Florida Health Networks and the collaborating Network of community-based organizations provide a comprehensive Wellness and Preventive health services menu, targeting older adults and persons with disabilities with two or more chronic conditions throughout the State of Florida.
Each consumer is assigned a Community Health Worker (CHW). CHWs work with each consumer to make sure they are accessing and completing each of the preventive health and disease self-management goals identified in their Wellness Care Plan. The CHW makes contact with each consumer on a monthly basis to ensure they have access to all of the supportive self-management tools necessary for successful disease self-management. The CHW program adheres to the Centers for Medicare & Medicaid Services (CMS) final rule for Chronic Care Management (CCM) Services.
Florida Health Networks complies with CMS requirements by providing 24-hour access to a clinical tele-health call center staffed by a multi-disciplinary care team led by Nurse Practitioners. Nurse Practitioners review and finalize the Wellness Care Plan, provide clinical supervision input to the care management services provided by the network of community-based organizations.
The Wellness and Preventive health services focus on three main areas:
Chronic Disease Self-Management Education
“Even the highest quality provision of care to individuals with Multiple Chronic Conditions alone will not guarantee improved health outcomes for this population. Individuals must be informed, motivated, and involved as partners in their own care.” U.S. Department of Health and Human Services. Multiple Chronic Conditions—A Strategic Framework: Optimum Health and Quality of Life for Individuals with Multiple Chronic Conditions. Washington, DC. December 2010.
Approximately 80% of older adults have at least one chronic condition. Among those, 50% have at least two chronic conditions, which often lead to disabilities and the inability to perform basic daily activities such as bathing, dressing, eating and moving around the house. To address these problems, there are dynamic solutions.
FHN offers multiple patient activation, behavior change and education programs to meet the specific needs of each patient. The programs include the Stanford University Patient Education menu of small group workshops and EnhanceWellness, a one-on-one health-coaching program.
Stanford Chronic Disease Self-Management Education evidence-based programs:
- Chronic Disease Self-Management Program (CDSMP) focuses on managing common symptoms suffered from various and multiple chronic diseases. The program enables the individual to build self-confidence to maintain their health and manage their chronic conditions. This program has been translated in 15 languages. Learn More
- Diabetes Self- Management Training (meeting American Association Diabetes Education (AADE) standards) focuses on problems and concerns common to people suffering from diabetes, providing them with the tools to manage the impact Diabetes has on their lives, emotions and health. Available in English and Spanish. Learn More
- Chronic Pain Self-Management Program focuses on managing common symptoms suffered by people who have a primary or secondary diagnosis of chronic pain, providing them different tools and techniques used to manage the impact chronic pain has on their lives. Learn More
- Cancer: Thriving and Surviving focuses on providing cancer survivors the tools to manage the impact this disease has on their overall health. Learn More
University of Washington and Senior Services of Seattle:
- Enhance Wellness is a one-on-one patient activation program with a motivational intervention that can help an individual to deal with barriers for self-management, such as fear of falling or depression. Learn More
Falls Prevention Programs
According to the Centers for Disease Control (CDC), older adults had 2.5 million nonfatal falls in 2013 and more than 734,000 were hospitalized due to a fall. By 2012, the direct medical cost of falls, which includes insurance companies, nurse care, doctors and other professionals, medication, as well as other needs, were $30 billion.
The CDC STEADI algorithm provides the framework for ensuring multiple risks factors are addressed and a targeted approach to education, physical activation and strength and balance training is prescribed.
Menu of evidence-based programs:
- A Matter of Balance: Managing Concerns About Falls is an evidence-based program designed to reduce the fear of falling and increase activity levels among older adults. The program is provided to individuals in small groups at a variety of community centers. Learn More
- OTAGO is an evidence-based, individually tailored strength and balance training home-based program led by a physical therapist to help prevent falls in older adults. Learn More
- Tai Chi for Arthritis for Fall Prevention is an evidence-based, gentle exercise regimen to improve balance, confidence, muscular strength, mobility, and physical performance to prevent falls in older adults and individuals with balance disorders. The program is provided to individuals in small groups at a variety of community centers. Learn More
- EnhanceFitness (group exercise offered by the YMCA, parks and recreation programs and others around the state) EnhanceFitness, a low-cost, evidence-based group exercise program, helps older adults at all levels of fitness become more active, energized and empowered to sustain independent lives. Learn More
Other self-led physical activation programs available to our clients:
- Go4Life, an exercise and physical activity program developed by the National Institute on Aging, (NIA), focuses on incorporating the four basic categories, endurance, strength, balance and flexibility, into older adults exercises. Learn More
- Walk With Ease, an evidence-based program developed by the Arthritis Foundation, teaches older adults how to safely make physical activity part of their everyday life if they need relief from the pain or just want to be active. Learn More
According to the CDC, depression is characterized by depressed or sad mood, diminished interest in activities, which used to be pleasurable, weight gain or loss, psychomotor agitation or retardation, fatigue, inappropriate guilt, difficulties concentrating, as well as recurrent thoughts of death.
According to the World Health Organization (WHO), depression was the third most important cause of disease burden worldwide in 2004. The CDC states that, approximately 7.7% of adults age 50 or older reported current depression, and 15.7% reported a lifetime diagnosis of depression. Learn more here.
Depression is more common in people who also have other illnesses (such as heart disease or cancer) or whose function becomes limited, therefore older adults are at an increased risk for experiencing depression, since 80% of older adults have at least one chronic health condition, and 50% have two or more. Learn more
Consequently, depression is a true and treatable medical condition, which can be controlled through evidence-based patient activation programs in community settings.
- PEARLS (Program for Encouraging Active Rewarding Lives): empowers people through behavioral techniques (problem solving, social, and physical activation) and scheduling enjoyable activities to reduce depression and improve their quality of life. Learn More