Practice Support Program Chronic Disease Management Session

1
Practice Support ProgramChronic Disease
Management Session 2

• November 7, 2007 North Shore
• November 8, 2007 - Vancouver

2
Chronic Disease Management-CDM

• Co-facilitated by
• Dean Brown (North Shore)
• James Lai (Vancouver)
• Cheryl Rivard
• Brian Evoy
• Guest Speaker
• Marshall Dahl
• VCH PSP Staff
• Sabrina Kang Elaine Grenon
• Karen Arthurs Bethina Abrahams
• Linda Hopkins April Lewis
• Jo Kontogiannis Bal Lasher
• Toby Kirshin

3
Agenda

• Welcome review CDM learning session
• Action period feedback
• Small Group Work Running reports
• Marshall Dahl CDM in BC Improving Diabetes
  Outcomes
• Small group work Action plan update
• Wrap up information on Self Management module

4
Learning Session Goals/Objectives

• Review how to run Toolkit reports
• Practice reading and analyzing Toolkit reports
• Attend to office visit productivity
• Examine Cardiovascular risk reduction
• Update Action period plans

5
CDM Module Components

• Develop patient registry
• Adopt CDM Toolkit
• Implement planned recall

6
Funding for CDM Action Periods
7
Funding for CDM Module Learning Sessions

• Eight Learning Sessions
• GP Session x 8 3,074.78
• MOA 32 hrs x 20 640.00
• Four Action Periods 4,946.94
• Potential Total 8,661.72

8
Action Period One

• Access to the CDM toolkit
• Select a population
• Apply for and install Patient Profile
• Populate your registry
• Try running a report (e.g. recall)

9
PDSA Cycle Feedback
10
Small Group Discussion Team Reports
11
Paul Wong MD

• Our Team
• Dr. Paul Wong
• Sandi Smith, MOA

12
Our Goals

• Download Digital Certificate
• Upload Physician Profile
• Enter Baseline Data for 61 Diabetic Patients

13
Accomplishments

• Downloaded Digital Certificate
• Uploaded Physician Profile
• Sandi is doing entry with bonus per entry plus
  time spent on entry
• Entered 61 Diabetic Patients Baseline Data

14
Barriers

• ?????

15
Christopher Ryan MD

• Our Team
• Dr. C. Ryan
• Jean OClery, MOA
• Christina, Data Entry Clerk

16
Our Goals

• Download Digital Certificate
• Upload Physician Profile
• Enter Baseline Data for 20 Diabetic Patients

17
Accomplishments

• Downloaded Digital Certificate
• Uploaded Physician Profile
• Hired and Trained Data Entry Clerk
• Entered 30 Diabetic Patients Baseline Data

18
Barriers

• Data is recorded in multiple locations in chart
• Data Entry Clerk worked primarily after hours

19
Generate Reports
20
(No Transcript)
21
(No Transcript)
22
(No Transcript)
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Xs and Os
24
Run Charts
25
(No Transcript)
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(No Transcript)
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Change Date to Baseline
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How to read a Run Chart
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(No Transcript)
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A1C
31
LDL
32
BP
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Team Activity

• How many patients have completed their Hemoglobin
  A1C blood test? PAGE 1
• What of patients have had a blood pressure
  completed in October 2007? PAGE 2
• What of patients had an HgA1c less than 7.0 in
  July 2007? PAGE 3
• What is total number of patients in your
  population?
• PAGE 4

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• How many patient have completed their Hemoglobin
  A1C blood test? Answer 9
• What of patients have had a blood pressure
  completed in October 2007?
• What of patients had an HgA1c less than 7.0 in
  July 2007?
• What is total number of patients in your
  population?

35

• How many patients have completed their Hemoglobin
  A1C blood test?
• What of patients have had a blood pressure
  completed in October 2007? Answer 82 (81.82)
• What of patients had an HgA1c less than 7.0 in
  July 2007
• What is total number of patients in your
  population?

36

• How many patients have completed their Hemoglobin
  A1C blood test?
• What of patients have had a blood pressure
  completed in October 2007?
• What of patients had an HgA1c less than 7.0 in
  July 2007? Answer 40
• What is total number of patients in your
  population?

37

• How many patients have completed their Hemoglobin
  A1C blood test?
• What of patients have had a blood pressure
  completed in October 2007?
• What of patients had an HgA1c less than 7.0 in
  July 2007?
• What is total number of patients in your
  population? Answer 55

38
BREAK
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Dr. Marshall Dahl
40
Action Period Work Plan Update
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Action Period Report Storyboard
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Next Steps

• Populate your registry (if not already complete)
• Establish your baseline
• Workflow Consider the best way to keep your
  toolkit up-to-date
• Prepare to perform your first planned recall in
  Action Period 3
• Call PSP team for support 604.875.4001

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Self-Management Slides

• Important element of the CDM flow sheets
• Examine the benefits of self-management for
  patients the health care team
• Learn approaches for supporting self-management,
  including
• the 5 As
• motivational interviewing
• patient action plans
• Conduct consistent patient evaluation and
  follow-up of self-management plans
• Examine the impact self-management will have on
  your billing
• Very interactive including role plays
• Gain 14 MAINPRO-M1 Credits (3.5 per session)

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Patient Self-Management Pathway

• Refine expand process
• Followup with previous pts
• Try it with a few more pts
• Problem solve with practice staff
• Troubleshoot issues w PS Team

Ongoing Support
Getting Started

• Refine expand process
• Followup with previous pts
• Try it with a few more pts
• Problem solve with practice staff
• Troubleshoot issues w PS Team

• Try it with a few patients (5-10)
• Problem solve with practice staff
• Troubleshoot issues w PS Team

LS3
AP3
LS1
AP2
Ongoing
LS4
LS2
Prework
AP1
Month 9-12
Month 0

• Share experiences (good bad) w peers
• Refine communication skills
• Troubleshoot issues
• Update action plan

• Share experiences
• Learn new pt educ support skills
• Troubleshoot issues
• Update action plan

• Share experiences
• Troubleshoot issues for sustainability
  improvement
• Discuss next steps

• Learn new clinical skills
• Learn how to help pts set their own goals
• Learn new pt educ support skills
• Develop an action plan

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Patient Self-Management
Learning Sessions
Action Periods
Potential Total 3,586.65
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How To Sign Up

• Speak to any PSP staff today
• Sign up at the front desk today
• Call PSP team for support 604.875.4001