Patient Centred Medical Home Readiness Program

Transcription

1 Module/workshop title: Patient Centred Medical Home Readiness Program Facilitated by: Australian Practice Nurses Association (APNA) Current as at 29/03/2018

2 For more information, contact: Cairns p: (07) Townsville p: (07) Mackay p: (07) e: w: primaryhealth.com.au Northern Queensland Primary Health Network acknowledges the Traditional Custodians of the lands and seas on which we live and work, and pay our respects to Elders past and present. 2

3 Patient Centred Medical Home Readiness Program SYNOPSIS Alignment with Bodenheimer s 10 Building Blocks of High Performing Primary Care Block 4: Team-based care Block 5: Patient-team partnership 8 10 Quality general practice of the future 9 Prompt access to care Comprehensiveness and care coordination Patient-team partnership Population management Continuity of care Engaged leadership Data-driven improvement Patient empanelment Team-based care Patient Centred Medical Home (PCMH) Readiness Program This program primarily focuses on system change and clinical education to support the general practice team to adapt and develop their chronic disease models of care to a more co-ordinated and teambased approach. Who should attend? Practice nurses Medical assistants Benefits of education Participants of the workshop will have the opportunity to strengthen their current skills and knowledge while preparing for the coming changes in relation to health reform. Attendees will gain skills to adapt and implement system change, and clinical education in regards to chronic disease management and a team-based, co-ordinated approach to chronic care. 3

4 Delivery mode(s) Mixed methods of delivery will be offered for this program, with the primary focus on an initial twoday face-to-face workshop, providing participants with the skills, knowledge, and abilities to provide an evidence-based, co-ordinated, multidisciplinary, patient-centred model of care. This includes: planning for team-based care roles and responsibilities change management and implementation care co-ordination and process mapping of care models upskilling in chronic disease management. In addition to the initial workshop, participants will be able to engage in online self-paced learning modules that may include: change management planning and team engagement clinical care models chronic disease management care planning health coaching and motivational interviewing care co-ordination clinical skills for chronic disease management. Workshop dates Cairns Tablelands Townsville Mackay WORKSHOP 1 Tuesday 13 March 2018 WORKSHOP 1 Thursday 21 June 2018 WORKSHOP 1 Tuesday 20 March 2018 WORKSHOP 1 Tuesday 27 March 2018 Wednesday 14 March 2018 Friday 22 June 2018 Wednesday 21 March 2018 Wednesday 28 March WORKSHOP 2 Tuesday 19 June 2018 WORKSHOP 2 Thursday 21 June 2018 WORKSHOP 2 Tuesday 12 June 2018 WORKSHOP 2 Tuesday 5 June 2018 Wednesday 20 June 2018 Friday 22 June 2018 Wednesday 13 June 2018 Wednesday 6 June Online training registration available for practice nurses only (limited numbers available). Registrations for Workshop 1 are now open for Cairns, Tablelands, Townsville, and Mackay. Follow the above links to register. Times have been scheduled to allow travel either side of workshop for those coming from outlying areas. 4

5 Patient Centred Medical Home Readiness Program SYNOPSIS Program outline Workshops Learning outcomes Participants will gain a comprehensive understanding of all the elements that are required to effectively implement new models of care with a specific focus on nurse-delivered, team-based care (nurse clinics). Training will be delivered in a workshop/active engagement model. Participants will be able to work through the learning topics through application to their own environment (i.e. we want to implement a diabetes management clinic) or they will be given a case study/scenario to work through. Start End Topics 10am 10.15am Welcome and setting the scene 10.15am 11.30am A clear plan identify the health care need creating the business case/plan aims and objectives clinic models am 1pm Clinical capability clinical/healthcare capability evidence-based care clinical guidelines. Funding Different types of funding available and how they apply to clinics. Patient engagement patient pathways creating appointments reminders and recalls promoting the clinic. 1pm 1.30pm Lunch 1.30pm 3pm Staffing and Human Resources (HR) roles and responsibilities/hr professional development work as a broader team formulating relationships change management. Supporting systems and process booking systems referrals patient registers forms and policies data management Location and facilities physical space clinic operating times equipment. 5

6 Workshops (continued) Learning outcomes At the end of day 2, participants will have a greater understanding of the skills and application of comprehensive care planning and care coordination that utilises a patient-centred care (health coaching) approach. The topics on day 2 will be framed by chronic disease conditions to help embed and support the practical application of the content. The proposed conditions will be coronary heart disease and chronic obstructive pulmonary disease. These conditions have been selected based on the chronic disease prevalence data noted in the NQPHN Health Needs Assessment. Start End Topics 8.30am 9.30am Re-framing the delivery of care planning and care coordination in a changing landscape looking at the big picture socioeconomic factors and considerations why we need to re-frame care delivery evidence for implementing behaviour change strategies in care planning and care coordination financing facilitation of behaviour change tips and tricks. 9.30am 10.30am Facilitating behaviour change in care planning and care coordination key considerations and principles of behaviour change in a care planning and coordination setting frameworks to facilitate behaviour change what and how to use balancing requirements and needs of all involved am 10.40am Morning tea 10.50am 12.30pm Future proofing care planning and care coordination building and maintaining patient engagement/buy in setbacks/barriers and common issues practical application what would facilitating behaviour change look like in practice? future developments in the care coordination team pm 1pm Lunch/close Online learning Australian Practice Nurses Australia s (APNA s) Online Learning Portal has over 100 learning modules. As part of this this program, NQPHN will provide support for practice nurses who are participants in the readiness program with access to this package of 39 online learning modules for a 12 month period. The learning modules range in length from one hour to twelve hours, with the majority of modules being one hour. In this training, APNA would provide a synopsis and overview of the online learning content, enabling the NQPHN practice support team to identify and guide participants to content that is able to meet their needs, based on the individual needs of the participants. APNA has costed this training as a series of three webinars over 12 months. 6

7 Patient Centred Medical Home Readiness Program SYNOPSIS Below are examples of online learning modules: Topic Change management Planning and team engagement Clinical care models, chronic disease management Role of general practice nurses Health coaching/ motivational interviewing/ self management Care Planning/ Care coordination/ case conferencing Health literacy and patient care Online learning modules Building resilience Why behavioural change communication is core nursing business Facilitating behaviour change Developing an Australian Health Leadership Framework What is leadership Leadership in action Building effective teams in primary health care Leading change in chronic disease management What do consumers want from primary health care Lifestyle medicine: its value in practice nursing Chronic disease, mental health, socioeconomic disadvantage, where do we begin? Understanding quality improvement in primary health care Obesity, chronic disease and fertility Living with COPD: The frequent attenders perspectives Lifestyle risk communication by nurses in primary care: an integrative review Cardiovascular disease risk assessment and management Nurse-led clinics in the UK sharing experiences with Australia Scope of practice General practice financing Opportunities for practice nurses Developing a positive patient experience with nurses in general practice Immunisation in the general practice setting An orientation for nurses new to general practice Leading the change nurses as role models for primary health Opportunities for practice nurses Integrating health self-management support and peer support in CDM Facilitating behaviour change The impact of nurse-led CDM the patient s perspective Planned assessment in primary health care Health promotion and preventative care in primary health care Population health for nurses in general practice Helping people to thrive in the face of co-ocurring illness Chronic disease, mental health, socioeconomic disadvantage, where do we begin? Why behavioural change communication is core nursing business Telehealth the changing way we care for patients Person centred care planning Health literacy improving communication and participation in health and health care delivery What do consumers want from primary health care Communication in primary health care Consumer perspectives disease associated with chronic conditions Management of obesity and health literacy in general practice 7

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