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PPC-4 Patient Self-management support
Element B: Self Management Support
The practice conducts the following activities to support patient/family self-management, for the three important conditions:
- Data Point 2. Provides education resources in the language or medium that the patient/family understands.
- Data Point 4. Provides or connects patients/families to self-management support programs.
- Data Point 5. Provides or connects patients/families to classes taught by qualified instructors.
- Data Point 7.Provides written care plan to patient/family.
Each chronic disease template in SETMA’s EMR provides a section for engaging the patient and family in discussions related to the patient’s responsibilities in managing their disease through pro-active measures such as becoming educated about the disease process, making lifestyle changes in diet, exercise, smoking cessation, alcohol consumption, coping with stress, and becoming a partner with his/her physician to maintain and/or improve his/her health. In addition, each patient is routinely assessed using the LESS (Lose weight, Exercise, Stop Smoking) initiative. Patients and family are then provided with a document of their assessment including weight, body fat percentage, waist and hip measurement. Based on the assessment, the patient is provided a documented plan to lose weight, an exercise prescription, and/or a smoking cessation contract. . A referral can be made to the Registered Dietitian (R.D.) for a more detailed explanation of the patient’s diet through 24-hour recall and eating patterns, further emphasis on lifestyle changes and assistance in working the plan into the patient’s and family’s individual lifestyle Each visit with the R.D. includes patient-chosen goals that are documented in the follow-up note for the applicable chronic condition. These behavior-change goals may be followed by the referring provider or subsequent visits with the RD.
The CHF Treatment Plan template has several areas that assess the patient’s lifestyle and changes that need to occur to manage CHF effectively. The general measures template allows the provider to collect in one place the patient’s:
- blood pressure
- lipids
- smoking habits
- alcohol consumption
- illicit drug use
- diabetes control
- thyroid levels
Any of these concerns about the care of a patient with CHR which are not at goal, appear in red and therapeutic recommendations appear. The fluid management template allows the provider to document necessary fluid and sodium restriction and encourage daily weight measurements of the patient with the patient and family. The provider is also able to give the patient education materials which allow the patient to take charge of their own care.
Weight loss, physical activity, and smoking cessation templates are also tied in to the CHF Treatment Plan template. Once the provider assesses and documents needed directives for the patient, the CHF treatment plan and follow-up document can be printed and provided to the patient and family.
The Hypertension Management suite in the EMR includes lifestyle changes, where the provider can document discussions about the expected reductions of systolic blood pressure with the following changes:
- Eliminate or reduce alcohol consumption to one drink per day. A reduction in alcohol intake may reduce your systolic blood pressure 2-4 mmHg.
- Eliminate or reduce caffeine intake.
- Take measures to reduce and control stress.
- Weight Loss -- Each 20 pounds of body weight lost equates to a lowering of systolic blood pressure by as much as 5-20 mmHg. Providing the patient with their current body mass index (BMI) and letting them know that a BMI of 25 or less is desirable.
- Increase potassium intake.
- Increase calcium intake.
- Maintain adequate magnesium intake.
- Increase fish oil intake.
- Reduce sodium intake to no more than 2.4 grams per day.
- Following a low sodium diet may reduce your systolic blood pressure 2-8 mm Hg.
- Adhere to the principles of a DASH diet. following the DASH diet may reduce your systolic blood pressure 8-14 mmHg.
- Increase potassium intake. With a document entitled, “The following are good sources of potassium”
The patient is given instructions on “Reasons To Call Your Doctor,” in which they are told, “If you have any of the following symptoms between appointments, you should call your doctor immediately.”
- Severe headache
- Excessive tiredness
- Confusion
- Visual changes
- Nausea or vomiting
- Chest pain
- Shortness of breath
- Significant sweating
And they are given the following information about “Take Care of Yourself”
- Take medications as prescribed.
- Don't abruptly stop or decrease your medications without asking your doctor.
- It is dangerous to stop taking certain blood pressure medications suddenly.
- Monitor your blood pressure regularly.
- You can do it yourself or have your doctor or other health care professional do it. Keep a chart of the readings.
- If you smoke, quit.
- Reduce salt intake according to your doctor's prescription.
- Start exercising regularly, with your doctor's approval.
- If you are overweight, lose weight.
- Limit the amount of alcohol you drink.
- Reduce stress or learn stress management techniques.
- See your doctor or healthcare professional as often as he or she recommends.
The plan also includes areas to document instructing the patient and family on self-monitoring of blood pressure and maintaining a blood pressure log, keeping physician appointments, and consistently taking medications as indicated. Documentation of the plan can then be printed and provided to the patient. .
The lifestyle section of the lipids suite enables the provider to document the recommended actions of the patient and family regarding the need to change the diet to any of the following that apply: low carbohydrate, high fiber, low fat, low cholesterol, low trans- fat, no sugar, and/or weight loss. The links to smoking cessation contract, exercise prescription are also available. Patient literature may be printed from the same template on the Step I and Step II diets, relationship between a inactivity and dyslipidemia. Upon completion, the Lipids Management Plan Follow-up document can be printed for the patient and family.
SETMA’s Weight Management initial assessment engages the patient and family in determining goals for weight loss, willingness to make lifestyle changes, triggers to food intake in the absence of hunger, previous attempts at weight loss, what has worked, and what impedes success. The patient and/or family are given instruction for a weight loss plan and individual behavior change goals are set. A follow-up document with instructions and goals can then be printed for the patient and family to bring home.
SETMA’s Diabetes Self-Management Education (DSME) program meets all of the requirements of the American Diabetes Association and has been certified by the ADA for the past five years. One such requirement is the initial assessment with the patient, which usually lasts about one hour, prior to the patient attending education. Family members are welcome and encouraged to attend this and all visits. The goal of the initial assessment is for the educators to have a clear idea of the patient’s/family’s understanding of diabetes, their current self-management skills and learning needs, the patient’s/family’s ability and motivation to learn, both cognitively and socially, barriers to learning and making lifestyle changes, and the patient’s/family’s personal goals for improvement. All of this information is documented in the electronic medical record templates as it is collected. A pre-program knowledge level is recorded for each of the content areas and an educational plan is then documented in the educational record.
The practice supports patient/family self-management through providing educational resources, and providing/connecting families to self-management resources
Each chronic disease template in SETMA’s EMR enables the provider to print out educational literature related to the patient’s and family’s responsibilities in managing their disease through pro-active measures such as becoming educated about the disease process, making lifestyle changes in diet, exercise, smoking cessation, alcohol consumption, coping with stress, and becoming a partner with his/her physician to maintain and/or improve his/her health. In addition, there is educational literature directed to the family of the patient to enhance understanding of the family’s role in managing the patient’ illness and encourage support. A referral can be made to the Registered Dietitian (RD) for improved understanding of meal planning and assistance in working the plan into the patient’s and family’s individual lifestyle The family is welcome and encouraged to attend each visit with the R.D., as often times dietary changes pose challenges for the entire household. Recommendations may be made to Nutrition and Services for Seniors, Food Bank or County Agencies that may be able to assist in meeting the patient’s needs.
The CHF Management template has a patient information section that enables the provider to print out a self-management book for the patient and family that includes:
- Welcome letter
- Glossary
- What is CHF?
- Treatment
- Treatment options
- Recovery prospects
- Low sodium
- Potassium in foods
- What is an echocardiogram?
- When to call your doctor
- Questions for your doctor
- CPET
- Fluid Restriction
- Hyponatremia
- CHF and inactivity
The Hypertension Management suite in the EMR includes lifestyle changes, where the provider can print out educational literature for the patient and family including low sodium diet, effects of excess alcohol consumption, smoking, and caffeine on blood pressure, losing weight, and the DASH diet. Included in this section are links to exercise, where a specific exercise prescription can be created and printed, and smoking cessation, where a contract between the provider and the patient can be devised, printed, and a tickler file set up so that the provider can call the patient to ensure that progress toward cessation is being made. A referral may be placed to the RD for the CardioMetablolic class where details of the DASH eating style and lifestyle changes that may decrease the risk of cardiovascular events are discussed with patients and families. Presentation includes power point, additional handouts, and worksheets for patients/families to improve their understanding of presented information.
The lifestyle section of the lipids suite enables the provider to print out educational literature for the patient and family including: low carbohydrate, high fiber, low fat, low cholesterol, low trans- fat, no sugar, and/or weight loss. The links to smoking cessation contract, exercise prescription are also available. Additional patient and family literature includes:
- Step I and Step II diets, description
- Step I, II diets and Fiber
- Alcohol and Lipids
- BMR --- Changing It
- Dining Out
- Dislipidemia and Inactivity
- Cholesterol and Weight Loss
- Foods to Eat, Avoid
- Inactivity and Cholesterol
- Training Intensity and Lipids
- Trans- fats and LDL
A referral may be placed to the RD for the Cardiobetabolic-Syndrome class where details of the heart healthy eating and lifestyle changes that may decrease cholesterol and the risk of cardiovascular events are discussed with patients and families. Presentation includes power point, additional handouts, and worksheets for patients/families to improve their understanding of presented information.
SETMA’s Weight Management template enables the provider to print out the educational materials covering topics such as:
- Nutrition Basics
- Approach to Calorie Reduction
- Food Weight Loss Tips
- Serving Sizes
- Meal Replacements
- Food to Remove
- Importance of Glycemic Index
- Applying Glycemic Index
- Glycemic Load
- Diet Recommendations
Patient may then be referred to the RD, where patient will receive an individual meal plan and weight loss plan based on his/her initial assessment. The provider may also print out an individualized exercise prescription.
SETMA’s Diabetes Self-Management Education (DSME) program meets all of the requirements of the American Diabetes Association. Patients/families may be instructed individually or in a group setting based on needs/abilities assessed. Modes of learning include lecture, PowerPoint presentation, video, in-class participation and worksheets, and demonstration. Instruction is determined by the diabetes educator, patient, and family.
The content areas of DSME include:
- Pathophysiology of diabetes
- Coping
- Monitoring- blood glucose monitor and prescription for testing supplies provided as needed
- Pattern Management
- Medications
- Prevention, Detection, and Treatment of Acute and Chronic Complications- referrals for diabetes shoes, and specialty departments provided as needed
- Sick Day Management
- Medical Nutrition Therapy
- Exercise
- Behavior Change Modifications/Goal Setting
Each education visit is documented in the EMR including the date and teacher’s initials. A post-program level of understanding is also documented on the Educational Record in the EMR. Patients are provided educational literature, videos, and log books to compliment their educational visits. Upon conclusion of planned educational visits, follow-up is based on post-level of understanding and goal setting. Each patient is encouraged to attend the Diabetes Support Group, which meets monthly, at no charge.
Patients are provided educational literature, videos, and log books to compliment their educational visits. Modes of instruction include individual/group discussion, lecture, PowerPoint presentation, in-class participation and worksheets. Upon completion of any of these classes, documentation is made in the note that the patient attended and instruction content in the EMR. Family/social support and patient goals are also documented, if applicable.
The practice encourages family involvement in all aspects of patient self-management.
Family members are welcomed and encouraged to attend Diabetes Self-Management Education and all Medical Nutrition Therapy (MNT) visits whether held in a group class or individual setting. Emphasis is placed on family support for MNT as changes for the patient often affect the entire household. Our Registered Dietitians help patients and families understand how to make modifications to family meals in order to meet the patient’s nutritional needs while alleviating some of the burden of meal preparation for the family unit.
By making certain that the patient designates appropriate family members on their HIPPA form, SETMA is able to communicate with family members about the self-care of the patient and to recommend strategies for the patient taking care of self.
Family attendance is highly encouraged, if not mandatory, for sick day management of diabetes and prevention, detection, and treatment of acute complications of diabetes. An explanation that these are times when the patient may be unable to care for him/herself often gains attendance by family members. If family cannot attend visits with the diabetes educator, patient is encouraged to share the information from the visit with his/her family and to have family members call the educator with any questions. Patients are provided the diabetes educators’ phone numbers and direct extensions.
Family is a significant part of the health care team. We need to help them understand the importance of the role they play in the total care of a patient. They are the window into the world of the patient that we can not observe in the healthcare setting. Family input will allow us to treat the whole patient.
- The family can alert us to subtle changes in the patient that can not be observed on a routine office visit. Knowing theses changes could lead to better preventive care and earlier detection of major problems.
- Make sure that all medications are purchased and taken as directed by the healthcare team. Alert us to barriers that prevent the patient from purchasing medications or supplies needed for compliance.
- Keeping the Healthcare team informed of any care received outside of SETMA. (VA, ER, MHMR Specialty MDs etc.) Including all medications, prescription and over the counter. As well as all alternative treatments.
- Help the patient keep all follow up appointments. Make sure that the patient and family understand the importance of follow up appointments.
- Inform the health care team of educational barriers that will prevent patient from understanding their role in their own health care.
How do we communicate with the family?
- By phone. Calls to be taken by our staff with interest. All concerns to be addressed in a timely manner. *
- By email. Once a system has been established, we will educate the patient and family on how to use this system. Emails will be addressed to the Primary Care Physician or Care coordinator. *
- By letter. Addressed to the Primary Care Physician or Care coordinator. *
- In person. This can happen one of two ways.
- Family to accompany patient to the visit.
- Appointment can be made with the Primary Care Physician or a member of the health care team to discuss concerns and issues. *
*We need to make sure that the family and the patient understands the HIPPA laws. We can take information from any concerned caregiver but we can only give information to the person or persons listed on the HIPPA form filled out by the patient. This form can only be changed by the patient or the persons who has a legal power of attorney on file.
How do we educate the patient and families?
- Utilize the educational materials, disease specific, already present in the EMR. Not only give a handout, discuss its contents. The menu below is a great source of information as well as the material found in the disease management templates.
- Educate the family and patient on programs and services provided within SETMA.
- Provide the family with resources available in the community. Such as adult day care, support groups, APS/CPS, financial assistance programs and respite care. As well as other services available such as home health care and hospice.
Educating Patient and Families
SETMA EMR also facilitates ease of patient education. Patients received follow up documents which are built into the Disease-Management Tools (for examples of these templates see Appendix A). These documents are personalized for each patient. In addition to their own personal compliance and laboratory results, these follow-up notes list changes to plan of care, when the patient is to be seen and other special information related to a specific disease process. For example, the diabetes follow up note also informs the patient of the status of their compliance with the standards of care from the Consortium for Physician Performance Data Set as well as current vital signs, BMI, latest lab results, instructions about diabetic foot care and a current medication list. An extensive educational piece on Hgb A1 C and its significance is included.
The weight-management follow-up document acts as a form of encouragement for patients making progress with their weight loss. This document provides patients with their starting weight, weight lost to date and their weight goal. It also lets the patient know that reaching their idea body weight is NOT necessary in order to gain health benefits from weight reduction. The note lets them know that a 10-20 pound weight loss and particularly a 10-20% weight loss can have profound health benefits for ANY and ALL chronic conditions.
In addition, patients are given SETMA’s LESS Initiative’s (Lose Weight, Exercise, Stop Smoking) educational document. The LESS Initiative is done with every visit or at set intervals. It is done at each visit, which is separated by at least two months. In other words, if a patient comes in after two weeks, the LESS Initiative is not given to a patient again until two months after his/her last receiving it has elapsed. Compliance with the LESS Initiative by providers is audited. After the data has been captured – it takes about 30 seconds for this to happen electronically -- the LESS document will be printed and given to patients. The document which includes a weight management assessment, a personalized exercise prescription and information on stopping smoking and nicotine addiction (if they smoke) is about 17-pages long. An explanation is given to the patient by nursing staff on the LESS Imitative and the physician or NP reinforces the elements of the LESS. Other educational material will automatically print to designated printers facilitating patient education.
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