Supporting Seniors and
Patients with Chronic Conditions
Fairview Red Wing Health Services
Partners in Aging
Palliative Care
Advance Care Planning
Living Well with Chronic Condition
Where is Red Wing?
*
PARTNERS IN AGING:
The Beginning
Journey…
Caregiver
Support
Groups
The Beginning…
• VISION
• BLUEPRINT 2010
- Preparing MN for the AGE WAVE
• OPPORTUNITY
- RFP to DHS
CS/SD Work Plan Focus:
• Expand and coordinate services to
persons with chronic illness and/or at
risk of nursing home placement.
• Palliative Care Focus
• Provide seamless linkages with
community programs and resources.
• Promote health and safety within the
home of the Senior
Palliative Care
Physicians +
Health Other
Care Providers
Preventive Medicine
Chronic Disease Management
Integrative Medicine
Faith in Action
•Transportation
•Friendly Visits
•Respite Care
Meals
On
Wheels
Home Care
and
Hospice;
Fall Prevention,
Medication Management,
Case Management
Private Pay
HC Providers
Parish Nursing
Goodhue
County Public
Health
Three Rivers
Community Goodhue County
Action
Social Services
South County
Health Alliance
Caregiver
Support
Groups
Technology
Driving
Simulation
Red Wing
Area Seniors
• Home
Modification
•Senior Home Work
• MyChart
• Tele-health
• Home Monitoring
•Life Line
Our CS/SD Grant VISION…
Empower
Seniors
Proactively access
Services that allow
Independent
and safe
living
Provide advocacy through a
Senior Patient Advocate
to develop a plan of care
that is personalized and
respects their wishes
and preferences
GOALS:
• Education and preventive measures to
promote wellness
• Increase the use of resources to support
independent living
• Utilize technology to track their progress
toward their goal
• Support to the Senior to gain greater
independence, safety, and the ability to
self-advocate, providing respect for their
life choices
Sharing, Linkages,
Education
• Palliative Care in our Outpatient Clinic
• Faith in Action
• Stratis Health Rural Health Palliative Care
Intiative
• Three Rivers Community Action, Inc.
• Living Well with Chronic Conditions
• Honoring Choices/Advance Care Planning
Role of the Senior Patient
Advocate
CHALLENGES
• Degree of complexity
of needs
• Time per client
• Resources (systems
& client)
STRENGTHS
• Collaborative support:
–
–
–
–
Leadership
Physicians
Other service providers
Community
• Respect
• Proactive not reactive approach
• Client self management/empowerment
2009 Patient Satisfaction
Survey
• Patients & families, 64% response rate
• High satisfaction responses
– “pleased with quality of support” – 98%
– “greater sense of security” – 100%
– “recommend program to others” – 98%
• Quotes from respondents
OUTCOMES
• Reported improved quality of life
• 40% increased utilization of Community
Based Services
• 33% receiving Palliative Care support
• Wellness Program/Living Well with
Chronic Conditions
• 54% clients documented discussion of
Advance Care Planning or completed
Health Care Directives.
PALLIATIVE CARE
• The goal of palliative care is the best
quality of life for patients with serious
illness and their families
• Our health care system is not designed
for chronic illness
• Many people want the “big picture”
What does palliative care look like?
• Relieves pain
• Decreases other symptoms (i.e. Being able to do
usual activities without pain or shortness of breath or feeling
tired)
• Helps both patients and families with
communication
• Makes a plan for now and the future (ACP
pilot)
• Coordinates the plan across settings of care
(hospital, clinic, nursing home, home health)
What does palliative care look like at
Fairview Red Wing Health Services:
•
•
•
•
•
Outpatient clinic
Home visits
Skilled Nursing Facilities
Home Care and Hospice
Collaboration with Partners in Aging
LIVING WELL with
CHRONIC CONDITIONS
• The Chronic Disease Self-Management Program
(CDSMP) is a evidenced-based chronic disease selfmanagement program developed by Stanford
University.
• In Minnesota this program is called “Living Well with
Chronic Conditions”
• Held in community settings such as senior centers,
churches, libraries and hospitals.
• People with different chronic health problems attend
together.
More
info:
• MDH provides the 4-day Facilitator
training to MN Communities at no cost.
• Workshops meet once a week for six
weeks in 2 to 2 ½ hour sessions
• Facilitated by two trained leaders (one
professional and one lay person)
Subjects Covered:
1) Techniques to deal with problems such as
frustration, fatigue, pain and isolation,
2) Appropriate exercise for maintaining and
improving strength, flexibility, and endurance,
3) Appropriate use of medications,
4) Communicating effectively with family, friends,
and health professionals,
5) Nutrition, and,
6) How to evaluate new treatments.
How does it work?
• It is the process in which the program is
taught that makes it effective. Classes
are highly participative, where mutual
support and success build the
participants’ confidence in their ability to
manage their health and maintain active
and fulfilling lives.
Participant Outcomes
• Adults who participate in a Living Well
workshop have shown improvement in the
self-rated health including:
– Better coping strategies and symptom
management
– Better communication with their physicians
– More energy and less fatigue
– Decreased disability
– Fewer physician visits and hospitalizations
– Better eating habits and increased physical activity
Advance Care Planning…
Your Decisions Matter
Honoring Choices
• History and “why” of this initiative
• Collaborative initiative with the Metro
Medical Society/Gunderson Lutheran’s
Respecting Choices model
• Began in summer of 2009
• Health Systems (Fairview, Allina,
HealthPartners, Park Nicolet, HealthEast, HCMC…)
Honoring ChoicesMinnesota
• Health Care Directives in medical chart
– LaCrosse Co. – 95%
– Fairview Red Wing – 28%
• Fairview Red Wing Health System
– 8 trained facilitators
– Leadership & clinical champions
– Goal is to improve process of completing &
documenting Health Care Directives
• 50% participation of target population
• Of those, 50% will complete Advance Care Planning
• Post pilot: Seamless team approach in health care
system (PCP to facilitator referral), community wide
involvement
Do you know…?
• What healthcare treatments you would
and would not want if you could not
speak for yourself?
• Do other people know what your wishes
are?
ADVANCE CARE PLANNING
Involves:
• Learning about treatment options
• Thinking about your values
• Talking about your preferences
• Documenting your wishes
MN law requires that a Health
Care Directive…
• Be dated
• State the person’s name & bear the
person’s signature or mark
• Be verified by a notary or two witnesses
• Include either health care power of
attorney or health instructions or both
• Be executed by person with capacity to
do so
• Be in writing
Give copies of your Directive
to:
•
•
•
•
•
Primary physician
All health care providers
Electronic Medical Record (EPIC)
Health care agent(s)
Family members and close friends
Keep a list of who has copies!
Questions and/or
Comments
Thank You for your time and
undivided attention!
Sheryl Voth ([email protected])
Trudi Paulson ([email protected])
www.redwing.fairview.org/Senior_Services