Developing a Poly-Chronic Care Network: An Engineered, Community-Wide Approach to Disease Management

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ISBN: 9781466554740 | 1466554746
Cover: Hardcover
Copyright: 10/29/2012

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Poly-chronic disease network is a concept in the management of cost, quality, access, and capacity for those with multiple chronic diseases. By combining existing engineering principles, technologies, and readily-available communal resources, the poly-chronic disease network can be designed and implemented in nearly any community. In addition to background information, this book covers the three core technologies in use today: health information exchanges, dynamic simulation, and home/virtual monitoring. It includes a how-to guide for setting up a PCDN and explains how this management system differs from an accountable care organization.

Preface	p. ix
Acknowledgments	p. xix
Introduction	p. xxi
The PCCN Concept: An Overview	p. 1
PCCN Description	p. 1
PCCN as a Visual	p. 2
Application Overview	p. 4
An Engineered Approach	p. 6
PCCN Components	p. 8
Resource Pool	p. 8
Resource Training	p. 12
Technology Infrastructure (TI)	p. 13
Palliative and End-of-Life Care	p. 16
Assimilation and Passion	p. 17
Capacity as Strategy	p. 17
Other Important Attributes of the PCCN	p. 19
An Additive Solution	p. 19
PCCNs and ACOs	p. 20
A Caveat to the Contents of This Text	p. 21
Two Missing Elements	p. 22
Mental Health	p. 22
The Bottom 50	p. 24
A Word on U.S. Privacy Regulations and the PCCN Concept	p. 24
Summary	p. 27
Endnotes	p. 27
A Brief History of Previous and Current Healthcare Reforms	p. 29
Been Here, Done This?	p. 29
Whence Innovation?	p. 30
Accountable Care	p. 31
Precursors to ACOs in Europe	p. 34
ACOs and HMOs	p. 35
Can ACOs Save the System?	p. 37
ACOs and PCCNs	p. 40
PCCNs and Other Business Models	p. 43
Summary	p. 45
Endnotes	p. 45
The Five Pillars of Healthcare for the PCCN	p. 47
Quality and Outcomes	p. 49
Access	p. 50
Capacity	p. 51
Cost	p. 52
Participant Gratification	p. 53
The Five Pillars and New Approach	p. 54
Summary	p. 55
Endnotes	p. 55
Assessing the Community and the Patient Population	p. 57
Selecting Patients	p. 57
Size, Scope, and Scale of Your PCCN	p. 61
Proximity of Space and Resources	p. 62
Physician Participation	p. 62
Technology Constraints	p. 63
Patient Population Chosen	p. 64
Community Acceptance	p. 65
Assimilation Propensity	p. 66
Cultural Barriers	p. 69
Barriers to Assimilation	p. 70
Summary	p. 71
Endnotes	p. 71
Care Strategies and Task Analysis	p. 73
Establishing BDPs and Patient Involvement	p. 74
Swimlane Mapping	p. 76
Task Classifications	p. 79
Task and Resource Considerations	p. 80
Risk	p. 81
Variation	p. 81
Process Variance	p. 82
Process Time Variance	p. 84
Process Time and the Impact of Variability	p. 84
Process Time Variance Example	p. 84
Interdependencies and Variability	p. 87
Process Time and Patient Attributes	p. 88
Impact of Variance on Capacity	p. 88
Tools for Analyzing Complex Systems	p. 89
Dynamic Standardization	p. 90
Data and Analysis of Current and Future States	p. 91
Process Data	p. 92
Demand Data	p. 93
Analyzing Community Demand	p. 94
Summary	p. 97
Endnotes	p. 97
Building the Communal Resource Pool	p. 99
Overview	p. 99
Resource and Capacity Variance	p. 102
Dynamic Demand-Capacity Matching	p. 103
The Demand-Capacity Continuum and Simulation Capacity Analysis	p. 105
Resources	p. 107
Using the Care Strategies	p. 107
Resource Options	p. 109
Resource Selection	p. 113
Selecting Physicians	p. 114
Creating a Care Circle Team	p. 117
Personalizing the Resource Pool	p. 118
Resource Assimilation	p. 121
Resources for the Resources	p. 122
Resource Education	p. 124
Setting up Educational Programs	p. 125
Leadership and Core Values	p. 130
Group Dynamics™ for Resources	p. 132
Challenges and Obstacles	p. 134
Legal Hurdles	p. 134
Too Many Cooks?	p. 135
Summary	p. 135
Endnotes	p. 136
Build it and They May Not Come	p. 137
Protecting the Herd	p. 138
Physician Participation	p. 141
Risk, Payors, and the Government	p. 142
Future PCCN Model Alternatives	p. 144
Summary	p. 145
PCCN Resources and Governance Structures	p. 147
Poly-Chronic Care Network Roles	p. 148
PCCN Management Team	p. 148
Chronicists	p. 150
Governance Structures and the Chronicist	p. 152
Specialists	p. 157
PCCN Manager	p. 158
PCCN Trainer	p. 160
Patient's Primary Communal Resource	p. 161
Education of the Community	p. 163
Governance as a Practical Matter	p. 164
More on Governance Structures	p. 165
A Word on Group Dynamics™	p. 170
Making Room for Skeptics	p. 172
Governance as a Legally Binding Concept	p. 172
Summary	p. 173
Endnotes	p. 173
PCCN Technologies	p. 175
Introduction	p. 175
Infrastructure Options: Overview	p. 176
Using the SCN	p. 178
Patient Connectivity	p. 179
Patient-Resource Connectivity	p. 180
Resource-Resource Connectivity	p. 181
PCCN Management: Resource-Patient Connectivity	p. 182
Resource-Clinician Connectivity	p. 183
Example of a SCN Use Case	p. 184
Another SCN Use Case: Discharge and Care Transitions	p. 187
Using Simulation	p. 189
Using the HIE	p. 190
Using the Chronic Disease Management System (CDMS)	p. 192
Using Virtual Monitoring	p. 193
Who Pays for It?	p. 195
How to Save on Implementation Costs	p. 196
PCCN Resources and the Technology Infrastructure	p. 197
Summary	p. 199
Financial Considerations of a PCCN Implementation	p. 201
Cost Analysis Assumptions	p. 202
Creating Your Own Cost Analysis	p. 206
Impact of the PCCN on Hospital Financials	p. 207
Impacts on Physician Office Costs and Revenues	p. 209
PCCN Cost Justifications	p. 212
Outcomes and Incentives	p. 216
Who Pays for What?	p. 219
Summary	p. 222
Endnotes	p. 222
PCCNs, Palliative Care, and End-of-Life Planning	p. 223
Palliative Care: Definition and History	p. 224
The Origins of Palliative Care	p. 227
Resources for Palliative Care	p. 228
End-of-Life Planning and Care	p. 229
Example: Gunderson Health System	p. 231
Integrating EOL and Palliative Care in the PCCN Model	p. 233
PCCN Process Evolution and Palliative and EOL Care	p. 236
The Payor Role	p. 238
Government and EOL Planning	p. 241
Summary	p. 242
Endnotes	p. 242
Final Thoughts	p. 245
Imagine	p. 250
Closing Comment	p. 251
Epilogue-The Latent Community	p. 253
Index	p. 257
Table of Contents provided by Ingram. All Rights Reserved.

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Developing a Poly-Chronic Care Network: An Engineered, Community-Wide Approach to Disease Management

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Developing a Poly-Chronic Care Network: An Engineered, Community-Wide Approach to Disease Management

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