Local programs leading the way for those suffering with chronic diseases
Chronic illnesses are putting a strain on the nation's health care systems. And with Americans living longer, the problem will only become more challenging unless something is done about it.
In the 1990s a group of physicians created a 'chronic care model' based upon the premise that many at-risk patients were not having optimum outcomes to their acute illnesses because, for one reason or another, they did not follow through with their health care as prescribed. They also discovered that the processes that physicians had been using were not as effective as they could be in terms of following the patient from 'initial visit through treatment.'
The basis for that early process has been updated and refined by a group of Calhoun County health care providers. The local effort, called 'Pathways to Health' uses this model in helping health care providers work with patients so they can manage chronic illness and effectively improve patient outcomes.
The model focuses on developing informed patients who work more closely with proactive practice teams of health care physicians. The initiative emphasizes four major system change components for delivering better care to the chronically ill:
- Leveraging the use of community resources and allied health care providers, such as nurses and health educators.
- Involving and motivating patients and families to help self-manage their chronic conditions.
- Redesigning the delivery of care to improve services for the chronically ill.
- Encouraging health systems to operate with explicit guidelines or protocols and use up-to-date clinical information systems.
Community Resources
To improve the health of the population, it is imperative that health care organizations form powerful alliances and partnerships.
Self-Management
Effective self-management is more than telling patients what to do. Patients have a key role in determining their care, one that encourages a sense of responsibility for their own health.
Delivery Care System
Delivering patient care requires more than determining what care is appropriate. It is also clarifying roles and tasks to make certain the patient gets the care, and that clinicians have access to centralized and up-to-date information about the patients' status, and then following up with care as needed.
Clinical Systems
To manage chronic illnesses or preventive care there needs to be a system or registry that can track individual patients.
"The management of chronic care diseases is becoming a major component of primary health care providers," says Dr. Mary Ellen Benzik, medical director of Integrated Health Partners. "In addition to physicians, nurse practitioners and other advanced practice nurses are particularly well qualified for chronic disease management due to their ability to address the multi-faceted nature of chronic problems. For this to be a success, it must be a total team effort-the clinicians and the patient."
The Calhoun County 'Pathways to Health' initiative, recognized nationally for its work, will report on its progress on Thursday, May 22, at the McCamly Plaza Branson Ballroom from 8 to noon. This Outcomes Congress will chronicle the process of change as well as share results of improved outcomes for its pilot patients.
If you would like to attend this public report or learn more about this initiative, please contact Integrated Health Partners (IHP) at (269) 660-3850.
Battle Creek Health System, sponsored by two parent organizations--Trinity Health (the fourth largest Catholic health system in the U.S. with 12 hospitals, 9 nursing homes, 19 senior house facilities, 8 home health care agencies, and 4 hospices in Michigan alone) and BCHS Community Partners, is accredited by the Joint Commission on the Accreditation of Healthcare Organizations. Battle Creek Health System as a recipient of the 2008 HealthGrades Orthopaedic Surgery Excellence Award(tm). HealthGrades is a leading health care information company that provides objective 'report card' ratings nationwide. BCHS provides excellent health care for the community and promotes wellness for the whole person with access and compassion for all. For the latest medical information, visit the BCHS web site at www.bchealth.com or call the BCHS Marketing Department at (269) 966-8132.
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