 15 has proven itself to be a fast, simple screen to quickly and efficiently identify those elderly who may be depressed.
Background (max 200 words): Depression in the elderly is an important public health concern worldwide. It is a silent disorder that afflicts many in the elderly population. It is the most common psychiatric disorder among the elderly yet unrecognized and under treated because attention is often focused on the physical medical conditions that are apparent during clinic visits. Typical signs and symptoms of depression are usually absent (such as lack of energy, loss of appetite, constipation, no interest in work, poor sleep or loss of weight) and are masked by physical manifestations of co-morbid conditions. In community practice case reports of elderly suffering from depression were regarded as consequences of the aging process. Contrary to this belief depression in the elderly is not physiologic. It is a pathologic condition that is reversible with prompt and appropriate treatment. Failure to recognize and treat depression increases the risk of a prolonged course of depressive illness as well as other conditions like malnutrition, significant metabolic illnesses, and a greater chance of dying.
Objectives (max 100 words): To determine the prevalence of depression and associated socio demographic and clinical conditions among the elderly in Rizal province. SPECIFIC OBJECTIVES: 1. To describe the socio-demographic and clinical conditions of the elderly in Rizal. 2. To detect depression among the elderly population using GDS SF 15. 3. To determine association between depression and socio-demographic and clinical conditions among the elderly
Methodology (max 400 words): A cross-sectional survey of the elderly population (aged 60 yrs old and above) in Rizal province, Philippines was conducted between August to October 2009. Simple random sampling was done to select 3 barangays from 3 municipalities in Rizal. A list of the elderly (60 years and over) was compiled from each of the barangays. All the subjects were contacted for a personal interview. The subjects' socio-demographic, socio- economic and clinical data were gathered during the interview wherein a structured questionnaire was completed. The Geriatric Depression Scale (GDS) SF 15 was used to screen for depression.
Results (max 400 words): The total number of elderly subjects included in this study was 196. There were 122 females and 74 males. Their mean age ± standard deviations was 67 + 6.89  (male 67.7±.6.7; and female 67.7±7) years. Most of the subjects were married, 56% (n=110) while 37.4% (n=73) were widowed. A few were single, (n=8, 4.1%) and separated (n=4, 2.1%). The majority were unemployed (n=173, 88.7%). Their source of financial support mostly came from their children (n=103, 62.8%). They live with either one or two married children (n=78, 40%) or their nuclear family (n=56, 28.7%). Most of the subjects were independent (n=127, 64.8%) and moved around without support (n=167, 86.5%). The top 3 medical conditions were Hypertension (n=75, 37.9%), Arthritis (n=50,25.3%) and other Heart diseases (n=18, 9.1%) . GDS SF scores suggestive of depression were reported in 52 (26.5%) of the subjects, and 13 (6.6%)  were in the almost always indicative of depression score group. Marital status (p= 0.044) and presence of multiple medical condition (p=0.018) correlated strongly with depression. Separated and widowed individuals are more likely to show symptoms of depression (R= 0.159).
Conclusion (max 400 words): Depressive symptoms are common among Filipino elderly in Rizal. Detection and early intervention may be helpful at the community level. A simple instrument such as the Geriatric Depression Scale SF 15 is useful and easily administered.