An Overview of the Alberta Screening & Prevention Initiative

Improvement Facilitator Training Session 1 Day 1

Objectives

• Overview of TOP • The Origins of ASaP• The ASaP Opportunity• The Benefits of ASaP• The ASaP Intervention • Improvement Facilitator Support• The Medical Home

Toward Optimized Practice

• Clinical Practice Guideline Program

• Clinical Process Improvement Program/s – Customized – Targeted

initiatives

The Origins of ASaP

National Context– Council of

Federation Health Innovation Initiative Working Group

– C – Change Cardiovascular Harmonized National Guideline Endeavour

Alberta Context – Integrated clinics

project – Pharmacy project – Worksite project

– ASaP project in partnership with key organizations

AHS

TOP

The ASaP Partnerships A7

Why ASaP?

• Family physicians do an outstanding job of screening individual patients during focused screening visits.

• The challenge is more than one-third of patients simply do not “self-present.”

• The majority of these patients are attached to physicians

• Evidence says the most effective behavior change tool is an invite from their primary care provider and team to complete screening

• There are a number of physicians in Alberta who have tried opportunistic and/or outreach engagement of patients for screening – it works !

• Methods are time and cost effective• ASaP will bring those methods to PCNs for PCNs to

provide to participating clinics

A2

The ASaP Opportunity

The ASaP Initiative is focused on supporting primary care providers ( physicians and nurse practitioners) and team members to offer a screening and prevention bundle to all their patients through enhanced opportunistic and planned outreach methods, targeting patients who do not present for screening care.

Maneuvers Menu for AdultsManeuver Age (years) Interval

Blood Pressure 18+ Annual Weight 18+ AnnualHeight 18+ Once lifetimeExercise Assessment 18+ AnnualTobacco Use Assessment 18+ AnnualAlcohol Use Assessment 18+ AnnualInfluenza Vaccination/ Screen 18+ AnnualPap Test Females 21 – 69 3 years

Plasma Lipid ProfileMales 40 – 74

Females 50 – 74 3 years

CV Risk CalculationMales 40 – 74

Females 50 – 74 3 years

Diabetes ScreenOne of:- Fasting Glucose- Hgb A1c- Diabetes Risk Calculator

40+ 3 years

Colorectal Cancer ScreenOne of:- FOBT/FIT- Flex Sigmoidoscopy- Colonoscopy

50 – 74

  2 years5 years10 years

Mammography Females 50 - 69 (74*) 2 years

A3

Practice Points

Maneuver Practice Points

Blood PressureUse automated B/P cuffs when possible and complete more than one readingThe evidence does not define an interval; recommends at “every appropriate visit”

Height & WeightHeight & Weight are useful when using risk calculators & determining osteoporosis risk. If patient is obese, see ACFP Tools for Practice 2011 Is any diet better for weight loss or preventing negative health outcomes? http://www.acfp.ca/Portals/0/docs/TFP/20111028_101605.pdf

Exercise Assessment

For evidence based intervention ACFP Tools for Practice 2009 Motivating Patients to Move: A Light at the end of the Couch? http://www.acfp.ca/Portals/0/docs/TFP/20111028_111954.pdf Canadian Physical Activity Guideline 2011: Recommend 150+ minutes per week, with bouts of 10 minutes of vigorous activity. No upper age limit; those over age 64 with poor mobility should perform physical activities to enhance balance and prevent falls. http://www.csep.ca/CMFiles/Guidelines/CSEP-InfoSheetsComplete-ENG.pdf

Tobacco Use Assessment

Tobacco use includes all forms including smokeless tobacco Evidence recommends that tobacco assessment commence at age 12 years; evidence does not define an interval

Alcohol Use Assessment

The AHS Addiction and Mental Health Strategic Clinical Network recommends the use of the following approach taken by British Columbia for primary care physicians: http://www.bcguidelines.ca/pdf/problem_drinking.pdfEvidence does not define an interval

Influenza Vaccination/ Screen

Pneumococcal vaccination is recommended once for all adults 65+ years; available at time of influenza vaccination.Influenza vaccine recommended annually for Albertans of all ages (free of charge)

Pap TestSome new guidelines recommend pap testing starting at age 25 yearsRemember to assess based on reported sexual activity and start tests once sexually active Evidence recommends 3 negative tests in 5 years, then every 3 years

Plasma Lipid Profile

Start males at age 40; females at age 50 or age 40 if post-menopausalCanadian Cardiovascular Society 2013: Recommends a 3-5 year interval for those with a Framingham risk score <5%, annual for those at higher risk. http://www.onlinecjc.ca/article/S0828-282X%2812%2901510-3/fulltext

Cardiovascular Risk Calculation

Highly recommended practice for determining CV risk using any accepted tool: Canadian CV Society recommends FraminghamCV risk tool is embedded in all Alberta qualified EMRsCanadian Cardiovascular Society 2013: Recommends a cardiovascular risk assessment, using the 10-Year Risk provided by the Framingham model be completed every 3-5 year. Screen more frequently if at high risk. http://www.onlinecjc.ca/article/S0828-282X%2812%2901510-3/fulltext

Diabetes Screen- Fasting Glucose OR- Hgb A1c OR- Diabetes Risk

Calculator

Recommended to use a Diabetes Risk Calculator (e.g. CANRISK, FINDRISC)Canadian Task Force on Preventive Health Care 2012: Does not recommend routine screening for Type 2 diabetes for adults at low to moderate risk of diabetes as determined with a validated risk calculator. http://www.cmaj.ca/content/184/15/1687

Colorectal Cancer Screen- FOBT/FIT OR- Flex

Sigmoidoscopy OR- Colonoscopy

FIT test proposed to be available fall 2013

Mammography*New guidelines recommend mammography for women to age 74 years Clinical Breast Examination not indicated in conjunction with mammography

Benefits of ASaP to Primary Care Providers & Their Teams

• Customized screening processes

• Patient panel processes and lists

• Enhance role of teams & EMR

• Improvement Tools & Resources

A2

Benefits of ASaP to Primary Care Organizations

• Practice Facilitation Identification & Training

• EMR support • Improvement

Results reported for providers, clinic and PCO

• Access to QI training Tools and resources

A2

How will this occur?

• Toward Optimized Practice will offer training, tools and resources to identified facilitators within primary care networks to support the screening and prevention improvements.

• Following training, primary care organizations will:– engage physicians to participate – offer practice facilitation to primary care

providers and team members to support the development of customized processes at the primary care organization and/or

clinic levels.

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The ASaP Intervention

Panel Identificatio

n

Focused Improvemen

t

Build on Success

Document process to ID patient/provider attachment

Generate patient lists for screening

Choose + document screening methods:

opportunistic and/or outreach

Choose + document screening maneuvers

Define & document team roles & responsibilities

Test small change (PDSA)

Standardize processes

Measure reliability of processes

Apply for CME credits

Identify other clinical improvement opportunities

Baseline Chart Review & Current Screening Process Assessment

4-Month Follow Up Chart Review & Screening Process Assessment

Sustainability Chart Review & Continued Follow-up Reviews

30 days

60 days

Ongoing

A6

14

Improvement Facilitator Training

Improvement Facilitator –

Building PCN Quality Improvement (QI)

Knowledge and Capacity

TOP Clinical Process Advisor•Designated QI support

specialist

Quality Improvement

Training in Cohort

•2+1+1 = 4 days face-to-face

•Cohort Webinars

Community of Learning

• Training Cohort• Other Cohorts• QI community

building

QI Knowledge Resources•Institute for

Healthcare Improvement (IHI):

Open School•Other resources

Electronic Medical Record

Knowledge Resources•Screening and

prevention

H4

PCN will be invited to • Identify improvement facilitators who will be

provided with the resources and mentorship to support clinics and primary care organizations implementing this initiative.

• Participate in planning and implementation activities to locally select changes to maximize screening and prevention methods and results.

• Participate in planning and implementation activities to support emerging communities of practice in facilitation and EMR use.

• Coordinate and deliver, with support, physician engagement events.

• Identify staff members who will receive resources, tools and methods to conduct standardized chart reviews.

Benefits of ASaP to Albertans

• Improve screening offers

• Improve early detection

• Progress toward patient-centred medical home

A2

The Medical Home A9

What is the difference between a medical

home and a medical hotel?

In your home, someone cares about you

even when you are not in their room.

Primary Care Sustainable Results for Active Participation in ASaP

A10