Chronic Disease Management

Question 1

What account for nearly 48% of all deaths?

Answer 1

heart disease and cancer

Question 2

more than ____ of adults are obese

Answer 2

1/3

Question 3

What are the four modifiable risk behaviors (which are responsible for much of the illness, suffering & early death from chronic diseases)

Answer 3

1. lack of physical activity 2. poor nutrition 3. tobacco use 4. excessive alcohol consumption

Question 4

____% of healthcare costs in US go to tx of chronic disease?

Answer 4

75%

Question 5

Chronic disease can be largely managed by what?

Answer 5

patient knowledge and behavior change

Question 6

Differences b/t acute vs. chronic illness

Answer 6

Acute- rapid, one cause, short duration, decisive diagnostics Chronic- gradual onset, many causes and indefinite duration

Question 7

erratic adherence

Answer 7

failure to follow treatment because it’s difficult and/or lifestyle disruptions interfere with regimen

Question 8

Unwitting non-adherence

Answer 8

believe that they are complying but fail because of language & cultural barriers, cognitive impairment, lack of knowledge, etc

Question 9

Intentional non-adherence

Answer 9

clear decision to alter/stop tx

Question 10

Top 4 causes of death in Virginia

Answer 10

Heart disease, cancer, chronic lower respiratory disease, stroke

Question 11

What is Healthy People 20/20

Answer 11

National health objectives designed to identify the most significant preventable threats to health and to reduce these threats (many are chronic diseases) -ID preventable threats -reduce them

Question 12

Goals for Heart Disease and Stroke

Answer 12

prevention, detection, treatment of risk factors -early identification and prevention once it occurs

Question 13

The leading modifiable/controllable risk factors for heart disease and stroke are…

Answer 13

high BP, high chol, smoking, diabetes, poor diet, overweight/obesity

Question 14

Goals for Diabetes

Answer 14

Reduce disease and economic burden of DM and improve quality of life

Question 15

Obesity Goals

Answer 15

promote health and reduce chronic disease through healthy diet and achieving/maintaining healthy body weights

Question 16

Overweight/obesity increases risk for:

Answer 16

high bp, coronary heart disease, diabetes, stroke

Question 17

Goals for cancer

Answer 17

reduce new cases and illness/death caused by it

Question 18

risk factors to reduce for cancer

Answer 18

-tobacco -physical inactivity/poor nutrition -obesity -UV light exposure

Question 19

Goals for resp. disorders

Answer 19

prevent, detect, treat to promote better respiratory health

Question 20

examples of some chronic resp disorders that are public health burdens

Answer 20

-asthma -COPD (VERY preventable b/c caused by smoking) -obstructive sleep apnea

Question 21

Risk factors (in general I guess?)

Answer 21

-unhealthy diet -physical inactivity -tobacco -overweight -not screening

Question 22

What is disease management?

Answer 22

system of coordinated health care interventions and communications for populations with conditions in which patients self-care efforts are significant

Question 23

What are Stanford Self-Management Programs

Answer 23

-self-management programs for people with chronic health problems -small group workshops -peers teach each other -highly interactive, focus on building skills, sharing experiences & support -arthritis, chronic disease, HIV, diabetes

Question 24

What is the essential element of successful chronic disease management?

Answer 24

success= fostering a pt.-centered partnership b/t the patient and healthcare team -a prepared practice team and informed/activated patient foster productive interactions

Question 25

What is the chronic care model

Answer 25

a comprehensive model for the healthcare system, team, and pt designed to improve outcomes for those with chronic illness

Question 26

What are the six components of the chronic care model?

Answer 26

1. community resources and policies
2. the health care organization
3. self management support
4. delivery system design
5. decision support
6. clinical information systems

Question 27

What is self-management support

Answer 27

helping people understand their health behaviors and develop strategies to live more fully/productively -helps pts/families gain knowledge and skills and set goals to manage a condition

Question 28

5 As for self-management support

Answer 28

1. ASSESS beliefs, behavior, knowledge 2. ADVISE health risks and benefits to change 3. AGREE collaboratively set goals 4. ASSIST ID barriers, strategies, problem solving techniques 5. ARRANGE plan for follow up

Question 29

Components of a Personal Action Plan (self management support)

Answer 29

1. list specific goals in behavioral terms 2. list barriers and strategies to address barriers 3. specify follow-up plan 4. share plan with practice team and patient’s social support

Question 30

What are the patient self management tasks?

Answer 30

-take care of the illness (medical management) -carry out normal activities (role management) -manage emotional changes (emotional mgmt)

Question 31

Self management support is…

Answer 31

helping people understand, decide & choose, adopt & change behaviors, overcome barriers, cope, follow through

Question 32

What self management support ISN’T

Answer 32

didactic patient education or lecturing, “you should..”, finger wagging, waiting for patient to ask for help

Question 33

Why is self-management support so important?

Answer 33

-It’s often ignored -Patients do most of the work in caring for the illness -this is the place where the practice team can collaborate with patient/caregivers

Question 34

Qualities of successful action plans

Answer 34

-the PATIENT WANTS to do it -behavior-specific -reasonable -confidence level 7 or more (what are you going to do, how much, when, how many days, etc)

Question 35

For low confidence levels… (what should you do to increase them?)

Answer 35

-ID the barrier or problem -brainstorm WITH THE PATIENT for solutions -adjust action plan -reassess confidence