A Path to Self-actualization: Maximizing Quality of Life for People with Chronic Disease Lisa Bujno, APRN Associate Chief Nurse, Quality and Performance White River Junction VAMC May 12, 2015 May 12, 2015
Agenda • NH Landscape & Chronic Disease Burden • Determinants of Health • Maslow’s Hierarchy of Needs • VA Programs Making a Difference • Health Impact Pyramid • NH State Health Improvement Plan (SHIP) • Changing the Context
NH Landscape • 1.3 million people • Aging population • Stagnant birth rate (9.9) • Increasing diversity • Migration: -1.2/1000 • Unemployment @3.9% • Crime rate rising • ER visits increasing • Rising healthcare costs
Growing Chronic Disease Burden • 34.9% overweight and 25.8% obese • 17.2% reported smoking • 4.2% ever diagnosed with coronary heart disease • 4.3% ever diagnosed with heart attack • 2.3% ever diagnosed with stroke • 9.1% ever diagnosed with diabetes; 21.3% among those aged 65 and older • 11.0% had current asthma in 2013
The Story of Mr. H • 64 y male • Dx of Polymyositis • Disabled • Confined to wheelchair with limited use of L arm, no use of R arm • Homebound • Married, wife works
Determinants of Health
Maslow’s Hierarchy of Needs
Medical Center: White River Junction, VT Community Based Outreach Clinics (CBOC’s): Rutland, Burlington, Newport, Bennington and Brattleboro, VT Littleton and Keene, NH
VA Programs Making a Difference • Home Based Primary Care • Home Telehealth • Geriatrics & Extended Care • Recreational Therapy Image courtesy of cooldesign /FreeDigitalPhotos.net
Home Based Primary Care (HBPC) • Serves frail, chronically ill veterans with complex health care needs who require comprehensive, longitudinal home care services
HBPC Services • Primary care visits at home by a physician, nurse practitioner or physician's assistant • Nursing care management • Coordination of services by a social worker • Therapy visits from a physical, occupational, or speech therapist • Mental health services • Nutrition counseling • Medication management
HBPC Outcomes • Reduction of inpatient admissions by 43.9% • Reduction of inpatient days by 60% • 10% reduction in repeat falls • 95% immunization rate for influenza; 98% for pneumoccus • End of life protections: DNR (91%), advanced directives (100%), long-term planning (100%)
Home Telehealth • Uses health informatics, disease management and telehealth technologies to target care and case management • Changes the location where health care services are routinely provided • Home telehealth, Clinical Video Telehealth, and Store-and-Forward modalities
Telehealth Services Clinical Video Telehealth (CVT) Mental Health CVT in Home(SCI, PT, OT ) Podiatry Ear, Nose & throat (ENT) Physical Therapy (PT) Wound / Ostomy Care Occupational Therapy (OT) Neurology Speech Therapy (ST) Nursing Preop Diabetes 1:1 Visits Pain Nutrition 1:1 Visits Genomics Weight Loss Group Hearing Aid Management Weight Loss Group Women Cardiology Weight loss 1:1 Ambulatory Monitoring Spinal Cord Injury (SCI) with Boston VAMC Urology
Telehealth Services Home Telehealth Store and Forward Diabetes Dermatology Hypertension Tele-Retinal Imaging Chronic Obstructive Pulmonary Disease Heart Failure Dementia Support for Caregivers Weight Loss Pallative Care Smoking Cessation
Telehealth Outcomes • Improved access to care and quality of life • Improved patient self-management • 25% decrease in length of stay • 19% reduction in hospital admissions • 9.8% mortality rate in HT patients versus 16.58% in Non-HT patients • High satisfaction rates among veteran patients Darkins, A. (2008) Care Coordination/Home Telehealth: The Systematic Implementation of Health Informatics, Home Telehealth, and Disease Management to Support the Care of Veteran Patients with Chronic Conditions, TELEMEDICINE and e-HEALTH Adam Darkins et. al (2014). Reduced Cost and Mortality Using Home Telehealth to Promote Self-Management of Complex Chronic Conditions: A Retrospective Matched Cohort Study of 4,999 Veteran Patients TELEMEDICINE and e-HEALTH, 20, 50. Decreased unscheduled primary care visits
Geriatrics & Extended Care (GEC) • Programs to maximize each Veteran’s functional independence and lessen the burden of disability on Veterans, their families, and caregivers • Focus on shared decision making • Institutional and non-institutional care options
GEC Services • Skilled home care/Homemaker & Home Health Aide • Adult Day Health Care • Hospice/Palliative Care • Medical Foster Home • Respite Care: in home or hospital • Caregiver Support • Veteran Independence Program
GEC Outcomes • Improved functional independence • Reduced caregiver stress and improved family functioning • Better coordination of care with non-VA providers • Veterans can remain in their homes longer • Reduced cost
Recreational Therapy • Provide recreation activities to treat and maintain the physical, mental and emotional well-being of Veterans with disabilities, illnesses or other disabling conditions. • Use a variety of techniques, including arts and crafts, sports, games, dance, music and community integration activities • Assist Veterans with disabilities to integrate into the community by helping them use community resources and recreational activities
Recreational Therapy Services • MOVE! • Adaptive sports programs • Greenhouse gardening • Arts and crafts • Music
Recreational Therapy Outcomes • Improves physical well being such as weight management and controlling diabetes and hypertension • Improves social functioning and help Veterans develop new leisure skills • Enhances creative expression and break down barriers for cultural expression
The Story of Mr. H “HBPC has made the biggest difference to me and my wife.” • Reduced burden of time spent navigating the health system to get needed care • Frees time to spend with family and pursue hobbies
Maslow’s Hierarchy of Needs
Health Impact Pyramid
NH SHIP: Top 10 health priorities • Tobacco • Healthy Mothers & Babies • Obesity/Diabetes • Infectious Disease • Cardiovascular Disease • Injury Prevention • Misuse of alcohol and • Emergency drugs Preparedness • Cancer Prevention • Asthma
Changing the Context • Leverage Points in a System – Information flow – System rules and goals – Paradigm Image courtesy of olovedog/FreeDigitalPhotos.net
Next Steps • Integrate Maslow’s principles into everyday practice • Help patients fulfill their needs beyond medical care & safety • Support policy changes that promote self-actualization for people with chronic diseases Image courtesy of Paul Martin Eldridge /FreeDigitalPhotos.net
Questions? Lisa Bujno, MSN, APRN Associate Chief Nurse, Quality & Performance 802-295-9363 x5380 Lisa.bujno@va.gov
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