Chronic Disease Self Management Pilot Studies

CP2 photoOver 22 percent of Medicare patients released from the hospital return within 30 days, and the leading cause is their inability to manage their condition. Kissito recognized that patients and their families could be empowered to maintain their health and break the hospitalization cycle.

Working with Dr. Steven R. Hahn, MD of The Albert Einstein College of Medicine, Kissito developed the Collaborative Patient Care Pathway or CP2. This evidence-based Model of Care has already been implemented in multiple provider settings across the country and early results show dramatically reduced readmission rates with patients enjoying longer, healthier and happier lives. Kissito is committed to making CP2 the standard Model of Care across multiple provider settings to achieve the “triple aim” for it’s development partners.

The Result

CP2_graphic_origIn skilled nursing homes, Kissito partners have realized a 28.5% overall increase in the patient and family’s self management skills and competencies.

In the PACE environment we have achieved an increase in patient centered-communication techniques resulting in cost savings of over $100,000 a month due to the decrease in ED, hospitalization, and nursing home utilization days.

The Challenge

Within the complexity and uncertainty of contemporary healthcare new opportunities have emerged, driven by the realization that current approaches are not optimal for achieving the “triple aim” of better experience and outcomes for individual patients, healthier populations and increased efficiency. Financial incentives are becoming aligned with achieving these goals rather than being tied to the complexity and quantity of the care that is delivered. Healthcare organizations are searching for new ways to provide care that satisfies patients and reduces utilization by maintaining health.

The most common strategy adopted is to intensify care with modalities that extend disease management into the patient’s home environment: telemedicine and transitional care patient navigation are two examples. Chronic disease self-management, a traditionally neglected dimension of healthcare, has also been demonstrated to have a powerful impact on outcomes. Even advance healthcare delivery systems such as PACE programs, patient-centered medical homes and care coordination programs that have expanded the frontiers of the two traditional agendas of disease management and rehabilitation have yet to fully address the “third agenda” of self-management.

The Opportunity

Chronic disease self-management is important across the continuum of care. In acute inpatient care effective assessment of patient and family self-management competency can focus transitional care patient education and add a critical perspective to assessment of mobility and ADLs in discharge dispositions.

Short term post-acute rehabilitation admissions can be transformed in “self-management universities” taking advantage of the two to four week stay in a high touch multidisciplinary environment to provide tailored educational intervention.

Home and community based care coordination programs can incorporate self-management assessment and education, and PACE and patient centered medical homes can use their multidisciplinary teams to address these goals. Despite the nominally recognized importance of chronic disease self-management, the fact is that the philosophy of care in these settings is still largely dominated by a clinical disease management mentality and the skills and tools necessary for effective chronic disease self-management assessment and intervention have been lacking.

Ongoing Studies and Pilot Programs

Kissito Collaborative Care Solutions is currently recruiting development partners to join pilot studies in the following care continuum settings:

  • PACE (Program of All-Inclusive Care for the Elderly)
  • Skilled Nursing Facilities
  • Patient Centered Medical Homes
  • Home and Community-Based Care Coordination Programs
  • Acute Care Hospitals
  • Managed Medicare and Medicaid Programs

For more information or to set up an online presentation with our team please contact:

Josh McGilliard, VP of Development
540-265-0322 x 102
josh.mcgilliard@kissito.org