The COPD and CHF Map Program

The purpose of this blog is to showcase how diabetes educators can expand their scope by providing COPD and CHF self-management education. For starters, let me introduce myself; I am Nick Armes, a Business Analyst at Healthy Interactions. I’ve been here over a year, having come from Lilly diabetes, as well as Cardiovascular divisions. I’m passionate about patient education because as a former drug rep I saw everyday that patients did not understand their conditions, diseases, or problems - they just wanted a pill to fix everything. Through Lilly’s Sales University, I began to better understand the anatomy and physiology behind diabetes and cardiovascular disease, and I think everyone who has these conditions would benefit from better understanding as to how the disease occurs, how it affects them, and what they can do to prevent or improve their own situation.

Currently, I strategize with health systems on how to maximize delivery outcomes driven through patient education and engagement. As a business analyst, I have partnered with group providers and health systems to increase, improve, and advance patient-centered, evidence- based, economically feasible solutions through Health Interactions’ programs.

Today, I would like to introduce you to Deb Zlomek who is a Registered Nurse and a Certified Diabetes Educator in Pottstown, Pennsylvania. Deb has been using our diabetes Conversation Map tools for over five years and has expanded her scope to also use COPD and CHF Map tools, as well as the digital platform – our Conversation MApp app.

1) Deb, what are a few things that generated the need for COPD and CHF Map tools at PMSI?

Our physicians recognize that COPD and CHF are the two chronic diseases that tend to have high emergency room utilization and readmission rates. They also understand that by preventing hospital readmissions and reducing ER visits with better patient education and self-care you can improve the qualify of life for patients as well as achieve healthcare savings both for the patient and healthcare system.

That's where the COPD and CHF map tools come into play at Pottstown Medical Specialists Inc (PMSI). PMSI has looked at trends in health care costs, increases in chronic diseases, readmission rates, over utilization of the ER and have determined a change needs to occur in the way we educate patients.

We believe in self-management education. Empowering patients allows them to be more engaged in their healthcare, and hopefully will reduce emergency room visits, unplanned hospitalizations, and improve health outcomes. At PMSI, which is a patient-centered medical home practice, we encourage patients to be involved in their own goal-setting, lifestyle changes and self-management skills.

Our vision is to have an integrated healthcare team in which patients "buy in" to the notion of personal responsibility for their day-to-day care. When they do, we've learned, they feel better about themselves, both physically and mentally. They know they are an integral part of their healthcare team.

2) Do your skills as a CDE help with COPD and CHF education?

I was already accustomed to using the diabetes map tools to educate and motivate people with diabetes  on self-care management of their chronic disease. COPD and CHF - and, frankly, all chronic diseases - are no different.

Self-management, patient empowerment, and team-based care strategies are essential to improved care and outcomes. When patients find it difficult to adhere to their treatment plan or make lifestyle changes that have an impact on their health, it's important to find out why.

Was there a cause for non-adherence? Do they lack an understanding of their disease, or the value of a specific component of self-management? That's where I think my educational skills, learned over time as an RN, CDE and BC-ADM, help me identify problems and more importantly, help guide patients in solving them.

3) How do you partner with other providers to deploy the COPD vs CHF session – does the deployment differ?

No, it doesn't differ. Clinical support staff members for both departments went through Conversation Map training so they could promote the sessions to patients. Promotional hand-outs are available in each exam room.

There also is a standing order that any patient with CHF or COPD may be referred to the program. Any patient who has been discharged with a diagnosis of COPD or CHF is scheduled for the next available session. Patients may attend as many times as necessary to help them reach their goals and make behavioral changes that will improve their self care.

4) What do you look forward to using the most with the Conversation MApp digital platform?

We're hoping the digital platform will increase patient engagement and accountability.

Cell phones are mobile personal computers. National statistics indicate a large percentage of the population owns a mobile phone, and uses it several times daily. If we can encourage patients to do their own "status check" on the digital platform just once a day, we're on the way to reinforcing the importance of self-monitoring and self-management. It has the potential to raise the level of patients' chronic disease consciousness, and that would be a good thing.

5) What are the examples of patient feedback or measurements of success?

We just started these two programs during July 2016, so I lack current measurable outcomes. However, patient feedback has been very positive. Patients have thanked PMSI for having the opportunity to meet with other patients who share their same disease and be guided through an interactive discussion so they can learn how to better manage their daily care.

6) What are the examples of provider feedback or measurement of success?

PMSI cardiologists Drs. Baman, Patel, Dhawan Krantzler and Levin, and pulmonologists Drs. Sbat, Pham and Patil, have been extremely positive and supportive in developing an educational and collaborative team approach to patient care. I am invited to attend the monthly cardiology staff meetings to report on the sessions. I communicate regularly with the pulmonologists and cardiologists on outcomes of each session.

7) What is your advice to other CDEs who would like to extend their practice by doing COPD and CHF Map sessions?

I think most CDEs will quickly discover their skills as educators are easily transferable to other chronic diseases. The seven self-care behaviors for diabetes management - healthy eating, being active, monitoring (weight, blood pressure, red flags for exacerbations), taking medications, problem solving, healthy coping, and reducing risks - are the same for COPD and CHF.

CDEs, by virtue of their certification, already know how to do what's important. They help patients with chronic diseases to understand their disease, and learn to use self-management skills to help them set goals to make behavioral changes that will improve their daily quality of life.

CDE’s strength lies in the ability to teach, to communicate, and to encourage ... the skills they already tap!

8) We know it’s early and you have many success stories from the diabetes Conversation Map tools, but have you seen any success stories in the COPD or CHF sessions?

Having patients respond so positively to invitations to join a session is success in my eyes. It tells me there was an unmet need for patients to learn more about their disease so they can become more active in their daily self-care.


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