NCOA Webinar Presentation
May 21, 2013
PRESENTERS
Kim Crilly, RN, MS
Coordinator, Chronic Disease Self Management Program
Holy Cross Hospital, Silver Spring, MD
Sarah McKechnie, MA, AHFS
Manager, Community Fitness
Holy Cross Hospital, Silver Spring, MD
Judy Simon, MS, RD, LDN
Nutrition and Health Promotion Programs Manager
Maryland Department of Aging
Department of Aging
Introduction to partnership with Holy Cross Hospital
Establishing grant deliverables with a new partner
Holy Cross Hospital
Why organization decided to invest in CDSMP
Impetus behind developing toolkit
Integration of the Toolkit into Holy Cross' day-to-day operations
Key portions of Toolkit from a hospital perspective
Referral processes and hospital staff education regarding program
Towson University
State Agencies
(DHMH, Medicaid)
Advisory Committee
MDoA
AAA’s
& Hospital
Local
Partners
Implementation
Interview
Four
Hospitals
Create
and
Consult
FINAL
Version
#1: Deliver CDSMP and DSMP Workshops
3/2010
3/2012
#2: Create Hospital Toolkit
9/2010 –
3/2011
3/2011-
1/2012
Presentations
3/2012
Maryland: Regional Grantee Meetings &
Advisory Council
National Forums: NCOA Webinars
NCOA Health Aging Library
Dorland Health, “The Case Manager’s Guide
to Readmissions.”
Tools and Tips to Enhance
Hospital and Community Partner
Adoption of CDSMP
History of CDSMP at Holy Cross Hospital
2007 - Two Faith Community nurses and Community Health’s
Manager of Community Fitness became certified master trainers.
2007 – 2009
: Held 6 workshops with 306 encounters.
2010 (last quarter)
: Provided 7 workshops with 310 encounters.
2010-2012 : Held 28 workshops with 1,599 encounters.
April 2012
– present
:
Held 8 workshops (one in session) with 298
encounters for seven of the workshops.
Why Holy Cross Hospital Invested in CDSMP
To uphold the hospital mission to provide service to vulnerable
communities
To establish partnerships with other organizations with similar
goals
To offer CDSMP as a resource to other hospital depts. including
discharge planning, seniors emergency, diabetes education,
health clinics, etc.
To be part of a national network dedicated to improving
Impetus Behind the Toolkit
MDoA requested the development of the toolkit as part of a
two-year (2010-2012) statewide grant.
Toolkit assists hospitals and community partners in the
adoption and implementation of CDSMP.
Toolkit helps foster a relationship between hospitals and
community partners.
Toolkit strengthens health promotion and prevention
networks in Maryland.
Toolkit encourages hospitals and community partners to
work collaboratively to help people living with chronic
conditions.
Primary Questions
Regarding Adoption of CDSMP
Time
–
Phase 1: Hosting a workshop
–
Phase 2: Adoption and Implementation of
CDSMP
Money
Integration of CDSMP into Daily Operations
at Holy Cross Hospital
Preventing Readmissions Program
Faith Community Nurse Program
Community Health and Community
Fitness Departments
Seniors Emergency Department
Holy Cross Health Centers
Key Portions of Toolkit:
A Hospital’s Perspective
Integration with Readmissions and
Discharge Planning
–
Navigation Web
(page 14)
–
Prescription Pad
(Appendix J)
Community Partnerships
(page 20)
How People are Identified for
Referral
Education of Hospital Staff Regarding CDSMP
Availability
Regular emails with a flyer listing the
upcoming workshops are sent to the
following:
–
Faith Community Nurse Program
–
Seniors Emergency Department
–
Holy Cross Health Centers
–
Preventing Readmissions Program
–
Community Health and Fitness
Working with Hospitals
Choose to partner with hospital that shares
a similar mission and goals as your agency.
Schedule an appointment with the hospital’s
Education Department or Community Health
Department.
Provide the hospital staff with the quick
reference sheets (timeline, budget and
outcomes).
Helpful Appendices
Timeline
(Appendices C and D)
Budget
(Appendix E)
Outcomes
(Appendices A and B)
Prescription Pad
(Appendix J)
CDSMP Budget Worksheet
Personnel Part-time coordinator 0.5 FTE $ $ $ Lay Leader 1 $ $ $ Lay Leader 2 $ $ $ Supplies/Equipment $ $ $ $ $ $ $ $ $ $ $ $ Travel $ $ $ Advertising $ $ $ Miscellaneous $ $ $
Outcomes
Chronic Disease Self-Management Program (CDSMP) Overview
Background
Developed at the Stanford University Patient Education Research Center as a collaborative research study between Stanford and the Northern California Kaiser Permanente Medical Center
Results of the five-year study showed that people who took the program, as opposed to people who did not take the program, improved their healthful behaviors and decreased their days in the hospital
The program is a six-week program, 2.5 hours per week
Healthful Behaviors Addressed by the CDSMP
Exercise
Nutrition
Cognitive symptom management
Coping skills
Communication with physicians
Outcomes
Why Adopt CDSMP?
This one page sheet was designed with the specific needs of hospitals in mind. It is a quick and effective way to provide an overview of the original Stanford study along with outcomes.
(Results of follow-up studies are included in the appendix of this toolkit for further reference.)
The Division of Family and Community Medicine in the School of Medicine at Stanford University received a five-year research grant from the Federal Agency for Health Care Research and Quality and the State of California Tobacco-Related Diseases office. Study was completed in 1996.
The purpose of the research was to develop and evaluate a community-based self-management program that assists people with chronic illness.
It was a randomized controlled trial.
Over 1,000 participants with heart disease, lung disease, stroke or arthritis participated in the study and were followed for up to three years.
Prescription Pad
Chronic Disease Prevention and Management Classes
Patient/Participant name: ________________________________________________________
Diagnosis or at-risk for: __________________________________________________________
Holy Cross Hospital’s Community Health Department offers a variety of classes to help you prevent or manage chron
ic disease. For more
information on these classes including schedules, locations and fees, please call
301-754-8800
or visit
www.holycrosshealth.org
.
Please check the box
for class referral(s).
Recruitment Phone Script
Phone Script for Calling
Living Well
Candidates
Candidate’s Name:
_________________________
Date: ________________
Hello, my name is ___________________________. I’m calling from Holy Cross Hospital.
May I speak with Mr. /Ms. ____________________?
The reason for my call is that you have been identified by the hospital as a good candidate for a free six
program we offer called
Living Well
. The program helps participants manage their chronic disease(s).
Some examples of a chronic disease are heart disease, cancer, high blood pressure, diabetes, and
arthritis. There are other chronic diseases as well. The goals of the workshop are to improve health
behaviors and prevent hospital readmissions.
Questions?
•
Toolkit URL
:
www.ncoa.org/improve-health/center.../Hospital-Toolkit-MD-2012.pdf
•
Contact Information:
–
Judy Simon, MS, RD, LDN
•
Nutrition and Health Promotion Programs Manager, MDoA
•
–
Sarah McKechnie, MA, AHFS
•
Manager, Community Fitness
•
[email protected]
–
Kim Crilly, RN, MS
•
Coordinator, Chronic Disease Self-Management Program
•