Local residents with heart failure and chronic obstructive pulmonary disease (COPD) will be the focus of care provided by a grant from The Office of Rural Health Policy in an effort to keep them out of the hospital.
Sarah Bush Lincoln was one of 16 organizations nationwide to receive a grant. The three-year, $565,942 grant will target 40 to 60 people with heart failure or COPD and who receive care at SBL Family Medical Center in Mattoon in an effort to keep them well and out of the hospital. Sarah Bush Lincoln is also committing $23,279 to the project over three years.
SBL Care Coordination Director Carol Ray, RN, said, “We are terribly excited about this opportunity. By caring for this select group of people, who typically experience unplanned hospitalizations, we hope to learn from the process and apply the principles to other locations and to people with other illnesses.”
The intent of the federal grant is to have a measureable impact on the patients by reducing unplanned hospital readmissions while improving health outcomes. Between 40 and 60 people with heart failure or COPD will be enrolled and tracked over the three-year project. The premise is that those enrolled will exhibit improvement in one or more of the following measures: patient activation, self-management behaviors, optimal medication management, and clinical quality measures.
Ray explained that the Patient Activation Measure (PAM) is one tool the team will be using. It assesses the knowledge, skills and confidence integral to help patients and their support team better manage their own health and healthcare.
Ray said that through the use of case management, Sarah Bush Lincoln had begun working with a number of people at Family Medical Center with heart failure and COPD more than a year ago. “Of those people, we realize some may not be candidates for this project. Some may not want to participate, but they all will continue to receive excellent care.”
The project also aims to improve the resources and skills of the SBL care team. Staff will use motivational interviewing techniques to discover what it would take to motivate someone to make a life or behavioral change. Ray said, “Helping patients determine and share their priorities can increase their motivation to make healthy changes. The point of motivational interviewing is not to make choices for the patient. Rather, it’s to engage patients as active partners in their care. Someone may not be motivated to adhere to a program in order to be well enough to take a long trip, but may be motivated enough to make changes to attend a grandchild’s wedding. People have different triggers and we need to uncover those to help them achieve their health goals.”
She added that this project would also apply Lean principles for continuous quality improvement. The care coordination team will support care transitions, work with patients to develop a “life” plan that reflects the patients’ values and priorities.
Ray added that information to support the coordination of care would be shared through the Health Center’s electronic medical record.
This project is supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) under grant number 1 G20RH30138-01-00. The $565,492 federal grant provides support for the project, “Care Coordination for CHF and COPD Patients at Family Medical Center,” over a three-year period. In addition, 4 percent of this project is financed by nongovernmental sources. This information or content and conclusions are those of the author and should not be construed as the official position or policy of, nor should any endorsements be inferred by HRSA, HHS or the U.S. Government.