Susan Butterworth, PhD, MS Associate Professor, Oregon Health & Science University
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Transcript of Susan Butterworth, PhD, MS Associate Professor, Oregon Health & Science University
Susan Butterworth, PhD, MS
Associate Professor, Oregon Health & Science University
President, Q-Consult
Chronic care management with commitment to patient-
centered approach
Collaboration between health care practitioners & community
service providers
Goal is improving health outcomes for high risk, complex
Medicaid cases
Population served have
multiple chronic diseases,
mental health issues &
history of substance abuse
RNs serve as care manager Partners: Aging & Disability Services, Senior Services,
community healthcenters, & Harborview Clinic
Access to team of health care professionals with clinical,
psychiatric, chemical dependency, social work and
pharmacological expertise
Outcome measures:
patient activation
utilization costs
clinical indices
One-day training in patient activation & use of Patient
Activation Measure (PAM)
Two-day MI training with staff and leadership
Identification of internal mentors
MITI coding and monthly coaching (skill-building) sessions
with mentors
Follow-up half day MI and Mental Health workshop
Identification of lead facilitator & support for self-
management of program
Decreased rate of successful follow-up; i.e. every contact
counts
Increased number of co- and multi-morbid conditions and
behavioral health concerns
Lower education and socioeconomic levels associated with
increased barriers to medical care, and lower healthcare
knowledge, ability to navigate system, and confidence levels
Increased level of defensiveness and feelings that system
has let them down
Increased level of cultural differences
traditional health care system views patients who do not
follow treatment plans as ‘non-compliant’.
In some cases, they are discharged from their primary care
clinic because they are deemed too challenging to work with
Medicaid patients who have dual diagnosis have pressing
social issues which take precedence over medical treatment
45 year old female with Russian origin; poor English
language skills and literacy
Homeless; living in tool shed with no electricity, plumbing,
and heat
Conditions: schizophrenia, PTSD, alcohol & tobacco
addiction, Chronic Obstructive Pulmonary Disease (COPD),
diabetes
KCCP care manager goals: get into public housing, address
addictions, address diabetes control, refer to mental health
specialist for review of meds
Patient goal: find housing that accept dogs
Intervention: Care manager successful in identifying housing
that accepts dogs as primary goal
Outcome (as of 9/30/10): Patient in public housing; has
agreed to mental health review; increased self-efficacy and
activation