Sharon Moffatt RN MSN Cost of Chronic Conditions

Sharon Moffatt, RN, MSN

Cost of Chronic Conditions is both Personal and Financial Care for people with chronic conditions accounts for: 83% of health care spending 81% of hospital admissions 76% of all physician visits 91% of all prescriptions filled

Wagner Model for Chronic Disease Care with Public Health

Informed, Activated Patient Productive Interactions Prepared, Proactive Practice Team Prepared Activated Community Improved Health Outcomes –Healthier People

Healthy Living Workshops Individual Focus • Stanford Patient Education Research Center - Self Management Program Evidence based research to affect individual health • Empowers individual and families in requesting more of health care

Healthy Living Participants Medical Care Visits to a health care provider’s office and the Emergency Dept decreased significantly at 6 & 12 months MD Visits ED Visits

Community Care Team • Supports individual and health care provider for improved health care • Connects individual with community resources • Replaces or enhances outside disease management programs

Community Care Team • Medical Social Worker • Dietician • Community Health Outreach Worker • Behavior Specialist • Public Health Prevention Specialist

Community Care Team Connected with Local Public Health Richford Westfield Enosburg Falls Orleans Barton Alburg 12 Vermont District Health Offices • Public Health Nurses • Nutritionists • Outreach Specialists • Prevention Specialists South Hero Canaan Island Pond Milton Lyndonville Winooski Hardwick Hinesburg Vergennes Wells River Chelsea Bradford Randolph Bethel Thetford South Royalton Rochester Brandon Castleton Woodstock Poultney Windsor Ludlow Chester Manchester Bellows Falls Towshend District Health Offices Community Locations Wilmington Stamford Gilman Waterbury Bristol Waitsfield Putney Guildhall

Vermont 2 -1 -1 • Call Specialists problem solve and refer callers from throughout Vermont to government programs, community-based organizations, support groups, and other local resources • A local call from anywhere in Vermont • Available 24 hours a day, 7 days a week • Live translation services for 170 languages • Access for persons who have special needs • Ability to transfer emergency calls to E 9 -1 -1

Community Quality Health Care and Quality of Life Ø Communities have walking programs year round for all ages Ø Farmers’ Markets have doubled in the last 5 years

Diabetes Related Hospitalizations, per 1, 000 Vermonters with Diabetes

Hospitalizations for Lower Extremity Amputations, per 1, 000 Vermonters with Diabetes

Resources/References Ø The Chronic Care Model: Improving chronic illness care a national program of The Robert Wood Johnson Foundation, www. improvingchroniccare. org Ø Wagner, E. H. Chronic Disease Management: What will it take to improve care for chronic illness? Effective Clinical Practice 1998; 12 -4. Ø National Estimated Cost of Obesity, CDC, BRFSS 1998 -2000).

Resources/References Ø Crossing the Quality Chasm: A New Health System for the 21 st Centry, Institute of Medicine, National Academy of Sciences, 2001. Ø To Err is Human: Building a Safer Health System, Institute of Medicine, National Academy of Sciences, 2000.

Resources/References Ø The Model for Improvement by the Institute for Health Improvement www. ihi. org Ø The Quality of Health Care Delivered to Adults in the United States. New England Journal of Medicine 2003, 348: 26. Ø Vermont Department of Health website: www. healthvermont. gov