CCHN is involved in a number of initiatives that promote the delivery of consistent, high-quality services across the continuum of care and uses the Wagner Chronic Care Model (CCM) as an evidenced-based guide for quality improvement. The CCM is a multi-dimensional framework for improving care and synthesizes basic elements of health care including the community, the health system, self-management support, delivery system design, decision support and clinical information systems. Using a blend of evidence-based programs and tools associated with each element, CCHN can foster productive interactions between informed patients who take an active role in their care and providers with resources and expertise. In partnership with IDS and AMP providers, CCHN has positioned itself to facilitate pilot projects using evidence-based models, and those that demonstrate effectiveness and result in improved health outcomes can be adopted and endorsed by the larger provider network. Individually and collectively these efforts result in integrated systems, improved care quality and communication, higher provider reimbursements, reduced health care costs and a healthier community.
PATIENT CENTERED MEDICAL HOME
CCHN endorses and supports the Patient-Centered Medical Home (PCMH) approach to providing comprehensive primary care. In 2008, the National Committee for Quality Assurance’s (NCQA) began the PCMH Recognition Program by developing a set of standards for practices to organize care around patients, working in teams and coordinating and tracking care over time. PCMH enhances the quality of patient care through the Chronic Care Model and facilitates partnerships between individual patients and their personal physicians who are trained to provide first contact, continuous and comprehensive care. Care is coordinated and/or integrated across all elements of the complex health care system (e.g., subspecialty care, hospitals, home health agencies, nursing homes) and the patient’s community (e.g., family, public and private community-based services). CCHN has assisted seven local practices in reaching Level 3 of PCMH 2008, the highest recognition that could be achieved for that specific set of standards. Practices that have achieved NCQA’s PCMH Recognition can take advantage of financial incentives that health plans, employers, federal and state-sponsored pilot programs offer. Moving forward CCHN will assist practices in achieving the new PCMH 2011, which builds on the success of the earlier standards and make the program even more responsive to patients’ needs. Although the standards have always pointed practices toward using systems—including electronic health records—to support tracking care, PCMH 2011 aligns closely with many elements of another CCHN-endorsed program, Meaningful Use, which rewards clinicians for using health information technology to improve quality.
NCQA DIABETES RECOGNITION PROGRAM
To address one of the most chronically ill patient populations, NCQA has developed the Diabetes Recognition Program (DRP) to help clinicians use evidence-based measures and provide excellent care to patients with diabetes. Physicians who achieve recognition are identified as high-quality clinicians who have demonstrated that they are on the leading edge of quality care delivery to diabetic patients.
Facilitated by CCHN staff, 36 local primary care physicians have received recognition for NCQA through the DRP by submitting data that demonstrates performance that meets the program’s key diabetes care measures. These measures include eye exams, blood pressure tests, nutrition therapy and patient satisfaction. When people with diabetes receive quality care as outlined in these measures, they are less likely to suffer complications such as heart attacks, stroke, blindness, kidney disease and amputation.
Developed by the Roger C. Lipitz Center for Integrated Health Care at the John Hopkins Bloomberg School of Public Health, Guided Care® has been tested in numerous clinical trials and studies. It has been shown to improve both the quality of patient care and patient satisfaction with care. Studies further show a reduction in the use of expensive services, especially in integrated care delivery systems.
CCHN has assisted several PCHM practices by training an RN within the practice as a Guided Care Nurse (GCN). GCNs will lead care delivery teams to improve case management for patients with multiple chronic conditions by maintaining care plans and managing transitions of care. GCNs will demonstrate and facilitate the use of evidence-based tools and programs resulting in improved care coordination and patient health outcomes.
Health Information Technology
To improve healthcare in the US, the Meaningful Use (MU) incentive program was established to increase the use of Electronic Health Record Systems in three distinct stages. In 2010, the standards for MU Stage 1 was developed by the Centers for Medicare & Medicaid Services (CMS) Incentive Programs and allows eligible providers and hospitals to earn incentive payments if they attest to meeting the specific criteria by 2014. If providers do not meet the requirements by 2015, they may be penalized. Providers can begin attesting to MU stage 2 in 2014, which will include a more advanced set of standards. CCHN assists providers with Electronic Medical Records (EMR) implementation and is currently assisting 93 providers inclusive of physicians and extender staff to achieve MU Stage 1. Many of the requirements for MU Stage 1 and PCMH 2011 overlap, allowing CCHN to leverage staff support to our providers.
Chronic Disease Registries With an overall objective to become clinically integrated, CCHN staff in partnership with the IDS has been building an IT infrastructure inclusive of electronic patient registries using Confident Health®. The patient registries allow CCHN staff to gather and analyze nationally-accepted, QI performance measures and provide feedback to physicians in a quarterly progress report that can be used to improve patient care and outcomes. A total of 10 area practices and 81 providers are participating in the registry project for Diabetes and Cardiovascular disease.
CHAUTAUQUA HEALTH CONNECTS
CCHN partnered with the Chautauqua County Office for Aging, Heritage Ministries, and Lakeshore Nursing Facility and was successful in garnering a $450,000 HRSA grant which made it possible to link 24 healthcare organizations through a web-based Health Information Exchange (HIE) designed to strengthen communication and information flow between organizations, reduce hospital readmissions and train provider offices in the use of the Guided Care and Care Transitions. This initiative is transforming the array of health, social and support services into a local integrated service delivery system. Organization of services around older adults “at-risk for institutionalization” has produced measurable improvements in health status. Through the achievement of the proposed goals and objectives, the community is realizing a holistic, multidisciplinary approach to long term care that helps to maintain older adults in their homes.
Cassadaga Valley Central School’s Hiking Club
Consumers are being asked to assume an increased role in their health and health care decision-making. From making healthy lifestyle choices to managing health conditions to making decisions about treatment options or insurance coverage, consumers need support to succeed in their new roles. Consumer engagement is a crucial element in the progress of care management efforts that include increased provider collaborations. CCHN supports a variety of initiatives designed to promote consumer engagement and help community residents to be informed decision makers. CCHN is committed to improving quality, containing costs and expanding coverage with a strong emphasis on the needs of patients. To that end we have focused on a number of patient centered initiatives including:
ADVANCE CARE PLANNING AND HEALTH CARE PROXY REGISTRY
CCHN has developed a county-wide initiative to improve the quality and cost effectiveness of health care for our residents. Our objective is to increase and strengthen cooperation among local providers to ensure that Chautauqua County residents have access to quality medical services and that their end-of-life choices are known and respected. Efforts include educational programs for individuals, health care organizations, physician practices and hospital personnel. The centerpiece of this initiative is a web-based registry containing thousands of health care proxies. Area residents over the age of 18 are encouraged to participate in the Health Care Proxy Registry to specify their health care wishes. Medical care providers have access to the Registry 24/7 and can download a copy of your proxy and ensure that your wishes are followed. Those who complete the proxy form are asked to think about their health care wishes and put them in writing using the a Health Care Proxy Form and appoint a health care agent. This should be someone with whom you have discussed your wishes and who will speak for you if you are unable to speak for yourself. The health care proxy form is a legal document for adults (healthy or sick) to designate an agent for future shared decision-making. The document goes into effect if an individual is declared by a physician to be unable to make their own health care decisions. For those who receive health care services in Chautauqua County, mail a completed copy of your proxy to: CCHN, 200 Harrison Street, Suite 200, Jamestown, NY 14701 or fax to CCHN at 716-338-9740. Your form will be entered in the Health Care Proxy Registry. For questions about the registry or other resources, contact Kathy Burch at 716-338-0010 or at email@example.com.
MEDICAL ORDERS FOR LIFE SUSTAINING TREATMENT (MOLST)
Individuals who wish to ensure that their medical wishes are followed should complete the Medical Orders for Life Sustaining Treatment (MOLST) form and have the order signed by a NYS licensed physician. The bright pink form includes medical orders and preferences regarding:
- Artificial hydration and nutrition
- Future hospitalization and transfer
- Intubation and mechanical ventilation
Unlike the health care proxy, a MOLST form is a medical document for patients of any age with an advanced illness. The form is available at your doctor’s office or by contacting the Quality Care Manager at 716-338-0010 or firstname.lastname@example.org. Additional support for end of life care is available at www.compassionandsupport.org.
Self Management Programs
The Stanford Patient Education Research Center developed, tested, and evaluated a number of self-management programs for people with chronic health problems. All of the programs are designed to help people gain confidence in their ability to control their symptoms and how their health problems affect their lives. Small group workshops are generally six weeks long, meeting once a week for about 2 hours, and are led by a pair of leaders. The meetings are highly interactive, focusing on building skills, sharing experiences and support. Chautauqua County Health Network is currently partnering with several organizations and volunteer leaders to offer three options of the self-management programs at locations throughout the county including Living Healthy for those with general chronic conditions, Living Healthy with Diabetes, and Living Healthy with Chronic Pain for those with those specific conditions. The programs are free and open to anyone with one or more chronic diseases(s). It also can help caretakers of people with chronic illness. The 2017 Schedule is available here. Our next informational meeting is June 21, you can find more information here and our next workshop starts June 27. For further information contact Kathy Burch at 716-338-0010 or at email@example.com.
POWERFUL TOOLS FOR CAREGIVERS
Caring for someone with a chronic illness such as dementia, heart disease, Parkinson’s disease or stroke can be stressful physically, emotionally and financially. Powerful Tools for Caregivers is a free six week workshop designed to provide you with the tools you need to take care of yourself. Learn how to reduce stress, improve self-confidence, communicate your feelings, balance your life, locate resources and increase your ability to make tough decisions. To register, call New York Connects: 716-753-4582 (Jamestown); 716-661-7582 (Mayville); 716-363-4582 (Dunkirk); or contact Kathy Burch at 716-338-0010 or at firstname.lastname@example.org.
NATIONAL DIABETES PREVENTION PROGRAM
The National Diabetes Prevention Program (NDPP) is a proven way to prevent diabetes in people who have pre-diabetes or are at risk for diabetes, by making small lifestyle changes. Developed by the Indiana University School of Medicine, NDPP participants meet in a group setting over a 16-week period followed by monthly meetings where personal lifestyle goals are set for each individual. Each free one-hour session covers diet, exercise and behavior modification to help participants reduce and maintain individual weight loss by 5-to-7 percent and participate in regular physical activity. The program helps participants learn to improve food choices, increase physical activity and learn coping skills to maintain weight loss and healthy lifestyle changes. Are you at risk for diabetes? Take the test. For more information about the NDPP program, contact Kathy Burch at 716-338-0010 or at email@example.com.
Individuals interested in ending their addiction to nicotine and beginning a new smoke-free life can access an array of resources by contacting the NYS Smokers’ Quitline 1-866-NY-QUITS FREE (1-866-697-4887) or www.NYSmokefree.com. Free nicotine replacement therapy is available to those who qualify. One to One smoking cessation counseling is available locally. To sign up for this free service, contact Ashley Risley at 716-338-0010 or at firstname.lastname@example.org
Best Practices and Evidence Based Tools
To support quality improvement initiatives, CCHN promotes the use of best practices and assessment instruments used for screening, diagnosing, and monitoring a number of chronic conditions from depression to diabetes.
This questionnaire incorporates DSM-IV depression diagnostic criteria with other leading major depressive symptoms into a brief self-report tool which is completed by the patient and scored by the clinician. Based on the scoring, provisional diagnoses are identified and a number of treatment recommendations are outlined.
Falls, especially for older adults, can lead to a number of serious complications. The Steadi (Stopping Elderly Accidents, Deaths and Injuries) Toolkit was developed by the CDC’s Injury Center for health care providers who see older adults in their practice who are at risk of falling or who may have fallen in the past. It gives health care providers the information and tools they need to assess and address their older patients’ fall risk. Click here to view the screening tool.