2. Syllabus1. Defining a persons needs and the evolving
National Health Information Infrastructure 1. Defining an emerging
Health Information Technology within the context of the US
HealthCare System2. Support , Process and Use Case 1. Samples of
Levels of Support Based on Functional Status 2. The Advocates
Process 3. Real Use Case 20113. Personal Health Records 1.
Selection 2. Components 3. Security 4. Process4. A Transition
Model5. Why We Do It11/23/2011 2
3. Untangled Healthcare Patient Advocacy Series Part Two 1.
Samples of Levels of Support Based on Functional Status 2. The
Advocates Process 3. Real Use Case 201111/23/2011 3
4. Untangled Health PatientsHave various support needs based on
our social and physical, mental and social health status Care Cycle
Ultimately we need major help in planning our lives Assess At times
our conditions become unstable , andMonitor Plan barriers to
getting better include lack or Care
5. The Patient Advocate Process Assist with reporting
Bio-Psycho-Social History outcomes to Discover Goals, Wants, Needs
PCP Functional Status Physical Social Insurance Exchange Cognitive
Monitor Activate Primary Care Compliance Comorbidity Medical Home
Patient Contract Patient Compliance Disease Self Mastery Identify
and link Learning Barriers community resources: Evaluate Assist
Transportation, Meals on Wheels, Patient Peers Primary and
Secondary Prevention Self Monitoring Resource Utilization Educate
Urgent Care Guidelines Communication Skills11/23/2011 5
7. Functional Domains Cognition Problem Solving Memory
Communication Psychosocial Expression Emotional Status
Comprehension Adjustment To Limitations Reading Self Care Mobility
Eating Transfers Elimination Grooming Toilet Bathing Shower
Sphincter Control Dressing Car Bladder Toileting Locomotion Bowel
Swallowing Walking/Wheelchair/St airs11/23/2011 Community Mobility
7
8. Activate If no insurance: Find a program e.g. Medicaid,
Safety Net Sliding Fee, Health Choice, Insurance Exchange in 2014
Patient and advocate select a PCP who claims to be a Primary Care
Medical Home During first visit: Suggest a compliance contract
between patient and physician e.g. first point of contact unless
life threatening event Set follow up dates and responsibilities
(COACH)11/23/2011 8
9. Assist Evaluate patient defined needs and goals: Educational
barriers Educational Plan Address functional deficits in ADLs and
IADLs Connect to community resources Connect to peer support
Follow-up several times per week in first month then decrease
encounter frequency11/23/2011 9
10. Education Take learning barriers into account and use
assistive tools where necessary e.g. times medication dispensing
containers. Connect patient with pharmacist if on more than five
medications. If patient is responsive to internet health records
set up a PHR that exchanges data with physicians PHR or Microsoft
Health Vault if Physician has not installed e- HR yet. Otherwise
create a paper based notebook that is the perpetual record of care
and interventions and outcomes. Test learning by return
demonstration at least one week post educational sessions. Dont be
afraid to involve family and friends11/23/2011 10
11. Evaluate Review care plan with patient Make sure patient
adds you to care team so you can access records in patient portal
at hospitals and practices and PHRs. First things first: What is
highest priority Medication reconciliation with no gaps in long
term medication fills without physician order All testing
appointments completed on time All follow up appointments completed
on time Lifestyle changes are beginning to migrate into patients
way of living Quantify use of hospital or ER services for
inappropriate reasons and try to define precipitating factors e.g.
physician not available Compare medications to insurance formulary
and if physician agrees switch patient to lower tier medications to
reduce cost for patient and insurance company Assess any new
functional limitations e.g. balance in the elderly and visual
acuity.11/23/2011 11
12. Monitor Set up monitoring schedule with patient with goal
for complete independence if possible. Teach patient to self record
data from home medical devices and PHR tools. Teach patient how to
use secure communication tools with provider and yourself When
comfortable discharge with assurance of your availability when
needed. Send report to physician. If physician using e-HR and
patient portal ask about submitting report through
portal.11/23/2011 12
13. Case ExampleReal Life 2011In two years she:1. Was a victim
of domestic violence2. Transitioned from military to public health
systems3. Was treated by 12 physicians and surgeons and behavioral
health specialists4. Was placed on twenty two different medications
some of which were within the same class and directly
contraindicated5. Lost her ability to think clearly6. Lost her
family7. So here we are. Our friend with her treatment records and
medicine during data collection step11/23/2011 13
14. Patient Medical Home or Procedural Contracting11/23/2011
14
15. Use Case: Care Coordination, Management and AdvocacyMiddle
Aged Chronically Ill Woman Migrating To NC from Floridas Safety Net
Patient Classification: Demographic: 50 y/o Caucasian female Bio-
Complex comorbidity (degenerative spinal disease, acute trauma with
questionable TBI, constellation of auto immune diseases Psycho-
History of episodic substance abuse ETOH and prescription
narcotics, depression, PTSD Social- Indigent, Income= $1300/MO;
homeless; divorce in process, domestic violence victim, Medicare
dually eligible SSDI, Post graduate degree in behavioral health
Functional- Mental: Cognitive defects memory and executive function
Physical: Chronic pain limitations to locomotion and IADL Summary:
Cant work, cant drive, cant think = NO HOPE11/23/2011 15
16. Given patient status how would the present clinical world
find all of this information during assessment? Patient interview
Patient SS Dept. attempt to locate data found on Repeated testing
to R/O dx street in North Hospital Critical Path Carolina Discharge
to community New Medical History Variant Patient ER Disconnected
from future episodes Visit Patient Acute Admission Subjected to DC
Planning Process DC next lower level care Classic Scenario Poor
transition management No portable record11/23/2011 16
17. The Patient Advocate Process Assist with reporting
Bio-Psycho-Social History outcomes to Discover Goals, Wants, Needs
PCP Functional Status Physical Social Insurance Exchange Cognitive
Monitor Activate Primary Care Compliance Comorbidity Medical Home
Patient Contract Patient Compliance Disease Self Mastery Identify
and link Learning Barriers community resources: Evaluate Assist
Transportation, Meals on Wheels, Patient Peers Primary and
Secondary Prevention Self Monitoring Resource Utilization Educate
Urgent Care Guidelines Communication Skills11/23/2011 17
18. Discovery and Documentation of BaselineObjective: My
Medicare.Gov1. Gather as much as possible and filter for sentinel
information Claims extract 1. Diagnosis 2. Procedures 3. Providers
4. Medications 5. Hospitalization Episodes2. Store Data in secure
online Good for preventive svcs, repository with proven connectors
to providers EMRs, PHRs and Vendor Hubs e.g. Hospitalizations and
visits. Quest, CVS Microsoft HealthVault Central Cloud Data
Repository Using Standardized Clinical Mode Mayo Clinic Personal
Health Record11/23/2011 18
19. Assemble on-line health record A repository that connects
to multiple systems A PHR that has built in decision support
Established Mayo Clinic Attempt to connect Health- Test Successful
PHR and completed data Vault to Mayo Clinic PHR entry for patient
CVS used Mayo PHR as Summary Pharmacy of Record choice11/23/2011
19
20. Patient Information Flow In Sample Patient Advocacy Case
Primary Portal To Patient Information11/23/2011 20
21. Final Outcome Combined Mayo Transported Patient to UNC
HealthCare with PHR with Manual Summary Documents and Films
Clinical Summary Patient Team Today Mayo PHR Primary Care MD
Psychiatrist Health Medicare Vault Physiatrist Patient Behavioral
Health Program Portable Health Record Medications Start = >20
CVS UNC Today = 8 Functional Status Independent all IADL Self
transportation Self perceived health status improved11/23/2011
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