Saturday, July 18, 2015

Indiana Jones and the Ominous Bridge

As a community and through sharing our experiences we discovered a lot about the current bridge for patients to self management, achieve health literacy and getting well at home.  This bridge looks and feels a lot like the ominous bridge in "Indiana Jones and the Temple of Doom".  We could say it exists but it would take Indiana Jones to cross it.  So how can we release patients and expect them to take the responsibility to cross this scary, rickety, collapsing bridge over crocodile invested waters?  We shouldn't be surprised when so many return, don't make it or even the bravest and most prepared get half way there, look down and then freeze. 

It is not just about giving the patient support to cross this bridge, we need to build a new bridge together.  Our goals are starting to converge.  Patients want nothing more than to get home and get well at home.  And now health systems because of the Hospital Readmission Reduction Program (HRRP) and as of October 1, 2014 the Medicare Spending Per Beneficiary (MSPB) are making it a priority to get patients well at home. 

Together we can build a bridge that is person centered and looks at the factors beyond just health.  This bride would invite patient to be part of their care and let them know there will be people to support them.  This bridge can be  welcoming, sturdy and have benches to rest along the way.  There are many kinds of bridges that can be built but all should have the same destination for patient to get and stay well at home.  

Here are our architectural drawings of the bridge we designed together over the last 4 months.  All the elements are important but there were two particular elements that seem to be the foundations of our bridge.  
  1. An invitation to the patient to be part of their own care. (Ed inserted a quote from some famous person "people don't like to take orders, they like to take part."  This summarizes why the invitation is so important.
  2. A patient created and updated medication list.  We believe this could be the keystone element that triggers a patient's knowledge and confidence in their health.  See below for a bit more detail. Also read Charles Duhigg's book "The Power of Habit" and specifically the section on the new Alcoa CEO's commitment to shareholder to focus solely on 100% Safety with an absolute commitment to 0 safety incidents and how focusing on Safety allowed management and union to come together, created record profits and quality.  
We are excited where our journey has led us and know it is time to test out our bridge by welcoming patients to take the first step.  Indiana Jones might be disappoint by the lack of adventure crossing this bridge. 

Take this with you to your doctor visits and pharmacy and keep it in case of an emergency. Go to your pharmacist every six months to have them review your list. Keep it up to date.

List your team especially know your friendly pharmacist who can coordinate and review your medications and list all your doctors, nurses and other team members so care professionals know who they are working with.

Monday, July 13, 2015

Finding Our Why

According to Simon Sinek, the author of "Starts With Why" and the concept 'the golden circle", the reason the Wright brothers, Dr. Martin Luther King and Apple are successful despite having access to the same or in some cases less resources is because they understand and were driven by the ‘Why’.  He believes what distinguishes successful ideas, companies or movements from unsuccessful is they start with the why (thanks Neil for sharing).

So it got me thinking about our why.  People want nothing more than the feeling of independence, identity, control and comfort of home whether they are sick or well.  My grandma Stella, like a inmate doing life who's only way out is hatching an escape plan, went to great lengths to escape the hospital.  She wanted to be home!  Hospitals, although sterile for a reason, are not conducive for healing. They aren't designed for emotionally and psychologically healing and some would argue without these physical healing can never be sustained.

Our Why

To empower elder to get control of their health so they can get and stay well at home.  This is where and what Stella wanted to be, at home and well.  Ask any nurse what the most frequently asked question they get in a hospital setting "when can I go home?" or "when am I getting out of here?".  Our homes are a fundamental part of us, our healing and our personal wellness (identity, emotional health, etc.).  Could this be our mantra “Bringing health, home.”?  

Our How

By providing the tools, awareness and approach to build the skills, knowledge and confidence to get control of their health at home.

Our What

Self directed health awareness to get and stay well at home (easy, visual, accessible and familiar tools, techniques and a personalized hands-on approach).  

Our community is developing a tool kit and the approach for a  person and their family to self direct their health with the coaching and support of health professionals to build skills, confidence and knowledge to get and stay well at home.
We have identified the elements that are important to health confidence.  We discussed them here last week and I have notes expanding on each element here:

With this family, spouse, caregiver and practitioners can better interact with your world to support you.  There is research that shows that to build skills, get knowledgeable and feel confident it is very important that this is built through hands-on application.  There are many teaching models that show positive results but the two most successful are the ‘Teach-back’ method and Dr. Coleman’s coaching model (simulated learning). We found that for my grandma Stella the keystone element was a visual medication list that built her knowledge and confidence in her medications and her health.

This week we will go over what this bringing health, home looks like and how we are going to make it happen.  We developed a design language and need to finalize the high level requirements.  We all agreed that we need to design and test in small, quick iterations with feedback from people we are trying to bring health home.  

Thursday, July 9, 2015

Hospital 2.0 = Learning Commons for the Sick and the Well

Follow me here ACA -> readmission prevention -> reduced Medicare Spending Per Beneficiary -> medical home -> patient's ability to self manage -> patient health literacy.

At the root is education.  Josh Luke, national leader in health care and readmission prevention, writes in his book Readmission Prevention, "patient self-management can be the most effective tactic if a patient and his caregiver comprehend the plan of care."  Patient and family education and their ability to be knowledgeable and confident in managing their condition and having the skills to do so is the 'most effective' way to transform our health systems and eliminate the above symptoms.  The primary function of our future health systems must be facilitating education.  

The future hospital will look more like an education center, a university, maybe more of a technical hands-on university, a learning commons.  Hospitals of the future will hire teachers, technical coaches, demonstration chefs, dietitians, gardeners and community volunteers will lead activities and personalize and empathetic information exchange.  The heart of the hospital will be hands-on learning commons where staff and community volunteers will support personalized information exchange and education to support people in our communities.

The future hospital will be a place where all practitioners will also work on prevention with community members and families coming to the "Hospital" or Community Health Learning Commons.  It won't just be about treatment but eventually these sterile industrial structures will evolve into welcoming place for the well.  

See you in the future.  

NOTE: Elderberry is working on a community design of an person directed education system that helps elder patients get and stay well at home.

You Bet Your Dupa - Getting Well at Home Is Best

Our story was keeping Stella well at home.  The barrier was her health.  Stella needed and wanted to be knowledgeable, confident and in control of taking her medication as prescribed to treat chronic ailments.  

Changes are coming and some are already here as part of ACA.  It has been proven that getting healthy at home, often referred to as 'medical home', is going to be critical to reducing cost of care and in technical jargon reducing the Medicare Spending Per Beneficiary (MSPB).  This is not only a cost reduction opportunity this is an ethics opportunity and human opportunity.  Being in a hospital, a skilled nursing facility (SNF) or long-term acute care facility (LTAC) is emotionally exhausting for patients and their family.  We all know that a person is body, but mind and spirit are as essential in health and recovery.

We can all intuitively agree, if you could ask my grandma Stella who had a history of escaping health facilities as she walked out the front lobbies in her hospital gown with her dupa showing (polish for butt), that getting a person home as soon as possible makes sense.  But (the non-dupa kind) we can't just send a person home to heal, recover and without the skills, knowledge and confidence to integrate prescriptions (medicines, diet, exercise, self monitoring, etc.) into their daily routine.  Home health nurses, therapists, caregivers and spouses can play a critical role in coaching and educating patients in their home but it starts in the hospital.  Med reviews, identifying personal goals, emotional assessment, a list of skills a patient should acquire, an understanding of their transition home, etc. all need to be part of the plan.  These are unique for each person and take time.  We can invest dollars to implement home monitoring systems that run out after a set time and do not build sustainable change or we can invest human time understanding the person and coaching/teaching the skills needed and integrating the right tools for the right situation so a patients confidence and knowledge is built and they can successfully get well at home. 

Getting or staying healthy at home is the best choice (financially, ethically, emotionally, psychologically) and we are creating the steps to achieve successful healing at home.  Join us on the journey to living healthy at home.  Please share your perspective and ideas as we finish developing our system of getting and staying well at home.  This system is develop for the person and with the support of caregivers, spouses, families, nurses, therapists, social workers and pharmacists.  

Monday, July 6, 2015


Why are we here?  My mom, Kathi and grandma, Stella and their struggle to deal with Stella's health.  They didn't know where to go.  They were intimidated to ask questions.  They were already dealing with the stress of Stella's failing health and they were using a health system that was difficult to navigate, disjointed, with very little time and that provided little direction.  We have heard similar stories from sons, daughters, caregivers, nurses, doctors, family members, friends, grandmas and grandpas, spouses over the last 3 years.  Something needs to change and something needs to change now.

I recently talked with a friend who is dealing with cancer.  She is in her late 30s and when diagnosed with cancer she had no clue where to start.  She was overwhelmed and her doctor raddled off her diagnosis and her next steps and that was it.  Confused, yet determined she spent hours on the internet learning about her condition.  The she stumbled upon a complementary medicine website called Believe Big .  She said the page called first steps immediately reduced her anxiety, gave her hope, gave her direction and a way to get started.  Our mission is similar.  We want to help elders and their families by giving them the guidance and the tools to navigate the health system, gain control and confidence and live free.  

What I noticed in the Believe Big was a couple themes:
  • Sources of encouragement (books, writings, etc.)
  • Guidance (make appts with three doctors to interview them before choosing, keep a note book, etc.)
  • Letting the reader know they are special and important and not just a number
  • The reader has a responsibility 
As I think about the stories we heard we have identified our first steps:
  • Its starts with you!  Your are the most important person in your care.  It is about your wishes not the wishes of someone else.  You deserve to be in control and below you will find tools and guidance to take control of your health and be well and get well at home. This also means you have a responsibility and the most important role in your care.  You must make a decision and if you choose to make that decision with the help of your loved ones you can do it and we have a list of resources and tools that will help you.  So the now if you want to join this journey to independence, freedom, peace of mind then read on.  
  • You are not alone.  Enlist the support of a friend or family member.  Who is someone you trust and see or talk to everyday?  They will know you best.  Write down that person's name?  This is your health companion. Ask them if they will be part of your team.  Bring this spouse, friend or  family member with you to every doctor, pharmacy or hospital visit.  Let them know they are important to you getting and staying well at home.  Just ask them if they can be an extra set of eyes and ears and make notes to questions you have and prescriptions your doctor, nurse or pharmacist makes.   
  • Listen to yourself.  Ask yourself why do I want to get well?  What is the thing I want to be able to do? To get back on the golf course or enjoy time with grand kids or be able to enjoy that cup of coffee with friends?  And then use that to make all your decisions.  Use this as your the thing that drives you to get well and stay well.
  • Get confident in your condition.  Before seeing a doctor make a list of questions to ask your doctor about your condition.  Ask your health companion to take these questions with you on your visit and make notes on this paper.  Think of being a sleuth that is trying to answer all those burning questions to solve the mystery.  You should feel more knowledgeable and confident each time you talk to your doctor or pharmacist and you or your health companion should have filled out this page.  Keep it as a record to refer to when you are at home.  Here are some sample questions:
    • Why is this happening?
    • What can I do to improve my condition?
    • What causes my condition?
    • What is part of my body is affected by my condition?  
    • What do I need to learn to improve or control my condition?
    • How will I learn this?
  • Make a list of skills.  Make a list of things you need to learn and who is going to teach you and when.  It has been proven that the best way to learn is hands-on.  Make sure the practitioner shows you, makes you do it, gives you feedback and allows you to do it until you feel confident.  Its your right!
  • Understand your personal routine.  We have a tool to help with this.  Think about what a typical day looks like When you wake up, what you do in the morning (coffee, breakfast), what daily activities.  Once you know this then you are equipped to have the conversation with the doctor and together you can determine how and where his health prescriptions fit into your daily routine.  Their is nothing more difficult than dealing with a health condition, being prescribed to make health changes (like take new medication, change diet or exercise) and also changing your routine.  Knowing your routine and taking the changes one step at a time.  Example a doctor might prescribe taking a certain medication at 8am before food but you might not wake till 10am...what should you do?)  If your doctor knows this he should be able to help you fit the medication into your personal routine.  Also understand where in your house does your routine take place, kitchen for making coffee, bathroom for brushing teeth, living room for watching jeopardy this will be important places to incorporate this new prescriptions and help reinforce them. 
  • Keep a list.  Keep a list of your medications.  We have found this could be the keystone of getting and staying well at home.  Because your medications are usually associated with a specific condition, that affects a specific system in the body if you know your meds you know your health.  And knowledge is power. This will also give you peace of mind in case of an emergency or when seeing multiple doctors and health systems.  You need to be the holder of the master key so they know how to treat you safely and quickly.  Having a master key allows you to avoid counteraction, double doses or taking unneeded medication.  There are simple lists available as well as a tool we developed.  Take this with you to the doctor, the pharmacist or in case of emergency.  You hold the key.  
  • Find a friendly pharmacist.  Find a pharmacist that is close, local and is willing to help.  Most pharmacist will jump at the opportunity to review your medication and advise.  This is what they are trained to do.  With the good comes the bad now that alot of medications are mail order it is important to have a medication specialist on your team that can see across your health team.  Sit down with them every six months to dispose of old medication, make sure you are being double prescribed (which is not only dangerous it is costly) and make sure there are no counteractions.  
  • Organize your medications.  Have you ever asked yourself did I take my blood pressure pill today?  I have done this and this is one of the most common challenges.  Use a pill organizer to set up your weekly medication.  Here is one our community found helpful  Organization is important to indicate whether or not you took your medication.  We also developed this nifty little tool to help indicate whether or not you took your medication.  Most importantly find a method that works for you.  
  • Keep a record of your medical history.  Don't you get annoyed when you go to the doctor and you have to fill out that stack of papers about your medical history and allergies.  Or as the Director of a local Senior ER said "[in an emergency situation] we need Definitely comprehensive medical records ...Vaccination history is also important. End-of-life care documentation. This needs to be reviewed every 6 months because health changes. [also] they need to document surgical history." This gives you and your family the peace of mind that in an emergency the medical professionals will be able to quickly and effectively treat you and get you back to health!  See our tool hear.
  • Make sure your wishes are grant.  Have an advanced directive and an assigned health advocate.  You want to be in control even if you are not able to make a decision in case of an emergency.  Plus your loved ones will thank you.
  • There is encouragement.  There are many places where you can find others who can empathize with you and have been through similar situations.  Here are a few places to start looking.
Things we still need to explore.....

Health Belief Model