Improving Outcomes through Enhanced Patient Self-Care Management April 25, 2005 Presented by Lisa Gorski, MS, APRN, BC, CRNI OASIS ANSWERS, Inc. Lisa.Gorski@oasisanswers.com Sponsored by Colorado Foundation for Medical Care Best Practices to Improve Self-Care Management can also Improve: - Ambulation/Locomotion - Toileting - Dressing - Transferring - Bathing - Management of Oral Medications - Frequency of Pain Interfering with Activity - Confusion Frequency - Dyspnea - Emergent Care - Discharge to Community - Acute Care Hospitalization What is “Self-Care Management?” Performance of health care related activities that, when performed by thepatient, have the potential to: – Improve/expedite recovery from illness or surgery – Decrease risk of complications or diseaseexacerbation – Allow early intervention(s) and decrease riskof hospitalization or emergent care Active patient involvement in care Examples of Self-Care Management Activities Taking medications as prescribed Monitoring for signs/symptoms that must be reported to the clinician or that require a specific action: – Patient with an indwelling urinary catheter develops dark concentrated urine and increases fluid intake – Patient on infusion chemotherapy monitors for s/s infection especially during the nadir period Measuring & monitoring a specific parameter that requires specific action(s) – Patient with heart failure (HF) monitors daily weights I&O, temperature – Patient on total parenteral nutrition monitors daily weights - Patient with diabetes monitors blood glucose Following and integrating dietaryrestrictions into family meals and when going out to eat Learning to use equipment/DME – Patient learns to manage oxygen therapy both in and outside of home – Use of incentive spirometer Avoiding actions/situations that increase risk of complications or side effects – Patient on chemotherapy infusion must avoid sun exposure and wear sunscreen – Patient with cardiomyopathy must avoid alcohol Home Care: An Exceptional Opportunity to Promote Self-Care Management The primary focus of home care is to educatepatients and their families to become independent with their care. Patients are seen on a continuing basis, offer ingrepeated opportunities to observe, teach, and counsel. Home care clinicians develop a unique relationship with the patient and family Comfortable patient setting decreased patient anxiety at home compared to the clinic or acute care setting – Ability to directly observe specific activities such as how medications are managed, what foods are kept in the home – Trust and confidence in the home care clinician develops over repeated home visits Potential Clinician Barriers in Promotion of Self-Care Management Labeling patients “non-compliant” – Not believing that one can make a difference! Lack of knowledge about patient barriers to self-care management Not actively involving the patient and family in development of the plan of care & goal setting Lack of knowledge about research related findings about patients and self-care management behaviors Lack of comprehensive assessments that focus not only on physical assessment but patient/family performance of and understanding of self-care behaviors Lack of clinician knowledge, skills, and/or tools necessary to provide effective patient teaching & counseling Potential Patient Barriers to Self-Care Management Lack of knowledge /limited understanding Lack of motivation – Unconvinced of the benefits of a regimen – Perception that side effects/inconveniences outweigh benefits Limited or poor family support Functional/Cognitive limitations – Example: forgetfulness Financial factors Enhanced Patient Self-Care Management PROBLEM: Clinicians may label a patient as “noncompliant,” may not believe they can make a difference, and may not work to develop appropriate self-care management strategies with the patient and family. BEST PRACTICE STATEMENTS: For patients who lack self-care management skills, the following clinical actions will occur: Assessing nurse or therapist will implement the CLINICIAN’S GUIDE: STRATEGIES TO IMPROVE PATIENT SELF-CARE MANAGEMENT SKILLS. Heart Failure: What does the research show ? Knowledge and self-care management Lack of knowledge among patients visiting a HF clinic – 2/3 had received advice/information from health care providers – However, 37% said they knew “little/nothing” about HF – 40% did not understand implications of daily weights – 80% knew they should limit salt but only 1/3 avoided high sodium foods – 25% did not understand alcohol risk associated with HF [Hanyu, N, Nauman, D, Burgess, D et al. (1999), Factors influencing knowledge of and adherence to self-care among patients with heart failure. Archives of Internal Medicine 159, 1613-1619.] Study of patients with chronic HF and adherence to diet – Lack of knowledge regarding link between high sodium, fluid retention and burden on heart – Interference with socialization and eating out – Limited food choices [Bentley, B, DeJong, M, Moser, D (2004), The hidden reason for patients’ nonadherence to low sodium diet recommendations. Abstract from Heart Failure Society of America 8th Annual Scientific Meeting] Study of high risk patients admitted to the hospital and self-care activities – When questions asked specifically about self care activities ˝ knew to weigh self 87% had scales but only 30% actually weighed daily 43% answered that medications were a “mystery to me” [Lockwood, EE, Hervas-Malo, M, Guitierrez et al. (2004) Patient knowledge of self-care activities in congestive heart failure. Abstract from Heart Failure Society of America 8th Annual Scientific Meeting] Heart Failure: What does the research show ? Hospitalization and self-care management Elderly patients with HF; as many of 53% of readmissions preventable; non-compliance with diet/medication major causes [Vinson, JM, Rich, MW, Sperry, JC et al.(1990) Early readmission ofelderly patients with congestive heart failure. Journal of the American Geriatric Society 38, 1290-95] Sodium and volume overload, often due to medication and dietary compliance, a factor in 55% of HF readmissions [Bennet, SJ, Huster, GA, Baker, SL et al (1998). Characterization of precipitants of hospitalization for heart failure decompensation. American Journal of Critical Care, 7, 168-174] Enhanced Patient Self-Care Management PROBLEM: For the patient with heart failure, a comprehensive evaluation of the patient’s clinical HF history, performance and understanding of self-care behaviors, patient/family learning preferences, and physical assessment are not consistently performed. BEST PRACTICE STATEMENTS: For all patients with HF, the following clinical action will occur: Assessing nurse or therapist will implement the CLINICIAN’S ASSESSMENT GUIDE: HEART FAILURE. PROBLEM: Some clinicians lack knowledge and understanding about HF and evidence based recommendations for care and management of the patient with heart failure; lack of knowledge contributes to lack of confidence & effectiveness in teaching patients and families. BEST PRACTICE STATEMENTS: For clinicians who care for patients with HF, the following clinical action will occur: The clinician will perform self-evaluation to identify areas of lack of knowledge & seek resources to improve knowledge and understanding of heart failure using the CLINICIAN SELF-ASSESSMENT HF KNOWLEDGE TOOL. PROBLEM: For the patient with heart failure, teaching tools to provide patient education are not consistently used BEST PRACTICE STATEMENTS: For all patients with HF, the following clinical actions will occur: a) Assessing nurse or therapist will implement the DAILY WEIGHT MONITORING TOOL b)Assessing nurse or therapist will implement the PATIENT ACTION PLAN FOR HF SIGNS/SYMPTOMS Enhanced Patient Self-Management Compared to other health care settings, home care clinicians have one of the best opportunities to intervene and improve patient self-care management. Improved self-care management can impact several outcomes that we measure through OBQI as well as some that we may not methodically measure including patient satisfaction and quality of life. Great Late Night Reading! OASIS resources: • OASIS Implementation Manual • OASIS Q&A’s • OASIS web-based training • Your state OASIS Education Coordinator • www.cms.hhs.gov/oasis OBQI resources: • OBQI Implementation Manual, www.cms.hhs.gov/oasis • OBQI Clearinghouse • Home Health Publicly Reported Quality Measures Resource Binder, www.medqic.org • QIO, www.cfmc.org Thanks to the Colorado Foundation for Medical Care Join us again for “Using your Patient Tally Report to Create your Agency’s Risk Profile for Acute Care Hospitalization” on May 16, 2005.