Transforming the Office Management of Heart Failure Using the Chronic Disease Model in a Family Medicine Residency Program

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Transforming the Office Management of Heart Failure Using the Chronic Disease Model in a Family Medicine Residency Program Rhett Brown, M.D. Janice Huff, M.D. Eric Schneider, Pharm.D. Department of Family Medicine Carolinas Medical Center Charlotte, NC Carolinas HealthCare System

Acute Care Model ,[object Object],[object Object],[object Object],[object Object]

Current status of Chronic Illness Care in the U.S. ,[object Object],[object Object],[object Object],[object Object],[object Object]

Chronic Illness ,[object Object],[object Object],[object Object],[object Object]

Quality Chasm ,[object Object],[object Object]

System Change Concepts Why a Chronic Care Model? ,[object Object],[object Object],[object Object]

Knowledge versus Performance ,[object Object],[object Object],[object Object],[object Object]

The Watchword Systems are perfectly designed to get the results they achieve

Remember: ,[object Object],[object Object],[object Object],[object Object]

Our Clinical Transformation ,[object Object],[object Object],[object Object],[object Object],[object Object]

Our Clinical Transformation ,[object Object],[object Object],[object Object]

Clinical Transformation Committee ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Critical Features of a Registry ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Registry Functions Patient Information entered into Registry Point of care data for patient visits Status reports provide clinician feedback Identify patients needing follow-up care

Why Use a Registry? ,[object Object],[object Object],[object Object]

Why Use a Registry? ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

CVDEMS Decision Rules ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Heart Failure Action Plan ,[object Object],[object Object]

Care Coordinator ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Patient Support Group ,[object Object],[object Object],[object Object],[object Object],[object Object]

Measure Outcomes ,[object Object],[object Object],[object Object]

Lessons Learned ,[object Object],[object Object],[object Object],[object Object]

“ Well, I do have this recurring dream that one day I might see some results.”

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Transforming the Office Management of Heart Failure Using the Chronic Disease Model in a Family Medicine Residency Program

1. Transforming the Office Management of Heart Failure Using the Chronic Disease Model in a Family Medicine Residency Program Rhett Brown, M.D. Janice Huff, M.D. Eric Schneider, Pharm.D. Department of Family Medicine Carolinas Medical Center Charlotte, NC Carolinas HealthCare System

8. The Watchword Systems are perfectly designed to get the results they achieve

10. Chronic Care Model

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17. Registry Functions Patient Information entered into Registry Point of care data for patient visits Status reports provide clinician feedback Identify patients needing follow-up care

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20. CVDEMS Flow Sheet

21. CVDEMS Visit Note

22. CVDEMS Visit Note

23. CVDEMS Visit Note

24. CVDEMS Flow Sheet

25. Services Needed/Recommendations

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27. Decision Tools

28. Services Needed/Recommendations

29. Patient Goal Setting