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NCOA Webinar Presentation May 21, 2013 PRESENTERS Kim Crilly, RN, MS Coordinator, Chronic Disease Self Management Program Holy Cross Hospital, Silver Spring, MD Sarah McKechnie, MA, AHFS Manager, Community Fitness Holy Cross Hospital, Silver Spring, MD Judy Simon, MS, RD, LDN Nutrition and Health Promotion Programs Manager Maryland Department of Aging Baltimore MD
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Page 1: NCOA Webinar Presentation May 21, 2013 PRESENTERS › wp-content › ... · NCOA Webinar Presentation May 21, 2013 PRESENTERS Kim Crilly, RN, MS ... Some examples of a chronic disease

NCOA Webinar Presentation May 21, 2013

PRESENTERS

Kim Crilly, RN, MS Coordinator, Chronic Disease Self Management Program

Holy Cross Hospital, Silver Spring, MD

Sarah McKechnie, MA, AHFS

Manager, Community Fitness

Holy Cross Hospital, Silver Spring, MD

Judy Simon, MS, RD, LDN

Nutrition and Health Promotion Programs Manager Maryland Department of Aging

Baltimore MD

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Department of Aging

Introduction to partnership with Holy Cross Hospital

Establishing grant deliverables with a new partner

Holy Cross Hospital

Why organization decided to invest in CDSMP

Impetus behind developing toolkit

Integration of the Toolkit into Holy Cross' day-to-day operations

Key portions of Toolkit from a hospital perspective

Referral processes and hospital staff education regarding program

Integration with readmissions and discharge planning

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Towson University

State Agencies

(DHMH, Medicaid)

Advisory Committee

MDoA

AAA’s & Hospital

Local

Partners

Implementation

Sites

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Interview

Four

Hospitals

Create

and

Consult

FINAL

Version

#1: Deliver CDSMP and DSMP Workshops

3/2010 3/2012

#2: Create Hospital Toolkit

9/2010 – 3/2011

3/2011-1/2012

Presentations 3/2012

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Maryland: Regional Grantee Meetings & Advisory Council

National Forums: NCOA Webinars

NCOA Health Aging Library

Dorland Health, “The Case Manager’s Guide to Readmissions.”

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Tools and Tips to Enhance

Hospital and Community Partner Adoption of CDSMP

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History of CDSMP at Holy Cross Hospital

2007 - Two Faith Community nurses and Community Health’s Manager of Community Fitness became certified master trainers.

2007 – 2009 : Held 6 workshops with 306 encounters.

2010 (last quarter) : Provided 7 workshops with 310 encounters.

2010-2012 : Held 28 workshops with 1,599 encounters.

April 2012 – present : Held 8 workshops (one in session) with 298 encounters for seven of the workshops.

Total number of workshops held: 49 with 2,513 encounters.

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Why Holy Cross Hospital Invested in CDSMP

To uphold the hospital mission to provide service to vulnerable communities

To establish partnerships with other organizations with similar goals

To offer CDSMP as a resource to other hospital depts. including discharge planning, seniors emergency, diabetes education, health clinics, etc.

To be part of a national network dedicated to improving chronic disease management

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Impetus Behind the Toolkit

MDoA requested the development of the toolkit as part of a two-year (2010-2012) statewide grant.

Toolkit assists hospitals and community partners in the adoption and implementation of CDSMP.

Toolkit helps foster a relationship between hospitals and community partners.

Toolkit strengthens health promotion and prevention networks in Maryland.

Toolkit encourages hospitals and community partners to work collaboratively to help people living with chronic conditions.

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Primary Questions Regarding Adoption of CDSMP

Time –Phase 1: Hosting a workshop

–Phase 2: Adoption and Implementation of CDSMP

Money

Outcomes

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Integration of CDSMP into Daily Operations at Holy Cross Hospital

Preventing Readmissions Program

Faith Community Nurse Program

Community Health and Community Fitness Departments

Seniors Emergency Department

Holy Cross Health Centers

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Key Portions of Toolkit: A Hospital’s Perspective

Integration with Readmissions and Discharge Planning

–Navigation Web (page 14)

–Prescription Pad (Appendix J)

Community Partnerships (page 20)

Timeline, Budget and Outcomes

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How People are Identified for Referral

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Education of Hospital Staff Regarding CDSMP Availability

Regular emails with a flyer listing the upcoming workshops are sent to the following: –Faith Community Nurse Program –Seniors Emergency Department

–Holy Cross Health Centers –Preventing Readmissions Program –Community Health and Fitness Departments

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Working with Hospitals

Choose to partner with hospital that shares a similar mission and goals as your agency.

Schedule an appointment with the hospital’s Education Department or Community Health Department.

Provide the hospital staff with the quick reference sheets (timeline, budget and outcomes).

Present your own outcome data.

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Helpful Appendices

Timeline (Appendices C and D)

Budget (Appendix E)

Outcomes (Appendices A and B)

Prescription Pad (Appendix J)

Recruitment Phone Script (Appendix M)

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Timeline: Phase 1

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Timeline: Phase 2

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CDSMP Budget Worksheet

Personnel Part-time coordinator 0.5 FTE

$

$

$

Lay Leader 1 $ $ $

Lay Leader 2 $ $ $

Supplies/Equipment $ $ $

$ $ $

$ $ $

$ $ $

Travel $ $ $

Advertising $ $ $

Miscellaneous

$ $ $

Total Per participant: Per workshop: Per year:

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Outcomes

Chronic Disease Self-Management Program (CDSMP)

Overview

Background

Developed at the Stanford University Patient Education Research Center as a collaborative research study between Stanford and the Northern California Kaiser Permanente Medical Center

Results of the five-year study showed that people who took the program, as opposed to people who did not take the program, improved their healthful behaviors and decreased their days in the hospital

The program is a six-week program, 2.5 hours per week

Healthful Behaviors Addressed by the CDSMP Exercise Nutrition Cognitive symptom management Coping skills Communication with physicians Stress management/relaxation

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Outcomes

Why Adopt CDSMP?

This one page sheet was designed with the specific needs of hospitals in mind. It is a quick and effective way to provide an overview of the original Stanford study along with outcomes. (Results of follow-up studies are included in the appendix of this toolkit for further reference.) The Division of Family and Community Medicine in the School of Medicine at Stanford University received a five-year research grant from the Federal Agency for Health Care Research and Quality and the State of California Tobacco-Related Diseases office. Study was completed in 1996.

The purpose of the research was to develop and evaluate a community-based self-management program that assists people with chronic illness.

It was a randomized controlled trial.

Over 1,000 participants with heart disease, lung disease, stroke or arthritis participated in the study and were followed for up to three years.

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Prescription Pad

Chronic Disease Prevention and Management Classes Patient/Participant name: ________________________________________________________

Diagnosis or at-risk for: __________________________________________________________

Holy Cross Hospital’s Community Health Department offers a variety of classes to help you prevent or manage chronic disease. For more

information on these classes including schedules, locations and fees, please call 301-754-8800 or visit www.holycrosshealth.org.

Please check the box for class referral(s).

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Recruitment Phone Script

Phone Script for Calling Living Well Candidates

Candidate’s Name: _________________________ Date: ________________

Hello, my name is ___________________________. I’m calling from Holy Cross Hospital.

May I speak with Mr. /Ms. ____________________?

The reason for my call is that you have been identified by the hospital as a good candidate for a free six

program we offer called Living Well. The program helps participants manage their chronic disease(s).

Some examples of a chronic disease are heart disease, cancer, high blood pressure, diabetes, and

arthritis. There are other chronic diseases as well. The goals of the workshop are to improve health

behaviors and prevent hospital readmissions.

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Questions? • Toolkit URL: www.ncoa.org/improve-health/center.../Hospital-Toolkit-MD-

2012.pdf

• Contact Information: – Judy Simon, MS, RD, LDN

• Nutrition and Health Promotion Programs Manager, MDoA

[email protected]

– Sarah McKechnie, MA, AHFS

• Manager, Community Fitness

[email protected]

– Kim Crilly, RN, MS

• Coordinator, Chronic Disease Self-Management Program

[email protected]

Thank You!


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