Integrating a Practical Clinical Model into Care Coordination for Health Promotion and Activities in Parkinson s Disease (CHAPS)
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1 Integrating a Practical Clinical Model into Care Coordination for Health Promotion and Activities in Parkinson s Disease (CHAPS) Improving Quality of Care in Parkinson s Disease: A Randomized Controlled Trial Karen Connor PhD, RN, MBA Principal Investigator VA-HSR&D-NRI Multi-Center Study Parkinson s Disease Research Education & Clinical Centers (PADRECCs) Karen.Connor@va.gov American Academy of Physical Medicine and Rehabilitation San Diego, CA November 15, 2014
2 Karen Connor PhD, RN, MBA Nothing to Disclose. 2
3 CHAPS MODEL Health System and Community GLA, Las Vegas, Long Beach, Loma Linda, San Diego VA Resources and Policies Local APDA, LA-CRC, NPF, PRO Resources and Policies Delivery System Redesign (CHAPS Nurse Care Managers, SDMM & SHC Notebook) Decision Support (Parkinson s disease Specialists, Evidence-based protocols & Empiric expertise) Clinical Information Systems (Care management registry/tracking tool) Self management (Coaching by CHAPS Nurse Care Manager in goal setting, coping, problemsolving & SHC Notebook) Prepared Proactive Care Management Team Productive, Veteran-Centered Communications and Interactions Informed Veterans and Their Care Partners Adapted from Wagner CCM IMPROVED OUTCOMES 3
4 The Challenge: Managing So Much Parkinson s related Clinical Information 4
5 5
6 List of Problem Areas/Care Plans (early draft) 1. Understanding Parkinson s Disease 2. Cognitive Impairment 3. Communication/Continuity 4. End-of-Life 5. Exercise 6. Functional Limitations (ADL, IADL, Hearing, Vision) 7. Gastro-Intestinal 8. Impulse Control Disorder 9. Long-Term Planning (Advance Directive, DPHC, Money Management) 10. Medication 11. Mood (Depression, Anxiety, Apathy) 12. Motor Problems (Dyskinesia, Dystonia, Tremor) 13. Psychosis (Delirium, Hallucinations) 14. Safety (Abuse, Falls, Driving) 15. Sleep and Fatigue 16. Speech and Swallowing 17. Urology 18. Weight/Nutrition/Dental 19. Prevention 6
7 The Siebens Domain Management Model (SDMM) An empiric clinical model derived from Internal Medicine/Geriatrics/Physical Medicine & Rehabilitation Concern on how to organize masses of information, more than in dementia care project Concern on how to teach the intervention to nurse care managers
8 Organizing CHAPS Assessment & Problem Areas with Care Plans - Integration of the SDMM¹ I. Medical/Surgical Issues (The Body) 1 Prevention 2 Medication 3 Motor-Related 4 Gastro-intestinal-Related 5 Weight/Nutrition 6 Swallowing 7 Urology-related 8 Pain 9 Sleep and Fatigue ¹ Hilary C Siebens MD 2005 Used with permission II. Mental Status/Emotions/Coping (The Mind) 10 Hearing 11 Vision 12 Speech 13 Cognitive Impairment 14 Psychosis/Hallucinations 15 Depression 16 Anxiety 17 Understanding Parkinson s Disease 18 Coping/Self-management 19 Apathy 20 Impulse Control Disorder 21 Preferences/Long term care planning 8
9 Organizing CHAPS Assessment & Problem Areas with Care Plans - Integration of the SDMM¹ III. Physical Function (Activities) IV. Living Environment (Surroundings) 22 Functional Limitations 23 Falls 24 Physical Activity (Exercise) 25 Driving ¹ Hilary C Siebens MD 2005 Used with permission. A. Physical home etc B. Social 26 Elder Abuse C. Financial & Community Resources 27 Access to Care 28 End of Life Resources 9
10 Clinical Documentation The SDMMis used in all clinical documentation CHAPS Assessment Summaries (initial, 12 mos fu) Nurse Care Manager Telephone Follow-up Visits Relevant problems are organized (problem and plan together) in each of the 4 domains Ensures context of health problems is kept clear
11 Partnering with Veterans & their Care Partners One Conceptual Approach (SDMM)¹ Domain Medical Name I Medical/Surgical Issues II Mental Status/Emotions/ Coping III Physical Function IV Living Environment Domain Plain Name Body Mind Activities Surroundings Plain Phrases for use with Patients 2 Health Issues Your Body Your Mind and feelings What You Do Where you Live and Work ¹ Table 2 from Siebens H. Proposing a practical clinical model. Top Stroke Rehabil 2011;18: (operationalizing the biopsychosocial and biopsycho-ecological models) Hilary C Siebens MD 2010 ² Plain phrases from Siebens Patient Care Notebook, Siebens Patient Care Communications 11
12 Partnering with Patients - A Veteran-centered Component of CHAPS Siebens Health Care Notebook (organized by SDMM) a 3-ringed binder, owned by patients Customized for each Veteran My Action Plan Single standard education sheet in each Domain Custom education sheets based on CHAPS Assessment/Veteran s priorities CHAPS Assessment copy for Veteran, in back of binder with instructions for other physicians copy if desired) 12
13 Partnering with Patients - A Veteran-centered Component of CHAPS Siebens Health Care Notebook Veteran utilizes this to organize information Place to keep medication list Place to record issues/concerns to share with 1) Provider at next visit 2) CHAPS care manager for next phone call encounter Tool to take to all appointments to show VA and Community providers and to participate in decisions Keep it going Dr. A, non-va neurologist (for peripheralneuropathy workup) when Veteran showed him the SHC Notebook (Vignette 2). 13
14 My Action Plan A CHAPS Communication Tool 14
15 Vignette 1 66 year-old (100% service connected), retired (worked in building), enjoys reading his Ebook, and lives with his wife and multiple dogs in a house; Parkinson s diagnosis in the 1990s. 15
16 Vignette 1 I. Medical Issues On 23 different pills (all prescription) BMI 34, Type 2 Diabetes mellitus, hypertension Had a stroke with residual left weakness Worsening tremors Moderate foot and jaw pain Urinary frequency II. Mental Status/ Emotions/ Coping Problem with vision and tracking with both eyes Taking meds for depression III. Physical Function Sometimes dragging left foot/trouble with balance No falls but in prior year had one with hypoglycemia IV. Living Environment Uneven gravel surfaces outside home 16
17 Vignette 1 Progress to date Expresses pride in being part of research, talking about the research in his VA PTSD Support group Reports seeing progress in his management of 20 medical problems (e.g., tremors better with less caffeine) Using SHC Notebook: Records information in notebook (wife too if pt requests help) Brings Notebook to all 10 appointments in last 3 months One provider stated, I m very impressed with this notebook, appreciates seeing it at visits Newlyusing MyHealtheVetwith help of wife Since Care Manager made Veteran aware of his fall risk (PD, stroke, & environmental hazards) Veteran asked PCP Questions (written in Notebook) about unsteady walking PCP and Veteran discussed several assistive device choices Veteran prescribed a rollator. I love it! 17
18 Vignette 2 85-year old Veteran, retired high school teacher, was Caregiver for wife prior to her death 2 years ago; son who travels a lot lives with Veteran in a single family home. Parkinson s disease for at least 8 years (3 meds) with multiple comorbidities 18
19 Vignette 2 I. Medical Issues 17 different meds (12 prescription, 5 OTC) Lightheaded w/ standing x 3mos Peripheral-neuropathic pain or arthritic pain Serial mgmt for pancreatic lesion II. Mental Status/Emotions/Coping Difficulty hearing No depression or anxiety Self rates health good Uses Internet daily Uses MyHealtheVet for med refills Has a will, Advance Directive, Trust, and Power of Attorneys III. Physical Function Independent in BADLs, help with IADLs, using cane and rollator Misses going to church due to no preferred drivers No falls (tho lightheaded ) Vet pre-fills meds, Son verifies Drives short distances only IV. Living Environment Limited income; has enough $ for food Trouble with med refills and reaching MDs, needs transportation to medical appointments 19
20 Vignette 2 -- Progress to date Veteran very pleased with CHAPS program Responded to awareness of apathy lecture with insight of no social contacts Renewed driving license Resumed going to church Actively considered VA Adult Day Health Care referral that he has been reluctant to accept for several months Now participating in VA Adult Day Health 20
21 Evaluation Surveys Whether or not study participants keep track of any changes they notice in their overall health (Pew Center survey) How patients prepare for doctor visits ( 1 item from a Stanford University survey) Medication adherence ( 2 items from ASK-20 survey) What factors in the participants lives might be preventing them from managing their health and healthcare (6-item Chaos Scale) 21
22 Challenges & Observations Comprehensiveness at first may seem overwhelming to patient and nurse; however, Identified issues often inter-related Addressing one issue helps resolve another, may empower/encourage Veteran There istime to work through issues Awaiting results 22
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