Shared Care COPD/Heart Failure Learning Plan

Transcription

1 Shared System of Care /HF Shared Care /Heart Failure Learning Plan Overriding Goals To improve the comfort and confidence of family physicians in diagnosing and treating their patients with and Heart Failure. To improve the quality of patient care available in non-specialized general practice for adults with and/or Heart Failure either as a primary diagnosis or comorbid with other health problems and chronic diseases. This will be accomplished by the use of tools that engage the patient in shared partnership and that lead to correct diagnosis and management of their condition. This will be measured by qualitative surveys and symptom and function changes. Learning Outcomes By the end of the implementation, participants will be able to 1. Use assessment tools to identify patients with possible and/or Heart Failure 2. Use evidence based treatment strategies for management of patients with HF and 3. Be aware of available HF and patient education tools and understand how to access and utilize them in their practices 4. Access available HF and resources and utilize them in their practices 5. Describe the indication for referring a patient to a heart function clinic, internist or cardiologist 6. Describe the indication for referring a patient to a respirologist or pulmonary therapist 7. Describe the roles of various diagnostic tests in the overall care plan for patients with HF and 8. Identify opportunities for shared care and opportunities to create practice efficiency in caring for patients with HF and Key Messages in this program include 1. Heart Failure and are typically under-identified and under-diagnosed. 2. A large percentage of patients with mild to moderate Heart Failure and can be effectively managed in primary care. 3. Heart Failure and are often co-morbid in a patient. 4. Appropriate pharmacotherapy can improve quality of life in patients with and Heart Failure. 5. Engaging and supporting patient self-management is a key enabler in chronic disease management. 6. It s not all up to you. Heart Failure and are chronic conditions and cannot be fixed but can be managed more easily with shared responsibility, patient engagement and negotiation. SCHF_PSP_Collaborative_Pathway_ COMBINED_2016_ of 1

2 Learning Session Outlines Learning Session 1 (3.5 hours): Introductions (15, include 5 for discussion) Opening remarks from family physician, Housekeeping, overview to PSP Module expectations with a poll/table discussions. Include Action Period Requirements. Patient Story or Video Clip (15) Core Content 101 (25) Local respiratory services (10, including 5 didactic + 5 questions) -6 training (30, 10 didactic + 20 trying it out) QuitNow (5) Integrate into the workflow discussion (10) Break (15) Heart Failure 101 (40) Local HF clinic services (15, including 10 didactic + 5 questions) Integrate into the workflow discussion HF (10) Action Planning Expectations (5) Reinforce deliverables: including average time spent for 6 per patient Action Period funding, support, requirements Engage MOA in data collection e.g. fax back weekly and registry Planning for the action period including evaluation (15): Action Period 1 Minimum Requirements 1. Create and HF Registries o Total patients on registry and on HF registry 2. Casefinding and testing with -6 device # patients Document FEV1 per patient visit. 3. Referred for Ejection Fraction or BNP Diagnostic testing - # patients y out a practice change with a respirologist /cardiologist/ internist regarding the referral and consult process. Learning Session 2 (3.5 hours): Action Period 2 Minimum Requirements Introduction Sharing AP review, set stage for next AP, success and lessons learned (35) Sharing Experiences (10) Core content: (130 min) Medication for both and HF (60, 40 didactic + 20 discussion) MOA break out: office flow, support smoking cessation, PSM, resources, education around HF, Ebsworth Scale, sleep apnea Break (15) PSM Support (70 min, 45 diadactic + 25 other) and AE Management (30, 20 didactic + 10 questions) Heart Zones and other PSM tools (30, questions) Smoking cessation (10, 5 didactice + 5 questions) Sharing the care with the specialist and referral process maybe Partners in Care Planning for Action Period 2, including evaluation (20): Smoking cessation interventions with patients # patients Patients with an exascerbation plan # patients HF patients who bring selfmanagement goal logs or who have been Rx ACE/ARBs or Beta Blockers # patients Review medications for and HF patients Learning Session 3 (3.5 hours): Co morbidity Intro (5) - handout evaluation form at beginning or at break; mention that they could mail it in. Sharing success and lessons learned HF and (60): Co-morbid Patient Story: (10) Core material: Comorbid patients (60, 40 didactic discussion ) o How to differentiate between HF and o o Comorbidity management) Sharing the care with the specialist, referral and resources (15, 10 didactic + 5 facilitated discussion) Optional: End of Life HF/ e.g. palliative sp Break (15) Planning for Sustainability (30, 15 didactic + 15 discussion): Wrap up (30 mostly evaluation and goal setting) Handout on billing codes MOA: tools for HF patients SCHF_PSP_Collaborative_Pathway_ COMBINED_2016_ of 7

3 Instructional Plan for /Heart Failure Outcome How to assess? How to teach? Resources needed? 1. Use assessment tools to identify patients with possible and/or Heart Failure 2. Use evidence based treatment strategies for management of patients with HF and Demonstrate use management pathways of and HF algorithms and/or EMR Templates Demonstrate use of 6 for screening Demonstrate use management pathways of and HF algorithms and/or EMR Templates Pre LS1 place algorithm on computer Install EMR templates on user computer and locate and identify as favorites as necessary Case based scavenger hunt using algorithm Paired practice with 6 Pre visit see note below table** Lecture Small group activities Office Computer Laptop for Learning Sessions Case studies for algorithm practice 6 with mouthpieces/nasal clips and laminated instruction sheets Office computer Lap top for Learning Sessions Case studies, tool practice 3. Be aware of available HF and patient education tools and understand how to access and utilize them in their practices Patient Handouts - Demonstrate ability to access tools in Algorithm Demonstrate use of Brief Action Planning and other Self-Management tools based on patient handouts Lecture Paired activity Lecture/video Case study with hidden info that requires elicitation Sheet of all patient handouts Copies of Patient Handouts?? Internet access if EMR being used Hidden info answers CCMI 2x2 Matrix BAP and Action period forms 4. Access available HF and practice resources and utilize them in their practices 5. Describe the indication for referring a patient to a heart function clinic, internist or cardiologist 6. Describe the indication for referring a patient to a respirologist or pulmonary therapist 7. Describe the roles of various diagnostic tests in the overall care plan for patients with HF and 8. Identify opportunities for shared care and opportunities to create practice efficiency in caring for patients with HF and MOA report Report from Coach Sharing experiences at next learning Sharing experience at next learning Coach report Sharing experience at next learning Coach report Sharing experience at next learning Coach report Lecture(s) rapid fire resource presentations Resource tables at back or side of venue Lecture, examples Specialist representatives Lecture, examples Specialist representatives Lecture/video Case study with hidden info that requires elicitation Sheet of all resources Internet access to all tools Resource representatives with presentations Timer Tables for Resource representatives Referral tool Referral tool CCMI 2x2 Matrix BAP and Action period forms **Pre-visit 1. 6 question survey of barriers desires encountered by family docs, 2. Orientation to Algorithm demonstrating location of tools on algorithm 3. confirmation of use of EMR 4. Setting up templates in EMR download, accessibility, favorites for workflow SCHF_PSP_Collaborative_Pathway_ COMBINED_2016_ of 7

4 First Learning Session (3.5 hrs) tion Period 1 Second Learning Session (3.5hrs) Action Period 2 Third Learning Session 3 (3.5 hours) Use assessment tools to identify patients with possible and/or Heart Failure Describe the roles of various diagnostic tests in the overall care plan for patients with HF and Use evidence based treatment strategies for management of patients with HF and Access available HF and resources and utilize them in their practices Describe the indication for referring a patient to a respirologist of pulmonary therapist Decribe the indication for referring a patient to a heart function clinic, internist or cardiologist Use assessment tools to identify patients with possible and/or Heart Failure: create and Heart Failure Registries Use 6 to identify adults who may have. Refer appropriately for spirometry to diagnose Refer appropriately for Echocardiogram and/or BNP to diagnose Heart Failure Integrate /HF tools and resources into an effective work flow Use evidence based treatment strategies for management of patients with HF and Integrate /HF tools and resources into an effective work flow Use appropriate tools to assess and plan a management strategy and treat patients with mild to moderate and Heart Failure Utilize the /HF hyperlinked algorithm to access all tools on your computer or EMR Use smoking cessation interventions with patients Develop acute exacerbations plans for patients Use self-management goal logs for HF patients Review medications for and HF patients Report increased comfort and confidence in dealing with patients with and HF Identify opportunities for shared care and opportunities to create practice efficiency in caring for patients with HF and Learning Session Activities PDSA Action Period 1: Learning Session Activities PDSA Action Period 2: Learning Session Activities 1. Introductions 2. Patient Story 3. Core Content 4. Local Respiratory services 5. 6 Training 6. Smoking Cessation Strategies Quit Now 7. Core Content HF 8. Local heart failure services 9. Action Period planning 1. Create Registry 2. Create HF Registry 3. Use 6 device for eligible patients 4. Refer patients for further assessment where appropriate 5. Refer HF patients for further assessment where appropriate 1. Sharing experiences 2. Medication management for 3. Medication management for HF 4. Case?? 5. MOA Breakout during 2 & 3 6. Smoking cessation strategies 7. Action Planning for AP2 1. Use smoking cessation strategies with patients 2. Develop Acute Exacerbation Plan and self-management goals with patients with 3. Develop Acute Exacerbation Plan and self-management goals with patients with HF 4. Review medications for and HF patients 1. Sharing experiences 2. Report from coach 3. AE Rx related to case 4. AEHF Rx related to case 5. Physician and Advocate Perspective 6. Break 7. Sustainability and improvement tips 8. Community Resource Café 9. Sustainability plan 10. Wrap up, evaluations SCHF_PSP_Collaborative_Pathway_ COMBINED_2016_ of 7

5 First Learning Session (3.5 hrs) Learning Objectives: Use assessment tools to identify patients with possible and/or Heart Failure Describe the roles of various diagnostic tests in the overall care plan for patients with HF and Use evidence based treatment strategies for management of patients with HF and Access available HF and resources and utilize them in their practices Describe the indication for referring a patient to a respirologist of pulmonary therapist Decribe the indication for referring a patient to a heart function clinic, internist or cardiologist Time Learning Session Activities Delivery Format 15 min Introductions (15, include 5 for discussion) /intro Opening remarks from family physician, Housekeeping, overview to PSP Module expectations with a poll/table discussions. Include Action Discussion Period Requirements. 15 min Patient Story or Video Clip 70 min Core Content 101 (25) Story telling Local respiratory services (10, including 5 didactic + 5 questions) -6 training (30, 10 didactic + 20 trying it out) QuitNow (5) Integrate into the workflow discussion (10) 15 min Break (15) Paired practice, activity debrief Think-pair-sharing 65 min 5 min Heart Failure 101 (40) Local HF clinic services (15, including 10 didactic + 5 questions) Integrate into the workflow discussion HF (10) Action Planning Expectations (5) Reinforce deliverables: including average time spent for 6 per patient Action Period funding, support, requirements Engage MOA in data collection e.g. fax back weekly and registry Facilitated table discussions Table brainstorming 25 min Planning for the action period including evaluation (15): 210 min Assessment: Activity debrief, how many docs selected appropriate tools on the algorithm Exit survey re impact of physician and patient advocate stories SCHF_PSP_Collaborative_Pathway_ COMBINED_2016_ of 7

6 Second Learning Session (3.5 hrs) Learning Objectives: Use evidence based treatment strategies for management of patients with HF and Integrate /HF tools and resources into an effective work flow Use appropriate tools to assess and plan a management strategy and treat patients with mild to moderate and Heart Failure Time Learning Session Activities Delivery Format 45 min Introduction Sharing AP review, set stage for next AP, success and lessons learned (35) /intro 60 min Core content: Sharing Experiences (10) Medication for both and HF (60, 40 didactic + 20 discussion) MOA break out: office flow, support smoking cessation, PSM, resources, education around HF, Ebsworth Scale, sleep apnea Table discussion re office experiences. 1 min each. Case presentation Small group activities, activity debrief 15 min Break (15) 70 min PSM Support and AE Management (30, 20 didactic + 10 questions) Heart Zones and other PSM tools (30, questions) Smoking cessation (10, 5 didactice + 5 questions) Sharing the care with the specialist and referral process maybe Partners in Care 20 min Planning for the action period including evaluation (20) then room questions Small group activity role playing 210 min Assessment: Activity debrief, how many docs selected appropriate tools on the algorithm Exit survey re impact of physician and patient advocate stories SCHF_PSP_Collaborative_Pathway_ COMBINED_2016_ of 7

7 Third Learning Session (3.5 hrs) Learning Objectives: Report increased comfort and confidence in dealing with patients with and HF Identify opportunities for shared care and opportunities to create practice efficiency in caring for patients with HF and Time Learning Session Activities Delivery Format 75 min Intro (5) - handout evaluation form at beginning or at break; mention that they could mail it in. Sharing success and lessons learned HF and (60): Co-morbid Patient Story: (10) 75 min Core material: Comorbid patients (60, 40 didactic + 20 discussion ) o How to differentiate between HF and o Comorbidity management) o Sharing the care with the specialist, referral and resources (15, 10 didactic + 5 facilitated discussion) /intro Room Discussion Think-Pair-Share then Mini-writes 15 min Break (15) Optional: End of Life HF/ e.g. palliative specialist 45 min Planning for Sustainability (30, 15 didactic + 15 discussion): Wrap up (15 mostly evaluation and goal setting) Handout on billing codes MOA: tools for HF patients Room questions Mini-Writes 210 min Assessment: Activity debrief, how many docs selected appropriate tools on the algorithm Exit survey re impact of physician and patient advocate stories SCHF_PSP_Collaborative_Pathway_ COMBINED_2016_ of 7