The document describes the services of Jeffrey Harris and Untangled Healthcare, which assists communities in monitoring and improving healthcare. It provides Harris' contact information and outlines a syllabus for a patient advocacy training series. The series will cover levels of patient support based on needs, the advocates process, and a real case study from 2011 involving a woman with multiple medical and social issues. It describes using a patient advocate to conduct a full assessment, assist with insurance, primary care, and identifying community resources to create a comprehensive care plan.

1. Jeffrey Harris
Untangled Healthcare
Jeffrey Halbstein-Harris
Untangled Healthcare
Assisting communities to monitor and improve healthcare
919 627-5038 Cell
919-779-7368 Office
Fax 888 783-6178 (Jeffrey Harris)
email: JeffHarris@untangledhealthcare.com
LinkedIn: http://www.linkedin.com/in/untangledhealth
Blog: http://www.untangledhealth.com/
Website: http://www.untangledhealthcare.com/
Twitter: http://twitter.com/UntangledHealth
Slide share: http://www.slideshare.net/jeffharris75
11/23/2011 1

2. Syllabus
1. Defining a persons needs and the evolving National Health Information
Infrastructure
1. Defining an emerging Health Information Technology within the context of
the US HealthCare System
2. Support , Process and Use Case
1. Samples of Levels of Support Based on Functional Status
2. The Advocates Process
3. Real Use Case 2011
3. Personal Health Records
1. Selection
2. Components
3. Security
4. Process
4. A Transition Model
5. Why We Do It
11/23/2011 2

3. Untangled Healthcare Patient Advocacy Series
Part Two
1. Samples of Levels of Support
Based on Functional Status
2. The Advocates Process
3. Real Use Case 2011
11/23/2011 3

4. Untangled Health Patients
Have various support needs based on our social and physical, mental and social health
status
Care Cycle Ultimately we need major help in planning our lives
Assess
At times our conditions become unstable , and
Monitor Plan barriers to ‘getting better’ include lack or Care <management
Our Health-Care
support and a lack of understanding on how to
Level of Assistance Needed
Coordinate Plan System ‘STEPS
manage multiple problems UP’ and manages
Educate
our conditions
As we age and sometimes
sooner we develop Care Coordination and
Education
uncomplicated chronic Drs and their staff
conditions and monitoring collaborate, coordinate,
WE ALL HAVE needs teach and coach us,
addressing ALL OF OUR
Primary and Secondary Prevention Rights PROBLEMS
Sometimes we have acute Supported Self Management:
temporary conditions Engaged by our doctors and assisted by their
staff
Informed Self Service : Education and Self Service Instructions
Usual Care: Diagnosis & Treatment Services
Our Life Span
11/23/2011 4

5. The Patient Advocate Process
Assist with
reporting Bio-Psycho-Social History
outcomes to Discover Goals, Wants, Needs
PCP
Functional Status
Physical
Social Insurance Exchange
Cognitive
Monitor Activate Primary Care
Compliance
Comorbidity Medical Home
Patient Contract
Patient Compliance
Disease Self Mastery Identify and link
Learning Barriers community
resources:
Evaluate Assist Transportation,
Meals on Wheels,
Patient Peers
Primary and Secondary Prevention
Self Monitoring
Resource Utilization Educate
Urgent Care Guidelines
Communication Skills
11/23/2011 5

6. Discovery
• disease mastery
• psycho-social stability
• patients knowledge
• functional status dimensions
11/23/2011 6

7. Functional Domains
Cognition
Problem Solving
Memory
Communication
Psychosocial
Expression
Emotional Status
Comprehension
Adjustment To Limitations
Reading
Self Care Mobility
Eating Transfers
Elimination Grooming Toilet
Bathing Shower
Sphincter Control
Dressing Car
Bladder
Toileting Locomotion
Bowel
Swallowing Walking/Wheelchair/St
airs
11/23/2011 Community Mobility 7

8. Activate
• If no insurance: Find a program e.g.
Medicaid, Safety Net Sliding Fee, Health
Choice, Insurance Exchange in 2014
• Patient and advocate select a PCP who
claims to be a Primary Care Medical Home
• During first visit: Suggest a compliance
contract between patient and physician e.g.
first point of contact unless life threatening
event
• Set follow up dates and responsibilities
(COACH)
11/23/2011 8

9. Assist
• Evaluate patient defined needs and goals:
• Educational barriers
• Educational Plan
• Address functional deficits in ADLs and
IADLs
• Connect to community resources
• Connect to peer support
• Follow-up several times per week in first
month then decrease encounter frequency
11/23/2011 9

10. Education
• Take learning barriers into account and use assistive
tools where necessary e.g. times medication
dispensing containers. Connect patient with
pharmacist if on more than five medications.
• If patient is responsive to internet health records set
up a PHR that exchanges data with physicians PHR or
Microsoft Health Vault if Physician has not installed e-
HR yet.
• Otherwise create a paper based notebook that is the
perpetual record of care and interventions and
outcomes.
• Test learning by return demonstration at least one
week post educational sessions.
• Don’t be afraid to involve family and friends
11/23/2011 10

11. Evaluate
• Review care plan with patient
• Make sure patient adds you to care team so you can access records
in patient portal at hospitals and practices and PHRs.
• First things first: What is highest priority
– Medication reconciliation with no gaps in long term medication fills
without physician order
– All testing appointments completed on time
– All follow up appointments completed on time
– Lifestyle changes are beginning to migrate into patients way of living
– Quantify use of hospital or ER services for inappropriate reasons and try
to define precipitating factors e.g. physician not available
– Compare medications to insurance formulary and if physician agrees
switch patient to lower tier medications to reduce cost for patient and
insurance company
– Assess any new functional limitations e.g. balance in the elderly and
visual acuity.
11/23/2011 11

12. Monitor
• Set up monitoring schedule with patient with goal
for complete independence if possible.
• Teach patient to self record data from home
medical devices and PHR tools.
• Teach patient how to use secure communication
tools with provider and yourself
• When comfortable discharge with assurance of
your availability when needed.
• Send report to physician. If physician using e-HR
and patient portal ask about submitting report
through portal.
11/23/2011 12

13. Case Example
Real Life 2011
In two years she:
1. Was a victim of domestic
violence
2. Transitioned from military to
public health systems
3. Was treated by 12 physicians
and surgeons and behavioral
health specialists
4. Was placed on twenty two
different medications some
of which were within the
same class and directly
contraindicated
5. Lost her ability to think
clearly
6. Lost her family
7. So here we are.
• Our friend with her treatment records
and medicine during data collection
step
11/23/2011 13

14. Patient Medical Home or Procedural
Contracting
11/23/2011 14

15. Use Case: Care Coordination, Management and Advocacy
Middle Aged Chronically Ill Woman Migrating To NC from Florida’s Safety Net
Patient Classification:
Demographic: 50 y/o Caucasian female
Bio- Complex comorbidity (degenerative spinal disease,
acute trauma with questionable TBI, constellation of
auto immune diseases
Psycho- History of episodic substance abuse ETOH and
prescription narcotics, depression, PTSD
Social- Indigent, Income= $1300/MO; homeless; divorce in
process, domestic violence victim, Medicare dually
eligible SSDI, Post graduate degree in behavioral
health
Functional- Mental: Cognitive defects memory and executive
function
Physical: Chronic pain limitations to locomotion and
IADL
Summary: Can’t work, can’t drive, can’t think = NO HOPE
11/23/2011 15

16. Given patient status how would the present clinical world
find all of this information during assessment?
Patient interview
Patient SS Dept. attempt to locate data
found on Repeated testing to R/O dx
street in
North Hospital Critical Path
Carolina Discharge to community
New Medical History Variant
Patient ER Disconnected from future episodes
Visit
Patient
Acute
Admission
Subjected
to DC
Planning
Process
DC next
lower level
care
Classic Scenario
Poor transition management
No portable record
11/23/2011 16

17. The Patient Advocate Process
Assist with
reporting Bio-Psycho-Social History
outcomes to Discover Goals, Wants, Needs
PCP
Functional Status
Physical
Social Insurance Exchange
Cognitive
Monitor Activate Primary Care
Compliance
Comorbidity Medical Home
Patient Contract
Patient Compliance
Disease Self Mastery Identify and link
Learning Barriers community
resources:
Evaluate Assist Transportation,
Meals on Wheels,
Patient Peers
Primary and Secondary Prevention
Self Monitoring
Resource Utilization Educate
Urgent Care Guidelines
Communication Skills
11/23/2011 17

18. Discovery and Documentation of
Baseline
Objective: My Medicare.Gov
1. Gather as much as possible and filter
for sentinel information
Claims extract
1. Diagnosis
2. Procedures
3. Providers
4. Medications
5. Hospitalization Episodes
2. Store Data in secure online Good for preventive svcs,
repository with proven connectors to providers
EMRs, PHRs and Vendor Hubs e.g. Hospitalizations and visits.
Quest, CVS Microsoft HealthVault
– Central Cloud Data Repository
– Using Standardized Clinical Mode
Mayo Clinic Personal Health
Record
11/23/2011 18

19. Assemble on-line health record
A repository that connects to multiple systems
A PHR that has built in decision support
Established Mayo Clinic
Attempt to connect Health-
Test Successful PHR and completed data
Vault to Mayo Clinic PHR
entry for patient
CVS used
Mayo PHR
as
Summary
Pharmacy of
Record
choice
11/23/2011 19

20. Patient Information Flow In Sample
Patient Advocacy Case
Primary Portal To Patient
Information
11/23/2011 20

21. Final Outcome
Combined Mayo Transported Patient to UNC HealthCare with
PHR with Manual Summary Documents and Films
Clinical Summary
Patient Team Today Mayo
PHR
Primary Care MD
Psychiatrist Health
Medicare
Vault
Physiatrist
Patient
Behavioral Health Program
Portable Health Record
Medications
Start = >20 CVS UNC
Today = 8
Functional Status
Independent all IADL
Self transportation
Self perceived health status improved
11/23/2011 21

22. Advocates Care Plan
11/23/2011 22

23. Care Plan Elements
Summary
11/23/2011 23

24. Plan of care
11/23/2011 24

25. Weekly priorities
11/23/2011 25