December 2007 e-Bulletin

Building Upon the Basics

The last three Best Practice Intervention Packages (BPIPs) in the HHQI National Campaign highlight interventions that build upon the foundational interventions that have already been made available. Patient Self-Management, Disease Management and Transitional Care Coordination will help agencies evolve to a higher level of care, improve patient outcomes, improve patient satisfaction and reduce avoidable hospitalizations. This series is called Building Upon the Basics. The packages will be available on the National Campaign Web site according to the following time line:

• Patient Self-Management - 12/3/07
• Disease Management - 1/2/08
• Transitional Care Coordination - 2/1/08 

What type of tools will be available in these packages?
Here are some examples:

• Patient tools - My Action Plan (Patient Self-Management BPIP)
• Staff tools - Planned Care: Patient Self-Management Support Staff Education Workbook (Patient Self-Management BPIP)
• Leadership tools - "The Business Case for Disease Management Programs in Home Care," by Lisa Remington (Disease Management BPIP)

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Best Practice Intervention Package:  Patient Self-Management

The Patient Self-Management Best Practice Intervention Package (BPIP) is a package within a package! The BPIP begins with defining patient self-management and self-management support and then identifying key principles in the previous BPIPs. The BPIP then introduces the package within the package, Planned Care: Self-Management Support in Home Healthcare.

Masspro, the Quality Improvement Organization (QIO) for Massachusetts, developed materials for a home health care collaborative that will be shared in this BPIP. The Leadership Track contains Planned Care: Self-Management Support in Home Healthcare. This is a comprehensive systems approach to self-management support. The tools in this Masspro package are included as part of the package and/or as links on the HHQI Web site.

There are many tools and resources in the package from Masspro and other sources. Both patient and clinician tools and resources are listed and described on the tool page in Leadership Track. The featured tool is a Patient Action Plan, which is a plan for patients to record their health actions, goals and confidence levels for health changes. There are three sample patient action plans available with the Patient Self-Management BPIP:

• Self-Management: Healthy Changes Plan and Confidence Scales (included in the Masspro package in the Leadership Track)
• My Action Plan - The featured action plan is included in the Leadership and Care Provider Tracks and is from Thomas Bodenheimer, MD, of UCSF Department of Family and Community Medicine. This action plan is also available in Spanish and Chinese.
• Another sample action plan was modified from New Health Partnerships and is available at the HHQI Web site under Patient Self-Management, Associated Resources. This is also available in Spanish.

Care Provider Tracks are designed for each specific discipline for patient self-management and self-management support. There are FREE continuing education opportunities for all nurses and therapists (including assistants). The Fast Track is also available for Patient Self-Management and is posted on the HHQI Web site.

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Previous Best Practice Intervention Packages

November - Fall Prevention
October - Physician Relationships
September - Immunizations
August - Telemonitoring
July - Teletriage
June - Phone Monitoring and Frontloading Visits
May - Medication Management
April - Emergency Care Planning
March - Hospitalization Risk Assessment

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The HHQI Web site is updated weekly with additional information, tools and resources. Bookmark the Web site and visit it often. The Quick Links on the home page facilitates easy travel to important sites.

Continuing Education

Free continuing nursing units (CNEs) for registered nurses (RNs) and certificates of participation for therapists and LPNs/LVNs are available with the HHQI Campaign Best Practice Intervention Packages. Below are quick links to existing free continuing education opportunities. Download the specific track (nursing or therapy) and complete the required activities. After completing the track activities, click on the link provided, and complete the appropriate evaluation/post-test. Complete the short online survey.

Please note that the continuing education is only available until 2/29/2008.

Registered Nurses

Best Practice Intervention Package	RN Contact Hours	Link for RN  Eval/Post-Test
Patient Emergency Plan	1.25	RN Test
Medication Management  - Nursing Track  - "Be Safe and Take" Clinician Enrichment Program	2.0	RN Test
Phone Monitoring and Frontloading Visits	1.5	RN Test
Teletriage	1.7	RN Test
Telemonitoring	1.0	RN Test
Immunizations	1.3	RN Test
Physician Relationships	1.6	RN Test
Fall Prevention	1.3	RN Test

Therapists

Best Practice Intervention Package	Therapy Certificate of Participation	Link for Therapy Eval/Post-Test
Phone Monitoring and Frontloading Visits	1.2	Therapy Test
Teletriage	1.0	Therapy Test
Telemonitoring	1.0	Therapy Test
Immunizations	1.0	Therapy Test
Physician Relationships	1.6	Therapy Test
Fall Prevention	1.3	Therapy Test

LPNs/LVNs

Best Practice Intervention Package	LPN Certificate of Participation	Link for LPN Eval/Post-Test
Immunizations	1.0	LPN Test
Physician Relationships	1.6	LPN Test
Fall Prevention	1.3	LPN Test

Fall Prevention BPIP Survey

The survey results from the Fall Prevention BPIP are now available on the HHQI Web site.

The Best Practice Intervention survey helps the HHQI team to:

• improve the packages
• understand barriers to accessing the packages, etc.
• know whether we are on target with the materials
• recognize when there is a need to modify the materials

Home Health Agency of the Month

Shore Healthcare at Home
Onley, VA

"Decreasing acute care hospitalizations creates a win-win situation for everyone, especially the patient who is able to remain in their own home. Achieving this takes a commitment and partnership between the agency, patient, physician, and HHQI. Participating in the HHQI National Campaign has provided us with practical, quality tools to improve patient outcomes. It is a privilege to be selected as HHQI’s Agency of the Month. We look forward to continuing to be part of this collaborative effort to give quality home health services in our community."- Glenna Melson, Director

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Spotlight on HHQI Campaign Champions

Carol Siebert, MS, OTR/L, FAOTA, and Karen Vance, OTR/L, have been important champions for the HHQI National Campaign. They represent the American Occupational Therapy Association and have provided their expertise for each of the Best Practice Intervention Packages (BPIPs) related to self-care management. They have promoted patient self-management in the health care arena for many years by giving presentations, publishing articles and coaching home care leadership and staff. Carol and Karen assisted with the creation of every Patient/Family Connection Page in the BPIPs, which focus on self-management principles for the monthly intervention topic.

Carol and Karen were significant contributors for this month's BPIP – Patient Self-Management. In addition to providing valuable information for the leadership and care provider tracks, they wrote a case study (included in the Examples of Excellence) and recorded the home health aide podcast. They continue to nationally advocate for the HHQI campaign and for patient self-management.

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View the November Tips of the Week.
View the October Tips of the Week.
View the September Tips of the Week.

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