S.M.A.R.T. Objectives
1. 80% of patients with kidney disease that seek care at Richmond, VA’s public housing on-site clinics will be assigned to a nurse case manager by January 31, 2018.
2. 100% of renal patient’s (in the program) health literacy will be evaluated during their initial visit with their nurse case manager or community health worker by one year of the program’s inception.
3. 40% of patients with renal disease will maintain a systolic blood pressure under 130 mmHg and a diastolic blood pressure under 90 for 6 consecutive months by the end of their first 12 months in the program.
4. 40% of patients with renal disease will adhere to all of their treatment plan regimens by May 4, 2018.
5. 40% of patients who have been diagnosed …show more content…
Research has shown that the Short Assessment of Health Literacy has good reliability and validity in both English and Spanish (Health literacy measurement tools, 2014). The tool is efficient and convenient because the test requires minimal training and only takes 2-3 minutes to implement (Health literacy measurement tools, 2014). The nurse case manager’s and/or community health worker’s documentation and the patients’ actual Short Assessment of Health Literacy tool will be used to determine the patient's health literacy level and the percentage of patients in the program that received a health literacy evaluation at the initiation of the program. This information will be used to provide health education on the patient’s treatment plan based on their health literacy level in the effort to ensure that patient thoroughly understand their treatment plan and medication …show more content…
o Data collection: Patient and nurse case manager surveys collected ever six months created by the program coordinator or program coordination team. Monthly pill counts and food diary review. o Data analysis/utilization: Program coordinator or coordination team created surveys can be tailored to identifying the barriers and behavior issues that contribute to the patient being noncompliant. NCW can use these surveys to create interventions to resolve the barriers and also implement behavior change and motivational interviewing techniques when necessary. Monthly pill counts and food diaries are ways to monitor if a patient is adhering to their treatment plan. Interventions can be initiated to address barriers to compliance and/or a need for re-education.
• 40% of patients who have been diagnosed with renal disease for more than one year prior to the start of being assigned a nurse case manager/community health worker will have improved patient outcomes by one year of being assigned a nurse case manager/community health worker. o Data collection: Medical record audits performed every 4 months. o Data analysis: The patient outcomes that will be measured during the audits
1. 80% of patients with kidney disease that seek care at Richmond, VA’s public housing on-site clinics will be assigned to a nurse case manager by January 31, 2018.
2. 100% of renal patient’s (in the program) health literacy will be evaluated during their initial visit with their nurse case manager or community health worker by one year of the program’s inception.
3. 40% of patients with renal disease will maintain a systolic blood pressure under 130 mmHg and a diastolic blood pressure under 90 for 6 consecutive months by the end of their first 12 months in the program.
4. 40% of patients with renal disease will adhere to all of their treatment plan regimens by May 4, 2018.
5. 40% of patients who have been diagnosed …show more content…
Research has shown that the Short Assessment of Health Literacy has good reliability and validity in both English and Spanish (Health literacy measurement tools, 2014). The tool is efficient and convenient because the test requires minimal training and only takes 2-3 minutes to implement (Health literacy measurement tools, 2014). The nurse case manager’s and/or community health worker’s documentation and the patients’ actual Short Assessment of Health Literacy tool will be used to determine the patient's health literacy level and the percentage of patients in the program that received a health literacy evaluation at the initiation of the program. This information will be used to provide health education on the patient’s treatment plan based on their health literacy level in the effort to ensure that patient thoroughly understand their treatment plan and medication …show more content…
o Data collection: Patient and nurse case manager surveys collected ever six months created by the program coordinator or program coordination team. Monthly pill counts and food diary review. o Data analysis/utilization: Program coordinator or coordination team created surveys can be tailored to identifying the barriers and behavior issues that contribute to the patient being noncompliant. NCW can use these surveys to create interventions to resolve the barriers and also implement behavior change and motivational interviewing techniques when necessary. Monthly pill counts and food diaries are ways to monitor if a patient is adhering to their treatment plan. Interventions can be initiated to address barriers to compliance and/or a need for re-education.
• 40% of patients who have been diagnosed with renal disease for more than one year prior to the start of being assigned a nurse case manager/community health worker will have improved patient outcomes by one year of being assigned a nurse case manager/community health worker. o Data collection: Medical record audits performed every 4 months. o Data analysis: The patient outcomes that will be measured during the audits