Boxwell-Community Care

Front 1

list the six aims of the health care system in the 21st century

Back 1

1. safe
2. effective
3. patient-centered
4. timely
5. efficient
6. equitable
*93,000 ppl died in hospital d/t med care

Front 2

list and describe the components for the chronic care model

Back 2

must draw circles; developed by dr. wager who says we need a group of conepts "pay for perfomance idea"

Front 3

What are the challenges for a different model of care?

Back 3

1. increased *longetivity, therefore*m more ppl with chronic conditions
2. emphasis on *management vs. short term treatemnt
3. increased complexity of care

Front 4

def of acute care

Back 4

immediate care, episodic, "cure" oreintaed (ex sore throat--given antibotics)

Front 5

def of chronic disease manageemtn

Back 5

management over time of the condition, continous, ongoing care, importance of quality of life...heart disese, CHF, AIDS, asthma

Front 6

What is morbidity reduction and what does it have to do with prevention?

Back 6

What you doing in majory of AIDS pat, chronic disease pts..tertiray prevention

Front 7

What are the main demands of the 21st that every physician is involved in?

Back 7

1. acute care
2. primoridal/primary prevention
3. chronic disease management-both secondary and tertiaray prevention
4. terminal (end of life) care

Front 8

if there is a problem with your practice, what should you do to fix it?

Back 8

we used to foucs on doctor, nmo its the system that needs to change

Front 9

how many ppl in WV were told they have diabetes from 1995-2004

Back 9

10.8%, its on the rise

Front 10

Def of chronic illness

Back 10

can include ADD; any cond that requires ongoing activites from personal and medical/ includes chronic mental and behviaor disordrders, addiction

Front 11

HOw much of chronic care takes up our expdentiures?

Back 11

95% (from 63% of beneficiares)

Front 12

what should a physician do to help teh pt in self-managment?**

Back 12

1. emphasize pt's centrla role in care
2. basic info
3. emotional support
4. strategies for living w/ci--must be a collaborative apporoach from all providers

Front 13

What's the "hidden health care system" mean?

Back 13

80% of what ppl do is outta our control , we do 20%

Front 14

What are "good" self-managers?

Back 14

ppl who are motivated to make dialy decisions to favor their health; involves taking medications; everyone self-manages-whether good or bad

Front 15

t or f clincal outcomes depend mainly on the physician, the experts

Back 15

f, pts are experts on their own body; provider has to be in partnership w/pt, clinical outcomes are dependent on pt actions

Front 16

early definition of self-management support

Back 16

including pts in their own care; encouraging pts

Front 17

What are 3 main tasks in self-management support?

Back 17

1. take care of illness
2. carry out normal activities
3. manage emotional changes

Front 18

How should a pcp emphasize the patient's role?

Back 18

1. simple message
2. consistent approach
3. cutlurally appropiate (language)--have a diverse staff

Front 19

Instead of goals, a pt should have _____ plans, that are how long?

Back 19

action plans that are behavior specific (s/one observes them doing it); confidence; should include stuff they WANT to do, barriers, follow ups, confiencence

Front 20

you should base goals on what you want the pt to achieve

Back 20

false, base goals on a pt. priorities

Front 21

Goals should be achieved in 3-6 months, but aren't behavior specific

Back 21

True

Front 22

Delivery System design involves going from a reactive health to a proactive approach and includes what imp factors?

Back 22

1. team approached planned visits
2. ensure regular followup*
3. be aware of health literacy and cultural sensitivity**two emerging concepts in health care

Front 23

Decision Support is based off of guidelines from what:

Back 23

clinical research, and these guidelines should be discuseed with pts, i should have ongoing training, involve supportive specialists

Front 24

When you decide to change a practice, how are new guidelines intergrated?

Back 24

thru reminders, feedback, to increase their visibiility at the time concial decisions are made

Front 25

What would Clinical information systems involve?

Back 25

timely reminders for needed service, summarizing the data to help keep track of plan care; electronic data base helps this

Front 26

in prevention there a difference b/n *screening and *diagnostic and survelience?

Back 26

screening-searching for s/thing-ex-fecal occult blood, then they come back for diagnostic testing, and surveillence-is colonscopy every 5 years

Front 27

What is taking out pop machines in schools an example of?

Back 27

community resources and policies-physician should be aware of ed classes obesity classes

Front 28

What supports improvement at all levels of the organization?

Back 28

Health systems-wants a comprehensive system change so senior leadership should make incentives available-"pay for performance" from insurance companies

Front 29

What other important factor should health system prvide?

Back 29

encourage pt info sharing across organization

Front 30

T or F--guidelines should be changed before the system

Back 30

false, --system changes first

Front 31

What's an example of a quality improvement program?

Back 31

the electronic data system--rapidly improving everyhing

Front 32

What's PDSA?

Back 32

a continous quality improvement-plan to do study act
1. plan-hypothesis
2. do-collect data
3. study-make conclusions
4. act-changes that are needed/additional test cycles

Front 33

Is the CCM model effective?

Back 33

yes, one year after implementation, 75% of practice sites had sustained changes in care

Front 34

T or F CCM improves outcomes and pt edu

Back 34

true

Front 35

pt empowerment philosophy

Back 35

pts are experts on their own live, and deine thier probs, so compliance and adherance aren't relevant concepts

Front 36

Collaborative care

Back 36

since we can't be there, we must have this to help pts achieve their goals