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EbookBell Team
4.7
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ISBN 10: 0387493695
ISBN 13: 9780387493695
Author: Jim Nuovo, Bui
Primary care physicians and allied health professionals must learn how to efficiently and effectively provide care for patients with chronic diseases. That is why the focus of this book is on optimizing management and outcomes rather than on routine diagnosis. The reader learns proven methods for treating the most common chronic conditions that they see in daily practice. Chapters are structured to help physicians quickly adopt evidence-based management techniques specific for each condition, such as the implementation of medication regimens. Of particular benefit are office visit templates for providers. The templates show what patient data should be collected and measured during each office visit. Other innovative approaches, including registry development, group visits, and shared medical appointments, are detailed as well. Special emphasis is placed on the use of action plans and educational resources for promoting patient self-management.
Section I Background
1 Overview of Chronic Disease Management
Reference
2 Self-Management in Chronic Illness
Summary
Introduction
Self-Management/Empowerment Overview
Background
Team Approach with the Patient as Captain
Behavior Change/Transtheoretical Model
Motivational Interviewing
Agenda Setting
Importance/Confidence Ruler
Typical Day Strategy
Hypothetical Look over the Fence
Exploring Pros and Cons of Changing or Not Changing
Appropriate Information Exchange
Assessment Tools
Cascade of Successes
Patient-Centered Care
Shared Medical Appointments
Goal Setting
Action Plans
Self-Management Education and Training Programs
Self-Monitoring, Data Management, and Use of Registries
Summary
References
3 Use of Group Visits in the Treatment of the Chronically Ill
Summary
Introduction
Group Visits Address Psychosocial and Medical Needs of the Chronically Ill
Three Current Major Group Visit Models
The DIGMA Model
Triple Productivity
DIGMAs Have Unique Features
Efficiency Is Gained in Two Ways
The Issue of Billing
Strengths
DIGMAs Have Widespread Applications
Patients
For DIGMAs to Succeed, the Physician Must Take Primary Responsibility for Inviting Patients
How Physicians Should Invite Patients
Staffing
The Behaviorist’s Responsibilities
How Documentation Is Handled
Larger Systems Need a DIGMA Champion, a Program Coordinator, and Dedicated Schedulers
Subtypes of the DIGMA Model
The Homogeneous Subtype
The Heterogeneous Subtype
The Mixed Subtype
Flow
With DIGMAs, Conduct as Much as Possible in the Group Setting
Few, if Any, Patients Will Need to Be Seen Outside of the Group
Weaknesses
Patients are Often More Open in the Group Setting
Although Counterintuitive, the Heterogeneous Model Is Often Best
Most Physician Fears Quickly Fade, but Ideal Group Size Remains an Ongoing Issue
Experience with Other Types of Groups Does Not Necessarily Make for a Good DIGMA
DIGMA Requirements
Facilities
Personnel
Promotional Materials
Chronic Illness Outcomes Studies Are More Difficult with DIGMAs Than with CHCCs
Keeping Sessions Filled When No Access Problems Exist
DIGMAs Can Exacerbate Preexisting Systems Problems
DIGMAs Represent a Major Paradigm Shift
The CHCC Model
Strengths
Patients
Staffing
Structure
Subtypes
Flow
Warm-Up
Educational Presentation
Working Break and Delivery of Medical Care
Questions and Answers
Planning for the Next Session
Individual Visits
Weaknesses
Practice Management Limitations
Limits for Chronic Illness Program Applications
Other Difficulties
The Physicals SMA Model
Hallmarks of the Physicals SMA Model
Subtypes
Respecting Patient Privacy in the Physicals SMA Model
Facilities
Overbook Sessions to Avoid Costly Down Time
Three Basic Components of Physicals SMAs
The Initial Patient Packet
The Physical Examination
The Interactive Group
Census Targets for Physicals SMAs
Strengths
Physicals SMAs Can Be Employed in a Wide Variety of Chronic Illness Programs
Staffing
Conduct Physical Examinations First, Before the Group
Conduct Your Group Visit Program by Sticking Closely to the Established Models
Subtypes
Billing
Weaknesses
The Logistics of Handling the Patient Packet Must Be Addressed
Final Comments on DIGMAs, CHCCs, and Physicals SMAs
DIGMAs Are Particularly Well Suited to Chronic Illness Treatment Programs
Which SMA Model Should You Start With?
Summary
References
4 Chronic Disease Care: Creating Practice Change
Change is Difficult: Summary
Background
Build a Team
Start with a Champion
Starting the Process
Start with a Patient Story
Designate Time: Consider Using a “Huddle”
Tools for Helping Clinical Systems Change
What Are You Trying to Accomplish?
How Will You Know That a Change Is an Improvement?
What Changes Can You Make That Will Result in Improvement?
A Tool for Testing Changes: The PDSA Cycle
Plan
Do
Study
Act
Linking Your Cycles
Summary: Lessons Learned
References
5 Medication Management in Chronic Diseases
Summary
Polypharmacy
Summary
Background
Costs
Epidemiology
Management
The Elderly Population
Medication Errors
Summary
Background
Discussion
Cost Containment
Summary
Background
Conclusion
References
6 Providing Culturally Competent Chronic Disease Management: Diabetes Mellitus
Summary
Background
Cultural Challenges
Methods to Enhance Cross-Cultural Understanding
Keep Lines of Communication Open
Acknowledge Differences in Beliefs
Foster Self-Management
Diminish Literacy Barriers
Use Community Leaders and Peer Counselors
Diabetes: General Education
Cultural Framing
Attitudes and Behaviors Regarding Diabetes Among Specific Cultural Groups
Summary
References
Section II Management of Specific Diseases
7 Type 2 Diabetes
Summary
Background: Burden as a Chronic Disease
Summary
Prevalence
Costs
Impact of Disease Management Programs
Summary
Screening for Diabetes
Summary
Risk Factors
Impact of the Obesity Epidemic
Screening Populations for DM
Screening Tests
Impaired Fasting Glucose Condition (Pre-diabetes)
Screening Recommendations
Initial Evaluation
Summary
Assessments
Management
Summary
Self-Management Support and Assessing Readiness to Change
Self-Management Support and Training for Patients
Self-Management Support/Promotion by Providers
Developing a Short-Term Action Plan
Helping Patients Set Their Goals
Motivational Interviewing
Education Supporting Self-Management
Monitoring Blood Glucose Level
Nutrition Therapy
Carbohydrate Counting
Reduction in Fat
Weight Control
Exercise
Foot Care
Behavioral Concerns
Education Resources
Medications
Summary
Starting a Medication Regimen
Cost Considerations
Areas of Caution
Weight Gain and Sulfonylureas
Metformin and Lactic Acidosis
Thiazolidinediones and Heart Failure
Thiazolidinediones and Hepatotoxicity
Glipizide and Hypoglycemia in the Elderly
Triple-Drug Regimens
Alpha-Glucosidase Inhibitors and Hypoglycemia
Insulin
Monitoring
Summary
Documentation
Quality of Care
Methods to Improve Outcomes
Alternative Therapy
Summary
Summary
References
Appendix A Diabetes Self-Management: Setting Goals
Appendix B Nutrition and Type 2 Diabetes
HEALTHFUL EATING
GENERAL NUTRITION GUIDELINES
SERVING SIZES/PORTIONS
TIMING OF MEALS
ALCOHOL
CALORIE-FREE SWEETENERS
FIBER
SODIUM
USE LESS FAT IN COOKING
ADD LITTLE OR NO FAT TO FOODS
STAY AWAY FROM “FAST FOODS”
WATCH OUT FOR THESE FOODS THAT ARE HIGH IN FAT:
USE “FREE FOODS”
READ LABELS FOR FAT CONTENT
DIABETES RESOURCE LIST
Appendix C Exercise: Getting Started
Appendix D Taking Care of Your Feet in Diabetes: Patient Education Sheet for UC Davis Health System
What You Should DO to Take Care of Your Feet
DO NOT DO THE FOLLOWING TO YOUR FEET
8 Asthma
Summary
Management
Monitoring
Background
Summary
Prevalence and Impact on Society
Cost of Asthma Health Care
Chronic Disease Management Programs
Summary
Recent Studies
University of California, Davis Asthma Network
Evaluation of Asthma: Initial and Subsequent
Summary
Diagnosis
Quality of Life Assessment
Management
Summary
Asthma Control
Assessing Importance
Management Key Points
Assessing Self-Efficacy and Confidence
Barriers to Self-Management
Fast Facts
Overcoming Barriers
Role for Respiratory Therapists
Difficult-to-Control Asthma
Clinical Performance Measures
Asthma Assessment
Pharmacologic Therapy
Plan-Do-Study-Act
Alternative Therapies
References
9 Heart Failure
Summary
Management
Monitoring
Burden as a Chronic Disease
Fast Facts
Background
Prevalence
Costs
Impact of Disease Management Programs
Summary
Background
Screening for Heart Failure
Summary
Documenting Heart Failure
Screening for Heart Failure
Detection of Left Ventricular Hypertrophy
Electrocardiogram
Two-Dimensional Echocardiogram
Brain Natriuretic Peptides
Initial Evaluation
Summary
Patients at High Risk for Developing Heart Failure: “Pre-Heart Failure”
Patients Identified with Heart Failure
Impact on Quality of Life
Classifying the Severity of Heart Failure
Other Methods of Assessing Function: The Six-Minute Walk Test
Ongoing Evaluation
Management
Fast Facts
Management of High-Risk Patients
Self-Management Support and Assessing Readiness to Change
Studies on the Effectiveness of Self-Management Support
Predictors of Self-Care
Methods of Promoting Self-Management
Use of a Pharmacy-Based Support Intervention
Web-Based Communication
Peer Support
Home Health Intervention
Patient Training
Barriers to Self-Care
Provider Support for Self-Management
Developing a Short-Term Action Plan
Helping Patients Set Their Goals
Education to Support Self-Management
Monitoring Symptoms
Nutrition Therapy
Exercise
Behavioral Concerns
Education Resources
Medications
Summary
Angiotensin-Converting Enzyme Inhibitors
Angiotensin Receptor Blockers
Beta-Blockers
Starting Beta-Blockers
Management of Worsening Heart Failure During Beta-Blockade
Aldosterone Antagonists
Digoxin
Isosorbide Dinitrate and Hydralazine
Cost-Effective Considerations
Monitoring
Summary
Background
Documentation
Measures to Improve Quality of Care
Alternative Therapies
Summary
Usage
Summary
References
10 Osteoarthritis
Chapter Summary
Management
Burden as a Chronic Disease: Summary
Introduction
Initial Evaluation
Systemic Analgesics
Acetaminophen
Nonsteroidal Anti-Inflammatory Drugs
Other Analgesics
Glucosamine
Intra-Articular Injections
Hyaluronan
Exercise
Assistive Devices and Joint Protection
Surgical Treatment
Self-Management Support
References
11 Obesity
Background: Burden as a Chronic Disease
Costs
Impact of Disease Management Programs
Initial Evaluation
Management
Medications
Monitoring
Alternative Therapy
Summary
References
12 Depression
Background: Burden as a Chronic Disease
Costs
Impact of Disease Management Programs
Initial Evaluation
Management
Treatment Options: Psychotherapy and Medications
Psychotherapy
Antidepressant Medications
Depression Disease Management Program
Monitoring
Alternative Therapy
Summary
References
13 Chronic Pain
Background: Burden as a Chronic Disease
Costs
Impact of Disease Management Programs
Initial Evaluation
Management
Medications
Opioids
Other Drugs
Comorbid Conditions
Self-Management Support
Patient Education
Referral to a Pain Specialist
Monitoring
Documenting Pain Severity
Comorbid Conditions
Developing a Pain Contract
Compliance with State and Federal Regulatory Boards
Alternative Therapies
Summary
References
Index
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Tags: Jim Nuovo, Bui, Chronic Disease Management
