The Four Pillars Four Pillars Medication SelfManagement n

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The Four Pillars

The Four Pillars

Four Pillars Medication Self-Management n Patient Centered Health Record n (PHR) Primary Care Provider/Specialist

Four Pillars Medication Self-Management n Patient Centered Health Record n (PHR) Primary Care Provider/Specialist Follow-Up n Knowledge of Red Flags n

Pillar #1: Medication Self-Management n Focus: reinforcing the importance of knowing each medication –

Pillar #1: Medication Self-Management n Focus: reinforcing the importance of knowing each medication – when, why, and how to take what is prescribed, and developing an effective medication management system

Pillar #2: Personal Health Record (PHR) n Focus: providing a health care management guide

Pillar #2: Personal Health Record (PHR) n Focus: providing a health care management guide for patients; the PHR is introduced during the hospital visit and used throughout the program

Key Elements of the Personal Health Record of patient’s medical history n Red flags,

Key Elements of the Personal Health Record of patient’s medical history n Red flags, or warning signs n Medication list and allergies n Advance Directives n Structured Checklist of critical activities (instructions, f/u appointments) n Space for patient questions and concerns n

My Me dicatio ns are : Medic ation _____ Dose _____ _____ Reaso _____

My Me dicatio ns are : Medic ation _____ Dose _____ _____ Reaso _____ n _ _____ Side E _ _ _____ ffects _____ _ _ _ Personal ________o_f: ____________ _____or health _____ __ecord _ ses _____ Health Th_e__P_e_r_s_o__n_a_l_H__e_a_lt_h__R_______ Ple_a_s_e_c_h_e_c_k_a_n_y_il_ln_we_sth you hav_e______ _m _ t _ belo __a_t ___ n _ _ d e _ _ te ti s a li _ _ P s _ _ e _____ ____ proble _ _. d _ e Record J_o_s_e_p_h_in c _ _ _ n e _ _ _ ri __ xpe _____ ___a_ti_on: _____ ever _e____ form _e In l _ a _ n _ s _ _ o ti _ _ rs h _ ___ _____ P ___A_rt_ _____ q _____ __a_l _H_eart Rh_y_th_m _A_d __ _q_ Abn_o_rm _____ re_s_s: _d _ _____ _ _____ _ Ph_o_n_e_#_: _____ _ e __H_o_m _ r _ e _ c _ n _ a _____ q__C __ _____ After __the _ _Before hospital…. I leave the hospital… _____ I leave _ _ s _ _ te _ Birth Date_: ____ b _ ia _ D _ __q _____ rteries ______ _ _ A # _ ____rd_ening o. Ifneed the __to _____1. I will write down questions I have q____I _have the instructions tient ID Alle. Pra Ha _____ q gies. N _ _ _ : e keep my health condition from _ _ _ condition. _____art Disease ______ about _____ my PCP : a_m : _ e ? s _ H _ e _ v _ _ q ti becoming worse. _ c _ _ e _ _____ Dir ______ __ take all bottles of medicine I _____ 2. _I_will Advanced _ti_oq _ : eart Failure n H _ I know what symptoms to watch _ _ a q _ _ rm _ _ _____ ure _____ tion Info am using to each doctor visit. /_/_for. ___H_ig_h Blood Press d: _out Hospitaliza e rg a q h c _ is D _ _ /_ _ _phone _re____ q I know the name ractu Admitted: Hip Fand _____ 3. I will call _________ qwho lization: __number a it p _ s __ o of to call if I see any _____ H __ r __ fo e s __ n a Remember __ o e s __ is a Re immediately at (XXX) XXX-XXX if I ung D L _____ itions __ q __ of these symptoms. __ __ l Back cond ____ a ic rg u to take this Record with __ you S l/ a experience any of the following: n: q My family or Medic close to q someone Informatio to all of your doctor visits ia n Caregiver o me knows q what I will need once I m • Temperature above 101° F Pneu leave the hospital. oke Name: Str ___ • __Uncontrollable pain q I know whatqmedications to__take, _____ _ _ Phone #: _ _ r: Otheand possible • Increased confusion how to takeqthem, Patient: Relation to side effects. • Increased redness or d q I will schedule a follow up drainage around wound appointment with my primary care doctor. • Questions about which q I will have a clear and complete medications to take copy of my discharge instructions. story i Personal H

Goal Attainment “What is one personal goal that is important for you to achieve

Goal Attainment “What is one personal goal that is important for you to achieve one month after you get home? ”

Response Categories 1. I have not worked on it 2. I have not met

Response Categories 1. I have not worked on it 2. I have not met that goal, but am working on it 3. I have met the goal as well as I expected 4. I have met the goal better than I expected

Findings n Patients who worked with the Transition Coach were more likely to achieve

Findings n Patients who worked with the Transition Coach were more likely to achieve their goals around symptom control and functional status

Pillar #3: Primary Care Provider/Specialist Follow-Up n Focus: enlist patient’s involvement in scheduling appointment(s)

Pillar #3: Primary Care Provider/Specialist Follow-Up n Focus: enlist patient’s involvement in scheduling appointment(s) with the primary care provider or specialist as soon as possible after discharge

Pillar #4: Knowledge of Red Flags n Focus: patient is knowledgeable about indicators that

Pillar #4: Knowledge of Red Flags n Focus: patient is knowledgeable about indicators that suggest that his or her condition is worsening and how to respond

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Medication errors Medication side effects Medication incidents WhatMedication errors Medication side effects Medication incidents What
Medication Labels Reading Medication Labels Medication labels varyMedication Labels Reading Medication Labels Medication labels vary
SelfManagement SelfManagement Today we will 1 Talk aboutSelfManagement SelfManagement Today we will 1 Talk about
Transition Skills Selfmanagement of expectations Selfmanagement of expectationsTransition Skills Selfmanagement of expectations Selfmanagement of expectations
What is selfmanagement Selfmanagement is the ability toWhat is selfmanagement Selfmanagement is the ability to
Selfmanagement skills le abilit di selfmanagement aiutano aSelfmanagement skills le abilit di selfmanagement aiutano a
Evidencebased Selfmanagement Translation of Knowledge into a SelfmanagementEvidencebased Selfmanagement Translation of Knowledge into a Selfmanagement
SELFMANAGEMENT The Contents of the Presentation Selfmanagement TaskSELFMANAGEMENT The Contents of the Presentation Selfmanagement Task