This product was developed by the Help Yourself: Chronic Disease Self Management Program at Marshall University School of Medicine in Huntington, WV
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1 This product was developed by the Help Yourself: Chronic Disease Self Management Program at Marshall University School of Medicine in Huntington, WV and the New River Health Association in Scarbro, WV. Support for this product was provided by a grant from the Robert Wood Johnson Foundation in Princeton, New Jersey.
2 MEDICAL GROUP VISITS: A Team Approach to Promote Self- Management New River Health Association Scarbro, West Virginia Marshall University School of Medicine Department of Family and Community Health
3 Appalachian State Isolated rural communities System of rural primary care centers Almost heaven West Virginia
4 New River Health Association
5 MGVs have Caught On at NRHA Began 5/01 One team - Doctor, Nurse and Facilitator 1 st and 3 rd Thursday of every month March Medical Group Visits Mental health (2 group) Black lung (1 group) Chronic pain -- GOLS (1 group) Chronic care teams (3 groups) Workers comp (1 group)
6 MGV Team Facilitator
7 Team Approach Providers get help with the many tasks of a chronic care patient visit Being in the same room, provider and nurse can easily flex to coordinate tasks Facilitator coordinates paper work, answers questions Patients actively participate as part of the team
8 Tasks that are Accomplished Chronic disease follow-up; exam; questions Lab results New prescriptions/refills/change medication X-rays, lab tests ordered Referrals Forms filled out (Comp, insurance, disability) Diagnose and treat new problems Private exam if needed
9 Visit Setting Conference room Computer with wireless link to lab, EMR, pharmacy Chairs in a circle Rolling stool for provider to scoot pt. to pt. Small table in center for visit supplies (gloves, foot exam pads, etc) Healthy refreshments in corner of room Private exam room & bathroom near by
10
11 Typical Time Frame 8:00 to 8:30 AM Patients given clip-board Vital signs recorded - Patient questions and needs noted Patient reviews EML and Continuing Problem List Introductions and patients list reasons for the visit
12 Time Frame... 8:30 9:30 Round one: doctor and nurse do individual medical exams Round two: Doctor will move around the room addressing patient needs Question and answer time
13 Time Frame... 9:30-10:00 Group Discussion - Lab reviewed and education topics discussed Goal setting and action plan
14 Key: Prepare Ahead Nurse (2-3 days before) Reviews census goal of scheduling pt. Organizes paper work visits sheets, billing forms, etc
15 Prepare Ahead Facilitator (day before) Reviews outcome data notes who may be struggling Reviews preventive health screen Creates wall chart with patients data Sends charts to provider the day before the MGV
16 Group Medical Visit Date: Initials A1C Total Trig HDL LDL Lipid Meds Other Lab due Last PE PE Pla n FU
17
18 Prepare Ahead Medical Provider Reviews the Last 3 visit notes Reviews med, & Lab list Outlines a plan for the MGV, including self management topics
19 Key: Reduce Doctor Busywork Chart reviewing done ahead Lab orders Follow-up plan done by the team Progress note writing Use of tablet PC with wireless connection to EMR
20 Benefits to Patients Almost no wait time for appointment More participation with medical team Discussion time/q&a Patients learn from and support each other Relaxed setting/healthy snacks Patients can schedule themselves Family members and support welcome
21 Benefits to Medical Team Saves time! Lab data on hand Referrals and apnt. made during the MGV Efficient use of other clinic support staff Lab, front desk, social worker Satisfied Patients
22 Back up a moment...
23 Behavior Change Materials Key Messages Balance your plate Choose to move Kick the habit
24 Self Management Booklets Educational booklets with basic information
25 Patient Decision-Making Action Plan Example This week I will Increase vegetables (What?) One serving (How much?) At lunch and dinner_ (When?) 5 days (How many?) How confident are you? _9_ (0 = not confident 10 = totally confident)
26 Maintenance I am ready PASSPORT Individuals have possession of health status data and can monitor their goals
27 Follow-up Help Yourself Chronic Disease Self-Management Program Developed at Stanford University A six-session course; weekly 2-hour sessions with a focus on skills training Leaders follow a detailed leaders manual Designed to be led by non-health professionals and individuals with chronic conditions
28 Conclusion Expansion of MGVs has been successful at NRHA MGV s improve patient access High level of patients and provider satisfaction with MGV process MGVs provide opportunity to integrate self management into patient visit Patients who attend MGV are more likely to be engaged in self-management activities
29 With financial support from the Advancing Diabetes Self-Management Program Robert Wood Johnson Foundation
30 Linda Stein, MS New River Health Association Richard Crespo, PhD Marshall University School of Medicine Sally Hurst
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