Greater Trail Seniors-at-Risk Initiative€¦ · Web viewThe registry is a basic part of the clinical information system that will inform the clinical care team’s practice redesign

“Working together for better care.”

COPD Service Framework - Physician Collaborative

Pre-Work Package

Improving the care of patients with Chronic Obstructive Pulmonary Disease:

Implementation of the COPD Service Framework

__________________________________________________________________________COPD Service Framework Physician CollaborativePre-work package for Clinical Care Teams, May 2007

1

COPD Service Framework – Physician CollaborativePre-work package for Clinical Care Teams

ContentsOverview 31. The aim, vision and approach of the Initiative

1.1 The Aim of the Initiative1.2 Vision1.3 Summary of the Approach

4444

2. Formation of and Support for Clinical Care Teams 2.1 Support and guidance for Clinical Care Teams2.2 Clinical Care Teams2.3 Reimbursement and payment for Clinical Care Teams2.4 Continuing Education2.5 Expectations of Initiative Partners

555666

3. Methodology and timeline3.1 Evidence-based care3.2 System change strategy3.3 Structured learning method3.4 Planned care3.5 Communication3.6 Timeline

7777999

4. Pre-work activities for Clinical Care Teams4.1 Create the team

4.2 Identify the patients and create a registry

101010

Appendices1: Members of the Steering Committee 112: Change Concepts for the Care of patients with COPD: Expanded Chronic Care Model

12

3: Fee payment, reimbursement and CME forms 154. Expectations of Initiative partners 175: Measures for the Initiative 186: COPD Flow sheet 197: Format for Clinical Care Team report 22


2

Overview

The Problem

Chronic Obstructive Pulmonary Disease (COPD) has significant personal costs for patients, their families and communities. It is also a burden on the resources of the entire BC health-care system. COPD is an umbrella term used to describe chronic bronchitis and emphysema. It is characterized by progressive, partially progressive airflow limitation, symptoms of dyspnea, cough and sputum production, systemic effects and exacerbations (Chapman, 2003; CTS, 2004). Tobacco smoking is the underlying cause of COPD in 80 to 90 percent of patients (Canadian Institute, 2001).

The prevalence of COPD is increasing throughout much of the world and BC is no exception to the pervasiveness. From 2003 to 2004 in the province, 8,000 new incidences were reported each year (Snapshot, 2005). It is expected that the incidence and burden of COPD will increase within BC as the number and proportion of seniors continues to grow.

There is no cure for COPD; however, significant opportunities exist to improve patient care. These range from primary and secondary prevention to interventions focused on improving patient quality of life through lifestyle modification, pharmacotherapy, exercise training and appropriate advance care planning, including end-of-life care.

The Mission

The COPD service framework is a set of action-oriented and comprehensive recommendations. It sets out the practices for individuals and the health system to provide patient-centered, evidence-based care, using the Expanded Chronic Care Model (ECCM). Recommendations cover the spectrum from targeted prevention of future COPD cases to advance-care planning and end-of-life care.

Within BC, a service framework is defined as a patient-centered approach to improving health outcomes across the conventional boundaries of the health system. It acts as a companion document to clinical practice guidelines. While clinical practice guidelines reinforce the patient-physician relationship, service frameworks extend much further. They address services from all providers across the health continuum, including the contributions from health and community agencies that affect the broader determinants of health. Recognizing this reach, service frameworks are often referred to as “system guidelines.”They do not attempt to prescribe care; rather, they suggest what services individuals should expect to receive based on optimal pathways of care.

The Interior Health Working Group (IHWG), which authored the COPD Service Framework document, has identified 20 specific recommendations as priority for implementation within the Central Okanagan (Oyama, Lake Country, Kelowna, Westbank, Peachland) and Nakusp, BC. The IHWG seeks to carry out a program of change in accordance with the Institute of Health Improvement’s “Learning Model” methodology for health care improvement. (See Methods section – Page 6) This will entail the establishment of physician-led teams, the adoption of innovations in clinical


3

practice, community involvement, care processes and information technology support to enable the collection and sharing of information that is key to improving care outcomes for patients.

This document is for the Clinical Care Teams and aims to provide them with the background and guidance they need to get started. Section 1 sets out the aim and summarises the approach of the Initiative.Section 2 describes the formation of Clinical Care Teams and the support they will receiveSection 3 outlines the quality improvement strategies that will guide the initiativeSection 4 sets out the activities Clinical Care Teams will undertake before the first Learning Session in May 2007.

1. The Aim, Vision and Approach of the Initiative

1.1. The aim of the Initiative:

The aim of this initiative is to provide optimal care for current and potential COPD patients, in the Central Okanagan and Nakusp, based on the COPD Service Framework. The outcome will be to increase the length and quality of life for COPD patients, improve patient and caregiver satisfaction and optimize the efficiency of health care resources.

“Through the introduction and use of the COPD Flow sheet in COPD care delivery, the initiative will provide best practice care to COPD patients of participating collaborative physicians. The initial focus is on a small group of General Practitioners in the Central Okanagan and Nakusp and will result in a decrease in urgent patient management , as measured by a 20% decrease in emergency room visits and a 20% decrease in hospitalization for their COPD patients during the duration of the initiative”.

1.2. Vision for the Initiative Participants in this Initiative will learn and implement an organizational approach to caring for COPD patients in a primary care setting. This population-based Initiative will involve the creation of practical, supportive and evidenced-based interactions between an informed, activated patient and a prepared, proactive practice team. The Initiative will be completed in March, 2008. At that point, its findings and achievements will be shared with the greater health care community at the Outcomes Congress. This will highlight the accomplishments of the initiative and share effective models of improved care for COPD patients.

1.3. Summary of the ApproachThe initiative’s aim will be achieved through the testing and implementation of changes in all areas of the Expanded Chronic Care Model by the Physician office teams. The approach will involve incremental performance improvements made by Clinical Care Teams. (Section 3 below sets out more details of the methodology the initiative will adopt.) After undertaking certain pre-work tasks (set out in section 4) teams will attend the first in a series of Learning Sessions. These allow teams to share their experiences and to learn from each other and from experts working with the initiative. In between the learning sessions, incremental change will be planned and tested by teams. A change


4

package has been developed and is based on the elements of the Expanded Chronic Care Model. (See appendix 2).

2. Formation of and support for Clinical Care Teams

2.1. Support and guidance for Clinical Care TeamsThis is guided by a multi-disciplinary Steering Committee. Its members are listed in appendix 1.

Among its members, individuals who will provide support to the Clinical Care Teams are: Dr Phil White and Dr. Chris Livingston – co-chairs of the Steering Committee Jason Kennedy, Project Manager for the COPD Service Framework Initiative. Collaborative Coordinator – current being recruited - responsible for the day-to-

day activities and coordination of the Initiative Dr Graeme McCauley (Respirologist) and Todd Gale (Respiratory Therapist) will

provide clinical advice. Connie Sixta, DSD, RN, MBA, coach, provides support on change management

and performance improvement.

Support provided will include: Medical and clinical advice – access to evidence based best practice and

expertise Information systems – advice and support on how to establish a registry. Designing Learning Sessions that meet the needs of the teams in terms of

performance improvement Managing communication for sharing expertise, lessons learned, and

performance improvement. Fees and reimbursement.

2.2. Clinical Care TeamsClinical Care Teams centred on a general practitioner’s office will be established. Members of the team will include:

One or several GPs working in the same office, Office administrative staff

The initial focus of the clinical care teams will be to:

1. Identify patients who have COPD based on the billing codes and enter their details on to the COPD flow sheet located on the CDM toolkit.

2. Begin using the COPD flow sheet located in the CDM toolkit to deliver care to your COPD patients.

Section 4 sets out activities that Clinical Care Teams will undertake prior to the first Learning Session in May 2007.

2.3. Payment and reimbursement for Clinical Care Teams__________________________________________________________________________COPD Service Framework Physician CollaborativePre-work package for Clinical Care Teams, May 2007

5

GPs will be paid sessional fees for attending meetings and the learning sessions. Action Period work will also be compensated via the BCMA, Practice Support Program. Costs for clinic administrative staff – for example to attend meetings will also be paid. Travel costs for out of town practice team participants will also be paid. See appendix 3 for more details.

2.4. Continuing EducationDoctors who attend the learning sessions will earn CME accreditation. The initiative’s collaborative coordinator will ensure that participants receive CME certificates.

2.5. Expectations of Initiative partnersExpectations of the partners involved in the Initiative are set out in appendix 4.


6

3. Methodology and Timeline

The Clinical Care Teams will use four key quality improvement strategies to achieve improved outcomes for their COPD patients.

3.1. Evidence-based careTeams will work together to implement the evidence-based clinical practice guidelines, identified in the COPD flow sheet, located in the CDM toolkit.

3.2. System change strategyClinical care teams will use the Performance Improvement Model to test and implement change in the care of COPD patients. This involves considering three questions that form the foundation for performance improvement:

What are we trying to accomplish? How will we know that a change is an improvement What changes can we make that will result in improvement?

Clinical Care Teams will undertake a structured trial of a process change using the PDSA cycle (see figure 1). This practical approach supports incremental improvements through:

Plan: a specific planning phase;Do: a time to try the change and observe what happens; Study: an analysis of the results of the trial; and Act: devising next steps based on the analysis.

This PDSA cycle will naturally lead to the plan component of a subsequent cycle.

Clinical care teams will be coached in how to use and report on this approach.

3.3. Structured learning model

The structured learning model (see figure 2) provides a framework for learning, action and collaboration. At the learning sessions, which will have a practice improvement and data focus, Clinical Care Teams will share their experiences and approaches with their colleagues and experts. Through plenary sessions, small group discussions and team meetings, attendees will identify what was learned through the PDSA cycles, what changes have been made and what the next steps should be.

Each learning session is followed by an action period, during which clinical care teams test and implement changes in processes and / or programs that will improve care for COPD patients.

Thus, over the 10-month period, Clinical Care Teams will share ideas and knowledge, learn and apply a methodology for organizational change, implement planned care office-wide and measure progress in population outcomes in a collaborative way – everyone teaches and everyone learns.


7

FIGURE 1 – PERFORMANCE IMPROVEMENT MODEL

FIGURE 2 – STRUCTURED LEARNING MODEL


8

3.4. Planned Care

Clinical Care Teams will implement the use of the COPD Flow sheet in the provision of care to their COPD patients.

3.5. Communication

Although participants focus on their own organizations, they will remain in continuous contact with other teams involved in the initiative and with the initiative’s advisors. This communication occurs through e-mail, conference calls, site visits and meetings. Clinical care teams also share the results of their improvement efforts in monthly reports.

3.6. Timeline

The initiative will run for 10 months, finishing in March 2008. During that time, all those involved will participate in up to four learning sessions. At the Outcomes Congress in March 2008, the initiative’s participants will share their findings and effective models of improved care with the greater health care community.

Learning Session One

LS Two LS Three Outcomes Congress

May 30, 2007 September 18, 2007

December 2007 March 2008


9

4. Pre-work Activities for Clinical Care Teams

To prepare for the first learning session in January 2007, teams will work with members of the Steering Committee to complete the following tasks:

1. Create the team.2. Identify patients and create a registry.

4.1. Create the TeamEach Clinical Care Team will include a GP, office administrative staff and any other person the team considers helpful to this work. Within each team individuals should be identified to take responsibility for the following roles:

The team leader / physician clinical expert who will ensure the success of the team. This person should have expertise in the care of COPD patients and sufficient authority to institute change.

The day-to-day leader, who will be the key contact for the team and be responsible for the day to day work and for compiling the monthly team report. This could be the office manager or MOA

4.2. Identify patients and create a registryGPs will identify individual COPD patients based on their COPD billing codes.

Once the patient listing is compiled, patient details should then be entered into the Flow sheet located in the CDM toolkit.

For those currently not using the CDM toolkit, please reference the below link, which will lead you through the registration process:

(http://healthnet.hnet.bc.ca/has/regagree/4614fil.pdf)

The registry is a basic part of the clinical information system that will inform the clinical care team’s practice redesign and be used to develop specific measures.

Note: Some time will be available following Learning Session One to enter patient information into the Flowsheet, should you not be able to complete this prior to May 30, 2007.


10

http://healthnet.hnet.bc.ca/has/regagree/4614fil.pdf

Apppendix 1: Members of the Steering Committee

Members of the Steering Committee

Dr. Phil White, General PractitionerLorne Yelland, Interior HealthTodd Gale, Interior HealthDr. Graeme McCauley, RespirologistDr. Douglas Rolf, RespirologistPeter Taylor, COPD PatientGerald Barr, COPD PatientDr. Erica Bell-Lowther, Interior Health Jaime Shipmaker, Interior HealthGlenn Kissmann, Interior HealthJason Kennedy, Interior HealthDr. Chris Rauscher, Vancouver Coastal Health AuthorityJudy Huska, Northern Health AuthorityDr. Treena Chomik, ConsultantPat Camp, ConsultantKelly Ablog-Morrant, BC Lung AssociationMichael Roch, British Columbian Ministry of Health ServicesConnie Sixta DSN, RN, MBA, Collaborative Coach

Contact details

Dr Phil WhitePhone: 250 368 8802 (clinic) E-mail: [email protected]

Jaime ShipmakerPhone: 250 980-5035Fax : 250 980-5060 E-mail: [email protected]

Connie Sixta, Collaborative CoachPhone: 713 826 4918 (cell) Fax: 281 485 4721E-mail: [email protected]

Jason KennedyPhone: 250 980-5039Fax: 250 980-5060 E-mail: [email protected]


11

mailto:[email protected]




Appendix 2: Change concepts for care of patients with COPD

Population-based care is the process of identifying health problems within a defined population of patients, sub-setting clinically important sub-populations, defining and assuring evidence-based interventions for members of each sub-population and regularly monitoring progress and scientific literature to keep interventions state-of-the-art. This Initiative will use the population-based Expanded Chronic Care Model (Expanded CCM) as the framework for population-based care measurement. The Expanded CCCM suggests that by working on both the prevention and treatment ends of the care continuum from a broad perspective, health care and other teams have the best opportunity for improving health outcomes in the long term. The Expanded CCM recognises the intrinsic role that social determinants of health play in influencing individual, community and population health. This action-driven model broadens the focus of practice to work towards health outcomes for individuals, communities and populations. Implementation of the components of the model have been reported to improve quality of chronic care, patient outcomes and professional satisfaction.


12

Components with suggested change concepts for this Initiative

Build Healthy Public PolicyDeveloping and implementing policies designed to improve population health. This approach combines diverse but complementary approaches, including legislation, fiscal measures, taxation and organizational change – the aim is to make the healthier choice the easier choice.

Partnerships with community organizations, providers and leaders are formed to develop evidence-based programs and health policies that support care for the COPD patient.

Common themes on risks for COPD patients are identified and ways of addressing these are incorporated into health plans.

Create supportive environmentsCreating supportive environments includes strategies to foster conditions for optimal levels of health in social and community environments.

Effective links between all providers in the community are created Open channels of communication with the community and the media are

developed

Strengthen community actionWorking with community groups to set priorities and achieve goals that enhance the health of the community. This approach encourages effective public participation, where health promotion aims to support people in finding their own ways of managing the health of their community.

Information on existing community resources is disseminated to patients to GPs, other providers and the community

Effective programs are identified and patients are encouraged to participate.

Health Care OrganizationA health care organisation that recognises the importance of improved care for COPD patients and supports the redesign effort is critical for achievement of improved patient outcomes. The development of public policy that supports care of COPD patients, the allocation of needed resources for this, and the implementation of physician incentive programs that reward improved outcomes are necessary to sustain health system re-design.

Senior leaders visibly support this Initiative Reports from the Initiative are discussed at IH senior management team

meetings Resources to collect and evaluate data are provided by Interior Health Improvement strategies that are known to be effective are used to achieve

comprehensive system change. GPs use the appropriate fee codes to provide care to their COPD patients

Self management / develop personal skills__________________________________________________________________________COPD Service Framework Physician CollaborativePre-work package for Clinical Care Teams, May 2007

13

Patients must be knowledgeable about their conditions and have the skills and confidence to take responsibility for the management of them

COPD patients and family members are fully involved in the development and implementation of their own care plan, which is based on their stated goals.

Patient assessment includes self-management knowledge, skills, confidence, supports and barriers.

Consistent tools that describe at risk situations (symptoms, meds, problems) and related patient responsibilities are utilized.

Effective behaviour change interventions and ongoing support with peers or professionals are provided.

Delivery system design Office infrastructure and clinical processes must be re-designed to accommodate planned visits, patient follow-up and proactive care. The roles and responsibilities of office team members must be maximised to achieve effective and efficient workflow.

Registry is designed and used to deliver coordinated planned care Regular follow up is undertaken based on patient needs

Decision supportThe clinical care provided must be consistent with evidence-based best practices. Guidelines for COPD best practices are outlined in the COPD flow sheet, located in the CDM toolkit.

Evidence based guidelines inform daily clinical practice

Information systemsIn order to provide good care to their COPD patients, physicians must know who these patients are. A patient registry helps to manage assessment, recall and follow-up.

A patient registry for COPD is created with clear processes for data entry and reporting identified.

Reminders of needed care are integrated into the clinical visit. Hospital discharge and ER visit information is provided to GPs in a timely manner Feedback to doctors on their performance is made available


14

Appendix 3: Fees and Reimbursement

GP Practice Compensation Summary

“Start up” funds Defray costs of implementation & change Encourage & enable thinking & working differently - not more

GPs & practice staff paid for their time

Local learning & networking sessions

In practice planning & implementation

Travel & accommodation reimburseable for out of town participants

May 2007 – Mar 2008

Participant Funding Rates Learning Sessions

GP Current GP sessional rate $384.31 per 3.5 hrs as of April 1, 2007 ($109.80/hr)

MOA or other practice staff $20 per hour (paid as expense to physician)

Action Periods Compensation for work completed Lump sum Not time-based Allows GP and MOA to decide how best to divide the work


15

[Forms to claim these fees and reimbursement to follow]


16

Appendix 4: Expectations of Initiative’s partners

The Steering Committee’s advisors are expected to: Provide evidence-based information on issues relating to the care of COPD and

on methods for process improvement, both during and between Learning Sessions;

Offer coaching to clinical care teams; Ensure that there is effective communication between all partners.

Clinical care teams are expected to: Attend all Learning Sessions Perform pre-work activities to prepare for the first learning session; Identify members of the team and confirm their individual roles and

responsibilities; Use rapid change cycles (PDSA tests) to implement the Expanded Chronic Care

Model and report progress every month; Participate in discussions and / or conference calls between learning sessions; Report on the achievement of selected outcome measures, including details of

changes made and data to support these changes both during and between learning sessions and at the Outcomes Congress; and


17

Appendix 5: Initiative Measures

The Steering Committee identified a number of measures, which are set out below.

MINIMUM DATA SET

Category Measure Target Data Source

Hospital Admissions

Previously hospitalized COPD Registry patients will have a significant reduction in COPD-related admissions compared to a COPD control group matched on age, gender & COPD hospital admission rate with the same hospital.

20%

Pre/Post analysis of Hospital Admissions data IHA / MOH

Emergency Room Visits

Previously hospitalized COPD Registry patients will have a significant reduction in COPD related hospital admissions through ER compared to a COPD control group matched on age, gender & COPD hospital admission rate with the same hospital.

Decrease in Emergency Room visits for COPD patients on Registry

20%

50%

Pre/Post analysis of ER

& Hospital Admissions data IHA /

MOH

ER data IHA

Pulmonary Rehabilitation Referral

COPD patients on Registry, who meet criteria (Table 2 on COPD Patient Care Flow Sheet), are referred to Pulmonary Rehabilitation

90% Flow Sheet

Flare up (Exacerbation) Plan in Place

COPD patients on Registry with COPD Flare up (Exacerbation) Plan developed with GP

90% Flow Sheet

Stopped Smoking COPD patients on Registry who smoke, stop smoking 30% Flow Sheet

Provided Smoking Interventions

COPD patients on Registry who smoke, were provided smoking interventions

85% Flow Sheet

Regular Visits with GP COPD patients on Registry visit with GP every 3-6 months. 85% Flow Sheet


18

Appendix 6: COPD Flow sheet

COPD Patient Care Flow Sheet

Patient Name (LAST, FIRST) Health Care # (i.e., BC PHN) Date of Initial Visit (DD/MM/YYYY)

Birth date (DD/MM/YYYY) Gender Male Female

Phone Number (include Area Code) Height (cm)

CO-MORBIDITIES ( alphabetized by row ) Alcohol Overuse Asthma Arthritis Atrial Fib CHF Cor pulmonale / PAH CVA Depression/Anxiety Diabetes GERD Hypertension Hypoxemia Insomnia Ischemic Heart Disease Kidney Disease Lipid Abnormality Liver Disease Obesity Obstructive Sleep Apnea Osteoporosis PVD Rhinitis/Sinusitis

Annual Weight (kg)

Smoker Yes No

Ex-smoker since __________

Bold = mandatory field = Yes / No / data / or date Baseline DATE OF VISIT (DD/MM/YYYY)

REVIEW EACH VISIT Date Date Date Date Date

DIAGNOSIS AND CLASSIFICATIONFEV1 % predicted COPD Classification (see table 1 on reverse side)

PREVENTIONDate of annual flu vaccine?Pneumococcal vaccine in past 5 years?

THERAPYHas the patient stopped smoking?Brief smoking interventions provided?Referral to stop smoking program?Short-acting beta2 agonist?Anticholinergic?

Long-acting beta2 agonist?

ICS? (see table 3 on reverse side)

Theophylline?

S & S of chronic hypoxemia or obstructive sleep apnea?Specialist Referral? (see table 4 on reverse side)

Call back / return visit in 3 or 6 months?

EDUCATION AND SELF-MANAGEMENT

Review pathophysiology, prognosis and treatment

Ask patient to set a physical activity goal/assess progress

Review medication use and side effects


19

Provide GPAC patient guide

Refer to Pulmonary Rehabilitation?(see table 2 on reverse)

EXACERBATIONSExacerbation Action Plan in place?Date of last exacerbation?Corticosteroids prescribed?

Record the antibiotic name or class prescribed and document rotation

Table 1. COPD Classification using Medical Research Dyspnea Scale (MRC) and/or Spirometry

MRC COPD Classification Spirometry Symptoms

0 - 1 At riskNormal spirometry: FEV1 / FVC > = 0.7 and/or FEV1 > = 80% of predicted

Asymptomatic smoker or ex-smoker or chronic cough and sputum

2 Mild FEV1/FVC < 0.7 FEV1 60-79% predicted

SOB from COPD with strenuous exercise or when hurrying on the level or walking up a slight hill

3 - 4 Moderate FEV1/FVC < 0.7 FEV1 40-59% predicted

SOB from COPD causing the patient to walk slower than most people of the same age or needs to stop after 100m of walking on the level

5 Severe FEV1/FVC < 0.7 FEV1 < 40% predicted

SOB from COPD resulting in the patient being too breathless to leave home, or dyspnea after changing clothes, or the presence of chronic respiratory failure, or clinical signs of right heart failure

Table 2.

When to consider Pulmonary Rehabilitation?

In clinically stable patients who despite optimal therapy, remain activity limited, due to their symptoms.

Table 3.

When to consider adding an ICS?

In patients who are asthmatic, or have an FEV1 < 50 % predicted and > 1 exacerbation in the past 12 months.


20

Table 4.

When to consider specialist referral?

The diagnosis is uncertain. There are signs and symptoms of hypoxemic or hypercarbic respiratory failure. The patient has the inability to cope due to social circumstances, anxiety, knowledge or complex/high

care needs. There are severe or recurrent exacerbations and treatment failure. The patient has severe COPD and disability requiring more intensive interventions. More intensive co-morbidity assessment and management is required. A young patient with limited smoking history. Difficulty in assessing home oxygen or sleep disorders.


21

Appendix 7: Format for clinical care team monthly report INTERIOR HEALTH AUTHORITY COPD COLLABORATIVE

MONTHLY PRACTICE REPORT

SECTION I: TEAM INFORMATION

Practice Name Report Date

Team Members: (List team members & update as needed (should include core & expanded team members)

Name Role Name Role

Aim:

Population Focus:

SECTION II: Key MeasuresRequired Measures Target Team Target1 Hospital Admissions Decrease by 20%

2 Emergency Room Visits Decrease by 50%

3 Pulmonary Rehabilitation Referral 90% referral rate

4 Flare Up (Exacerbation) Plan in Place 90%

5 Stopped Smoking 30%

6 Provided Smoking Interventions 85%

7 Regular Visits with GP (every 3 to 6 months) 85% SECTION III: Description of Tests of ChangesComponent Date Description of Tests of ChangeCommunity

Self management

Delivery system design

Organization of healthcare

Decision support

Clinical information systems


22

INTERIOR HEALTH AUTHORITY COPD COLLABORATIVEMONTHLY PRACTICE REPORT [2]

SECTION IV: List of Changes ImplementedList, by component of the Chronic Care Model, changes tested that have been adopted permanently. These changes are now part of the clinic routine. A one-sentence description is all that is needed.Component Date Description of Tests of Change

Community

Self Management

Delivery system Design

Organization of Healthcare

Decision support

Clinical information systems

SECTION V: Summary of Results


23

Documents

Greater Trail Seniors-at-Risk Initiative€¦ · Web viewThe registry is a basic part of the clinical information system that will inform the clinical care team’s practice redesign