AMGA and Pfizer Inc. present the Models of Excellence Collaborative on Patient Adherence and Health Literacy

Holzer Clinic, Gallipolis, OH
Enhanced Care for CVD

EXECUTIVE SUMMARY: Our physician group practice averages 450,000 patient encounters per year and has approximately 800 employees. Internal auditing has revealed that diabetes, hyperlipidemia, and hypertension are among the top five diagnoses of our estimated 450,000 annual patient encounters. Our audit confirms the State Department of Health’s report of a high prevalence of cardiovascular disease (CVD) in our region.

The organizational leaders acknowledge the role our group practice needs to play in the education of our high risk patient populations. They also recognize the challenges associated with obtaining consensus among our physicians for standards of care. It is our intention to pursue concerted educational efforts to expand the scope of our established Diabetes Pathway Program and combine internal resources to address patient adherence to medication and treatment regimens for CVD. Our objectives will be to:

• Address the specific role of self-management and create compliance with lifestyle changes to reduce the risk for CVD
• Encourage adherence to physician recommended treatments and medications using individualized care plans and case management
• Promote educational emphasis on the risks of CVD; in particular, elevated blood pressure, glucose, and lipid levels.
• Promote active participation and physician involvement in establishing accepted standards of care

The Enhanced Care Program (hereafter referred to as the program) will be implemented as a pilot study in the Family Practice Department. The precursor risks to heart disease will take educational precedence in this program. Primary attention will be focused on conveying what a physician says, to a patient concerning treatment and disease processes, into meaningful patient directed management and lifestyle changes. This program of individual and group educational techniques, is expected to result in compliance with physician directed care and patient understanding of the CVD process.

The program will be evaluated for “spread” to other physicians and as a template for other disease states at the conclusion of the pilot. It is anticipated that this form of patient intercession will produce meaningful improvement in patient driven lifestyle changes as well as significantly impact the effectiveness of the individual physician’s practice. Tools and protocols developed for this program will be evaluated for use in other clinical pathways. It is expected that the program will meet some resistance from the physicians and patients. Barrier issues will be discussed and evaluated as they arise and the program adjusted as needed.

PROJECT PLAN: The program will be implemented initially as a pilot study in the Family Practice Department. The precursor risks to heart disease, specifically identified as hyperlipidemia, diabetes, and hypertension, will take educational precedence in this program. Primary attention will be focused on translating what a physician says, with respect to treatment and disease processes, into meaningful patient directed management and lifestyle changes. The conversion of the scientific side of health care into common language and the utilization of individual and group educational techniques as reinforcement, is expected to result in compliance with physician directed care and patient understanding of the CVD process.

The Diabetes Coordinator will manage the program with direct input from the participating physicians and the Director of Nursing. The same will be involved with any barriers to program implementation, and will act as advisors for the program as it progresses. Additional staffing will not require at this time. In-house personnel will divide program tasks during less busy schedule times.

To evaluate specific interventions, the program will select a group of patients between the ages of 20 and 55 years that have a family history of heart disease and two of the three risks mentioned risks above. Reimbursement for health care, via self payment for services or insurance coverage will be noted but not used as a deterrent to participation. No more than 50 and no less than 25 individuals will be included in the pilot program. All participants will be asked to sign a consent to release medical information, agree to participate in the curriculum, and designate specific self-management goals. A copy of the consent and agreements will be on file and a copy given to the patient.

An initial health risk assessment and physician/health care evaluation will be used to create a baseline of significant routines, lifestyle activity, and opinions currently held by the participants relevant to CVD. Appointments, educational sessions, group activities, and one-on-one counseling will be coordinated with nursing personnel for case management purposes. Educational materials, techniques, and in-office displays will be geared to appropriate reading levels and special emphasis will be placed on patient comprehension. Further education materials and methods will be tailored to include learning types and, where appropriate, topics will include audio, visual, and kinesthetic activities to promote comprehension and effectiveness. Special attention will be given to ensure individuals are able to participate without fear of embarrassment, as in the case of being unable to read. All materials will promote the opinions and attitudes of the American Heart Association, the American Diabetes Association, and our own physician-defined guidelines of health.

Each participant will be in the program for six months and will be expected to attend four of six scheduled group sessions. At the end of six months a post health assessment and a physician/health care questionnaire will be obtained. Six months from the end of the program a follow up will be documented to see if participants maintained their self management commitments.

All interventions, materials, and participant contacts will be conducted according to HIPAA guidelines and internal confidentiality policies. At the completion of the curriculum the effectiveness and activities will be summarized and the cumulative results given to the participating physicians, clinical managers, department chairs, and board members. Pertinent documents relating to the tracking of information, costs, etc are included in the supporting document section of this proposal.

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