Collaboration In Practice

Collaboration in Practice

Building a Better Tomorrow Initiative

Participant’s Manual

Acknowledgements

Building A Better Tomorrow An Atlantic Provincial Primary Health Care Initiative

Many people and organizations contributed to the Collaboration in Practice Module for the Building A Better Tomorrow Initiative. The Nova Scotia Department of Health, the New Brunswick Department of Health and Wellness, the Newfoundland Department of Health and Community Services and the Prince Edward Island Department of Health and Social Services gratefully acknowledges the contributions of Future Learning Inc. who designed the module, the Members of the Provincial Education Advisory Committees, the Accreditation Teams, Dalhousie University (Continuing Medical Education, Faculty of Medicine) and Memorial University’s Centre for Collaborative Health Professional Education, Faculty of Medicine who reviewed the module and specifically the facilitators and health care providers of the Atlantic provinces who participated in the piloting of the module.

Production of this module has been made possible through a financial

Contribution from the Multijurisdictional Envelope of the Primary Health Care Transition Fund, Health Canada.

The views expressed herein do not necessarily represent the official policies of Health Canada, the Nova Scotia Department of Health, the New Brunswick

Department of Health and Wellness, the Newfoundland Department of Health and Community Services and the Prince Edward Island Department of Health and Social

Services.

Building A Better Tomorrow, Primary Health Care Nova Scotia Department of Health

PH: 902-424-3522 Fax: 902-424-0402

E-mail: [email protected] www.gov.ns.ca/health/pchrenew

Collaboration in Practice Participant’s Manual

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Building a Better Tomorrow

Atlantic Provinces Primary Health Care Initiative

Through Building a Better Tomorrow (BBT), a Health Canada funded initiative, all four Atlantic Provinces are working together to develop and deliver education and training opportunities that will support health care providers to become part of a primary health care team. The need for health care providers to successfully embrace change has been of great concern and one met with varying degrees of success. BBT is creating and delivering effective educational and orientation content that will support and sustain change, not create new models of care. A needs analysis was conducted to identify the learning needs of health care providers and to ensure sufficient input from key stakeholders across the four provinces. Providers, professional bodies and educational institutions have all played a part in the development of effective content.

Based on the focus groups conducted during the development of the proposal and the completed needs assessment, with frontline health care providers the following content areas were identified; understanding of primary health care, conflict management, team building, working with the community, working with the electronic patient record, facilitation, collaborative practice and clinical program planning and evaluation. The needs analysis has been used to further refine these areas, identify other content and develop the curriculum outline and delivery methods. Education working groups and accreditation teams have been created that include; interprofessional practitioners from all four Atlantic Provinces, university extension departments, academia representatives, regulatory bodies, professional health associations and representatives of provincial community and health programs. The groups serve in a consultative and advisory role with respect to the development of the educational content and delivery methods. An Atlantic education-working group was established and includes consultants from Dalhousie University (Continuing Medical Education, Faculty of Medicine) and Memorial University’s Centre for Collaborative Professional Education, Faculty of Medicine, who provide expert consultation and technical advice. The working group brings together information from all four provincial education advisory groups across the Atlantic Provinces on a regular basis to ensure there is a sharing of knowledge and a coordinated effort toward content and delivery development and evaluation. Partnerships developed with key stakeholders through this initiative, as well as learning from experience, will sustain this change management strategy. Exploring opportunities to embed curricula into existing continuing educational programs, along with the development of curricula in post-secondary training and education programs for new providers, will facilitate sustainability. For additional information, contact your provincial project manager as listed below: New Brunswick Yves Ducharme [email protected] Newfoundland and Labrador Brenda Hancock [email protected] Nova Scotia Gerard Murphy [email protected],ca Prince Edward Island Diane Boswall [email protected]


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UNIT 1 Building a Better Tomorrow Initiative

One focus of primary health care is on teams of health care professionals working together to improve the health of all citizens. That’s a big change from a system that has depended upon family doctors working solo, or in small groups, to look after us. Building a Better Tomorrow is a federally funded initiative, which has all four Atlantic Provinces working together to assess, develop and deliver the training and skills health care providers need to support transition to Primary Health Care practice. The first step was to determine precisely what health care professionals need to learn to fulfill their roles in a primary health care environment. The providers, professional bodies and educational institutions have all helped to develop content. The courses themselves are being delivered through post-secondary training and education programs, as well as existing continuing education programs. This way, health care providers make a greater contribution to primary health care renewal.

Other Building a Better Tomorrow Initiatives Prince Edward Island

– Understanding Primary Health Care – Collaboration in Practice

Newfoundland and Labrador

– Team Building I & II – Electronic Patient Record

New Brunswick

– Facilitating Adult Learning I & II – Electronic Patient Record

Nova Scotia

– Building Community Relationships – Electronic Patient Record

Newfoundland and Labrador and New Brunswick

– Conflict Resolution Nova Scotia and Prince Edward Island

– Getting Started in Program Planning and Evaluation


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COLLABORATION IN PRACTICE

AGENDA

Introductions

Definitions for Collaborative Practice

Principles of Collaborative Practice

BREAK

Target Populations

Roles and Scope of Practice in the Primary Health Care Team

Collaborative Practice Workshop (Part One)

LUNCH

Collaborative Practice Workshop (Part Two)

BREAK

Strategies for Collaboration

Closing


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Workshop Description This practical one-day workshop is for health care professionals who would like to acquire the knowledge, skills and confidence so that they can collaborate effectively within a primary health care environment. This workshop is intended for no more than 25 people in total, to adequately manage activities. Success will be best achieved if your entire team can participate – for the purpose of the workshop, individuals working in three different disciplines should be represented. Through lectures, activities, and practical exercises, participants conceptualize collaboration and will practice collaborative processes applicable to their working lives. Upon completion of the training, participants will be able to:

• Describe the concepts, principles and practical application of the collaborative practice process as they relate to their specific role as a primary health care team member.

• Describe the process to identify the target population, who needs to be

involved, and the information sources that are required in the collaborative practice process.

• Compare and contrast the skills and functions of all members of the

primary health care team.

• Apply a collaborative practice process to their work in providing primary health care services.

• Summarize the strategies of collaboration and apply this understanding to

their work as primary health care providers.


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UNIT 2 Definitions

Primary Health Care Primary health care refers to the basic, everyday health care services assessed by

Canadians. Primary health care is about:

Preventing people from becoming ill or injured Managing chronic conditions Making the most effective use of health provider expertise Treating acute and episodic illness Efficiency and co-ordination Access Individuals playing an active role in their own health care

Primary health care defies a single, easily understood definition. However, there is a general acceptance of, and support for, the following four key pillars or elements that underpin all models: Healthy Living

Healthy living encompasses prevention, the management of chronic illness, encouraging support for self-care and the idea that factors outside of the health system can influence individual and community health.

Team Approach

The team approach is about health care providers working together to improve the continuity of care, reduce duplication and ensure individuals have access to appropriate health professionals. Patients/clients are a part of the team, as well, and are involved in, and empowered to make, decisions about their own health.

Access 24/7

Primary health care is about ensuring that Canadians have greater access to the right services when and where they are needed. It recognizes that Canadians need advice, information, and care outside of regular office hours.

Information

Primary health care is about improved sharing of information between health providers and expanded access to information for Canadians using the health system or seeking health advice. It’s about using tools like electronic health records and diagnostic instruments to improve the quality, access and co-ordination of health information.

From National Primary Health Care Awareness Strategy Web site: www.phc-ssp.ca.


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Definitions (cont’d.) Population Health “Population health refers to the health of a population as measured by health status indicators and as influenced by social, economic and physical environments, personal health practices, individual capacity and coping skills, human biology, early childhood development, and health services. The population health approach focuses on the interrelated conditions and factors that influence the health of populations over the life course, identifies systematic variations in their patterns of occurrence, and applies the resulting knowledge to develop and implement policies and actions to improve the health and well-being of those populations. “(Health Canada, 2002) A population health approach is one that is targeted to the entire population rather than individuals. It refers to the health of a population (e.g., a province) or sub-population (e.g., Aboriginal people) and assesses health status and health status inequities over the life span at the population level. This approach considers why people smoke, eat unhealthily, and are physically inactive. The approach tackles the environment and conditions that influence healthy choices and health outcomes. Population health strives to make healthy choices the easy choices. Reducing the risk factors for chronic disease is the greatest opportunity to improve the health of Canadians and to sustain the country’s health care system. There are two main approaches to promotion and prevention which address the common risk factors for chronic disease: 1) Those that aim to improve the knowledge and skills of individuals. 2) Those that aim to promote healthy public policy and supportive environments that

make healthy lifestyle choices easy choices. In the past, most efforts have been directed at individual knowledge and skills, but this approach has proven to have limited success in changing these risk factors. Rather than focusing on educating individuals alone, the aim of a population health approach is to create environments and conditions that are conducive to creating and maintaining healthy habits.


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A population health approach requires that policy and program decisions are based on sound evidence. Information on health status, the determinants of health and the effectiveness of interventions are used to assess health, identify priorities and develop strategies to improve health. Best practices make effective use of available resources. Achieving population-wide changes requires a long-term commitment that includes multiple interventions carried out in a co-ordinated way at different levels over a period of time. As well, certain settings such as schools, workplaces, municipalities and local communities offer practical opportunities for effective health promotion.


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Definitions (cont’d.) Collaboration “A process through which parties who see different aspects of a problem can constructively explore their differences and search for solutions that go beyond their own visions of what is possible. Collaboration involves joint problem solving and decision-making among key stakeholders in a problem or issue.” (Chronic Disease Prevention Alliance of Canada, 2001)

Collaborative Practice “Collaborative practice is an interprofessional process for communication and decision making that enables the separate and shared knowledge and skills of care providers to synergistically influence the client/patient care provided.” (Way and Jones) The benefits of a collaborative practice approach include: • patients/clients have improved access to other physicians and providers located in

the practice; • continuity of care is enhanced; • physicians have the potential to take on new patients who do not currently have a

family physician. The practice population is expected to increase as a result of alternate providers providing services and as a result of efficiencies gained by appropriate utilization of providers; and

• physicians and other providers have an opportunity to work in a more supportive and

collegial environment.


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The Four Levels of Partnership While many people use the word "collaboration" to refer to any type of partnership, there are really several different types of partnerships, of which collaboration is only one. These different types of partnerships form a continuum, which runs from least to most intensive commitment.

Communication The least committed level of partnership, communication includes activity that has as its purpose sharing of information and non-material resources. Coordination includes activity between two or more agencies or organizations that has as its purpose prevention of duplication of efforts and assurance of provision of service. Cooperation Slightly more intensive, cooperation is activity between two agencies or sectors that aims at some integration of operations, while not sacrificing the autonomy of either party. Collaboration The most intensive level of partnership, collaboration is a mutually beneficial and well-defined relationship which involves people from different agencies or sectors of the community joining together to achieve a common goal. Usually, that goal could not be achieved as efficiently (or at all) by any individual organization. The result is a highly shared endeavor in which members eventually commit themselves as much to the common goal as to the interests of their own organizations.

Communication

Coordination

Cooperation

Collaboration


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Communication Coordination Cooperation Collaboration Color

commitment formality low

personal contact

high

Color high autonomy low

Examples of high and low levels of commitment, formality, personal contact and autonomy:

LOW HIGH

Commitment Verbal agreement to work together if the opportunity arises.

Memorandum of Understanding exists between partners.

Formality No set procedures for any aspect of shared work.

Established procedure for managing disputes.

Personal Contact Little or no interaction between partners.

Regularly scheduled partner meetings.

Autonomy Partners consult with each other on a regular basis to plan each organizations schedule.

Each partner operates its own program with little thought of what the other partner is doing.

Source: http://www.sustainabilityonline.com/HTML/Collaboration/index.html


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Definitions (cont’d.) Team “A team is a small number of people with complementary skills who are committed to a common purpose, performance goals, and approach for which they hold themselves mutually accountable.” (from The Wisdom of Team, p. 45) Characteristics of Effective Interprofessional Health Care Teams • members provide care to a common group of patients; • members develop common goals for patient outcomes and work toward those goals; • appropriate roles and functions are assigned to each member, and each member

understands the roles of the other members; • the team possesses a mechanism for sharing information; • the team possesses a mechanism to oversee the carrying out of plans, to assess

outcomes, and to make adjustments based on the results of those outcomes. What are the main issues for Teams?

• What is the team’s direction/purpose? • Who performs which tasks and with whom?

o roles and responsibilities • What mechanisms are needed to facilitate and maintain high team performance?

o conflict resolution, information sharing, leadership Leadership and decision making • What types of team member behaviors foster high work accomplishments?

o teamwork knowledge, skills, attitudes o knowledge and practice skills

Limitations of interprofessional team care

• process of team formation is time consuming & requires matching of schedules of different team members

• collaboration requires communication between team members, which takes time away from patient appointments in busy practices

• a comprehensive approach to health care may lead to increased use of limited services and resources

• a successful team requires on-going conflict resolution and goal re-assessment; failure of these tasks may impair health care delivery

Grant RW, Finnocchio LJ, and the California Primary Care Consortium Subcommittee on Interdisciplinary Collaboration. Interdisciplinary Collaborative Teams in Primary Care: A Model Curriculum and Resource Guide. San Francisco, CA: Pew Health Professions Commission, 1995.


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Effective Team Decision Making - The Steps

• Recognize the problem • Define the problem • Gather relevant information • Develop alternative strategies • Select best alternative • Implement best alternative • Evaluate the outcome


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UNIT 3 Principles of Collaboration

Working collaboratively requires a shift from the current primary care system where providers often work quite independently of each other, to one where a variety of providers work together to combine resources and strategies, and share responsibility for their patients. Collaboration enhances communication, increases the efficient use of health care resources, and can improve health outcomes and quality of care including patient and provider satisfaction (CNA, CMA, 1996; Schraeder, Shelton and Sager, 2001; Goldberg, Jackson, Gater, Campbell and Jennett, 1996; Schmitt, 2001; Koerner, Cohen, and Armstrong, 1985; and Lorenz, Mauksch, and Gawinski, 1999). Eight key principles, based on those proposed by the Canadian Medical Association (1996) and the Canadian Nurses Association (1996), form the basis for collaboration in family health centres in Prince Edward Island: • Client-centred care with a minimum of two caregivers from different disciplines

working together with the client to meet assessed health needs; • Shared or common vision, values and philosophy focused on meeting care needs; • A clear definition and understanding of team member roles and responsibilities by all

stakeholders; • A climate of respect, trust, mutual support and shared decision-making; • Effective communication among all team members; • Empowerment of all team members; • Respect for autonomous professional judgement; and • Respect for autonomous choices and decisions of the care recipient NOTE: There are other collaborative practice teams, not clinically-based, that work

very successfully using these same principles.


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Take some time to conduct a private assessment of how your team is currently doing in manifesting the principles of collaborative practice. Provide a rating from 0 (not currently happening) to 5 (a well-established practice) in response to each of these questions:

# Question Rating (0 – 5) 1. Do team members trust each other?

2. Do team members respect each other?

3. Are team members committed to collaboration?

4. Do team members co-operate with each other?

5. Do team members communicate with each other?

6. Do team members demonstrate flexibility?

7. Do team members have a good understanding of the distinction between roles?

8. Do team members believe that they could not do their jobs as well without each other’s assistance?

9. Does your team have a formal means to facilitate dialogue among all team members?

10. Do your team members talk together about similarities and differences including role, competencies and stereotypes?

Identify your team’s top strength and your top challenge. What are some successful collaboration strategies that you know of or have practiced in your work setting?


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UNIT 4 Target Populations

What characterizes a “prepared” practice team? At the time of the visit, they have the patient information, decision support, people, equipment, and time required to deliver evidence-based clinical management and self-management support. Their evidence-gathering is an on-going process. The team continually updates its knowledge of the health status of their client population and the trends of target groups. For example, they access and utilize local and regional surveillance data along with demography and epidemiology. They use community resources such as the Heart and Stroke Foundation or the Diabetes Education Centre. They match the information and resources with their clients’ needs. Team members need to find answers to this series of questions:

• Who is the target group?

• What data sources provide information on the target group?

• What does the data say about the target group?

• What community resources are available and appropriate for the target group? Understanding target populations helps team members to meet the needs of the community. Along with clients/patients, they work to understand how they can effectively combine resources to address the needs of the target population.


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UNIT 5 Roles and Scope of Practice

“Without trust and respect, cooperation cannot exist. Assertiveness becomes threatening, responsibility is avoided, communication is hampered, autonomy is suppressed and co-operation haphazard.” (Norsen, 1995) The key elements of interdisciplinary teams include the following: • Physicians, registered nurses, and other providers work together as a cohesive team

with shared responsibility for patient/client outcomes, and practice to the full extent of their skills and competencies. The different skills offered by various providers are complementary and when combined, will be synergistic providing patients/clients with improved primary health care services. For example, dietitians can play a key role as part of an interdisciplinary team in the prevention and management of chronic disease. Education is key to preventing the progression of diabetes. Similarly, 85% of seniors have one or more chronic conditions such as osteoporosis, hypertension, diabetes, and heart disease, all of which can benefit from nutrition intervention (Dietitians of Canada, 2001).

In PEI family health centres: • Physicians and registered nurses will form the interdisciplinary team initially,

followed by other providers such as mental health therapists and dieticians depending on the needs of the patient/client population. A triage system will be in place for access in person or by phone, and for guidance to the most appropriate provider.

• Once registered, patients/clients will have a comprehensive assessment completed

to identify health concerns and risk factors. While diagnosis and treatment of acute and episodic illnesses will be integral to this service, health providers will place more emphasis on health promotion and education to help patients/clients in the self-care and management of chronic disease. Improved coordination and comprehensiveness of service will potentially lead to fewer complications and hospitalizations for chronic conditions such as mental illness, diabetes and heart disease.

• Integration with community-based services will be enhanced, as team members

collaborate with healthy living coordinators and provide referral to community organizations and other parts of the health and social services system who have essential roles in the continuum of care for prevention, support and management of disease conditions. Partnerships with the community and other sectors will be formed to implement innovative strategies for reducing risk factors for chronic disease.


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Successful collaboration is based on provider equality not on hierarchy or supervision. This involves a mutually agreed upon division of roles and responsibilities which may vary according to the nature of the practice, personalities, and skill sets of the individuals. Some of the elements for successful collaboration include: • Mutual trust and respect • Recognition of unique expertise • Understanding of team members’ scope of practice • Good team structure • Understanding of legal responsibility • Dealing with hierarchy • Team members’ practical experience • Shared values Successful collaboration should result in case management that has these features: • Regularly assesses disease control, adherence, and self-management status. • Either adjusts treatment or communicates a need to primary care immediately. • Provides self-management support. • Provides more intense follow-up. • Provides navigation through the health care process.


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UNIT 6 Collaboration Workshop

Protocols

Care management protocols and/or guidelines have been developed to assist in negotiating roles, functions and responsibilities of providers in the care process for health / disease entities. The protocols/guidelines reflect the principle of collaboration and are flexible enough to enable providers to practice to the full extent of their education and experience while maintaining patient choice and patient safety. Advice of professional organizations is sought regarding professional practice issues. Collaborative efforts in family health centres in Prince Edward Island are based on the work of the Institute for Health Improvement in Boston. Recognizing the burden of chronic disease on individuals and health care systems, the Institute identified the need for a model of care that would result in better outcomes for clients. The Institute recognized that to effectively meet the needs of clients with chronic diseases, collaboration with the client and various care givers and professionals is essential. The Institute developed a process to build a "Collaborative" for a specific chronic disease that involved a review of the latest literature and clinical practice guidelines, collaboration with other professionals and educators involved and a review of recommendations. Recognizing that the process of implementing such a model had to be cognizant of time used away from clinical practice, the Institute developed a workshop process that includes education about collaboration and team building, use of recommended clinical practice guidelines that include client centered care, regular follow-up by a team of professionals and educators, and teaches and encourages client self-monitoring skills. The United Kingdom National Health Service (NHS) have adopted the concept of "Collaboratives" to address the needs of clients with chronic diseases and other common problems in their community. There are over 2500 practice settings in England and Wales using the collaborative process to provide service to specific health problems, and the NHS have included a new program within the Department specifically to encourage and support "Collaborative" practice settings.


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For Facilitators and Scribers Goal: Team members will experience the process of negotiating ‘Who does

what?” for the Collaborative Practice patients/clients with the disease / health entity chosen by the team.

By the end of this session, the team will have reviewed the first page of the Practice Guidelines and come to some decision on these matters:

A) Which staff members need to be added to the Practice Guidelines for your Collaborative Practice?

B) What activities on the list have shifted and to whom?

C) What was the process like?

• Did the process move the team any closer to deciding ‘Who does

what?’

• What did the process (negotiating / give and take) feel like?

• What needs to happen for this process to work back at your Collaborative Practice?

Your Role as Facilitator includes these responsibilities: • Keep people on track. (Experiencing the process is extremely important!) • Ensure everyone has input and challenge non-movers / non-participants if

necessary. • Ensure that group decisions made on the matters listed above (A, B, & C) are

recorded accurately. (This is not a word-smithing exercise, but you may need to check that the wording reflects the decisions that were made by the group).

• Enlist a team member to report back to the larger group. Your Role as Scriber includes these responsibilities: • You are not expected to take minutes. This process is more about capturing

decisions and process after the discussion. • Ensure that group decisions made on the matters listed above (A, B, & C) are

recorded accurately. It will be the role of the facilitator to check that the wording reflects the decisions that were made by the group.


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Process Before arriving at the workshop, your team should have selected ONE practice guideline that is applicable to the population your primary health care team serves. The guidelines provide evidence-based best practices and possible roles and responsibilities that each member on your team might carry given their education and experience while providing service for a patient/client/individual. You may also have invited a patient/client/individual who is experiencing this issue and/or representatives of community-based organizations that contribute to the health of the target population. The team members listed on the guideline may need to be changed to reflect the reality of who is currently on staff in your work site and based on who is here to participate today. For example, you may have a health care professional that is not listed on the outline. If that is the case, please add another column. If someone is missing today, include a statement about what role / responsibility you expect that person to carry out. If you have clients or community members present, add columns to reflect their roles and responsibilities. The goal of the exercise is for you to experience the process of negotiating ‘Who does what’ for the patients/clients at your centre who are experiencing the disease / health entity that you have selected. Within the time provided, your team should complete the following tasks: 1) Begin with Page 1: “Activities of the Initial Visit” on the Clinical Protocol. 2) Answer a number of questions:

a) Which staff members need to be added to the Practice Guidelines for your work site?

b) What activities on the list have shifted? c) Who is doing the activities that have shifted?

3) Provide feedback on the decision-making process by answering these questions:

a) Did the process move the team any closer to deciding ‘Who does what’? b) What did the process (negotiating / give and take) feel like? c) What needs to happen for this process to work back at your work site?

If there is time and interest from the group, you can repeat Steps 2 and 3 with Page 2: “Activities of the Follow-up Visit”.


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UNIT 7 Workplan for Collaboration

Clinical Protocol:

Action Target Date Responsibility Resources / References Needed


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UNIT 8 Closing

Take time to think about some questions. Write your responses below. What did you find surprising about today’s workshop? What did not surprise you today? Has your assessment of your skills as a collaborative practitioner changed after today’s workshop?


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APPENDIX A Building a Better Tomorrow Initiative (BBTI)

Training Module Evaluation Process The trainer is responsible for coordinating the distribution, collection and return of a number of evaluation instruments associated with the evaluation of this training module and the BBTI. There are 3 evaluation tools which accompany the participant’s manual for this training module and 1 evaluation tool which accompanies the trainer’s manual. These evaluation tools include: Participant Manual Evaluation Tools 1. Participant Satisfaction Survey

The Participant Satisfaction Survey is an anonymous evaluation tool which is intended to measure participants’ satisfaction/reaction to the training module. This survey is included at the back of the participant’s manual. This survey should be completed by the participants immediately after training completion. The trainer is responsible for reminding and encouraging participants to complete the survey. The trainer is also responsible for collecting the evaluation surveys and forwarding these to the evaluation consultant address identified below.

2. Pre-Training Confidence Survey The Pre-Training Confidence Survey is an anonymous evaluation tool which is intended to measure participants’ confidence in skills and abilities related to the subject matter of the training module. The Pre-Training Confidence Survey is included at the front of the participants’ manual. This evaluation tool should be completed by the participants immediately before the training begins. The trainer is responsible for reminding and encouraging participants to complete this evaluation tool. The trainer is also responsible for collecting the pre-confidence surveys along with the post-confidence surveys upon training module completion, and forwarding these to the evaluation consultant address identified below. Pre and post-confidence surveys are only to be collected together at the completion of the training module. Note: Trainers should receive a participant registration list for each module. This list should identify a code # for each participant. Please instruct each participant to record their individual code # on both the pre and post-confidence survey.

3. Post-Training Confidence Survey The Post-Training Confidence Survey is an anonymous evaluation tool which is intended to measure participants’ confidence in skills and abilities related to the subject matter of the training module. The Post-Training Confidence Survey is included at the back of the participants’ manual. This evaluation tool should be completed by the participants immediately after training completion. The trainer is responsible for reminding and encouraging participants to complete this evaluation tool. The trainer is also responsible for collecting the surveys and forwarding these to the evaluation consultant address identified below. Pre and post-confidence surveys are only to be collected together at the completion of the training module.


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Note: Trainers should receive a participant registration list for each module. This list should identify a code # for each participant. Please instruct each participant to record their individual code # on both the pre and post-confidence survey.

Trainer Manual Evaluation Tool 1. Trainer Observation Form

The Trainer Observation Form is intended to record the trainer’s observations of the training session, as well as observations on the effectiveness of the training process, subject matter, ease of use of training support materials, and trainer support. The observation form is included in the trainer’s manual. This survey is to be completed by the trainer after each module which he/she facilitates and forwarded to the evaluator along with other participant evaluation instruments.

Evaluation Consultant Return Address:

Building a Better Tomorrow Evaluation c/o Centre for Collaborative Health Professional Education

Faculty of Medicine Memorial University of Newfoundland

St. John’s, NL A1B 3V6

For more information on the evaluation, please contact: Vernon Curran, PhD Director of Research and Development Centre for Collaborative Health Professional Education Faculty of Medicine Memorial University of Newfoundland St. John's, NL A1B 3V6 Phone: 709-777-7542 Fax: 709-777-6576 Email: [email protected]


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Building a Better Tomorrow Initiative (BBTI) Evaluation Framework

Evaluator Centre for Collaborative Health Professional Education Faculty of Medicine Memorial University of Newfoundland Prince Philip Drive St. John’s NL Canada A1B 3V6 Phone: 709-777-6912 Fax: 709-777-6576 Web: www.med.mun.ca/cchpe Contact: Vernon R Curran [email protected] Evaluation of the Building a Better Tomorrow Initiative Evaluation is an important aspect of the Building a Better Tomorrow Initiative (BBTI) and is intended to foster improvement in the quality of training and education which is facilitated, while also demonstrating the merits of the BBTI. There are two types of evaluation planned for the BBTI - formative and summative. Formative evaluation refers to the systematic collection of information for the purpose of informing and determining the quality of instructional materials while they are in the design and development stages. Formative evaluation will occur on ‘pilot’ offerings of the BBTI training modules prior to full-scale delivery. This formative evaluation will enable program developers to enhance the instructional activities and materials before they are offered to the target audience. Summative evaluation occurs after an instructional program has been developed and delivered to the learner. It is meant to collect information that enables decision-makers to judge the impact or effectiveness of a program. Summative evaluation will take place after the completion of each training module and on an ongoing basis over the course of the BBTI. Figure 1 depicts the different types of evaluation which will be conducted for the BBTI, as well as what stage they will be occurring. Evaluation Framework An evaluation framework refers to a plan for conducting an evaluation of a particular instructional program or product. A well know evaluation framework in the adult education literature is that of Kirkpatrick (1967). Kirkpatrick identified four levels of program evaluation that increase in complexity in terms of behavioural changes and encompass outcomes related to learner reactions, evaluation of learning, transfer of behaviour, and the impact of learning on the organization or workplace. The four levels are not hierarchical, although within each level, it becomes increasingly difficult to account for potentially confounding factors related to educational interventions. This is particularly evident when examining results of impact that


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might typically occur over extended periods of time after the interventions and which may need to be accommodated through longitudinal approaches to evaluation. For the purposes of the BBTI evaluation a modified version of Kirkpatrick’s (1967) evaluation model, proposed by Freeth, Hammick, Koppel, Reeves and Barr (2002), has been adopted. Table 1 provides an overview of the levels of evaluation suggested by Freeth et al. (2002) and which encompass Kirkpatrick’s levels of evaluation as well. Table 1 Components of Freeth et al.’s (2002) Evaluative Framework

Evaluation Level Example Outcomes

Reaction Learners’ views of the interprofessional education experience.

Modifications of attitudes & perceptions Changes in perception or attitudes towards the value and/or use of interprofessional teams and teamwork.

Acquisition of knowledge & skills Knowledge and skills related to interprofessional collaboration.

Behavioural change Transfer of interprofessional learning to practice settings and changed professional practice.

Change in organizational practice

Impact and changes in health care organizations or health care system.

Benefits to patients or clients Improvements in health or well being of patients or clients.

This evaluation schema has been adopted as the basis of the evaluation framework for the BBTI. This evaluation will also be complemented by an examination and monitoring of the health care context or environment within which the BBTI is situated. This will provide a useful overview of the health care setting, conditions and environment of the various provinces participating in the BBTI. Table 2 provides a summary of the proposed evaluation framework for the BBTI based on Freeth et al.’s (2002) modified model. Table 2 Building a Better Tomorrow Evaluation Framework Component (Evaluation

Level) Instrument/Method Summary

Participation • # of educational sessions (modules) conducted

• #s of participants in educational sessions

Information collected by each project manager and later reported for Atlantic Canada.

Reaction (Satisfaction) Formative Evaluation (Pilot) Focus Group Focus group with participants from each module ‘pilot’.

Areas to be evaluated:

• Subject Matter


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Interview Interview with each ‘pilot’ module facilitator.

• Instructional Process; • Time; • Instructional Materials

Participant Satisfaction Survey • addresses learning needs • content • instructional process • facilitation • likes/dislikes • commitment to change

The Participant Satisfaction Survey is an anonymous instrument and will be included in the participant manuals. This survey is to be completed by participants after each module, collected by the trainer and forwarded to evaluator for data collection.

Trainer Observation Form • observation of the training

process, subject matter, trainer support, ease of use of the trainer’s manual

Focus Group Focus groups with representative sample of trainers from across Atlantic Canada.

The Trainer Observation Form will be included in the trainer’s manual. This survey is to be completed by the trainer after each module and forwarded to the evaluator along with other participant evaluation instruments. Focus group conducted 3 months after initiation of training delivery across Atlantic Canada. Trainers will be asked to comment on support systems for trainers in BBTI, as well as suggestions for fostering training transfer.

Modification of attitudes/perceptions

Pre and Post Confidence Survey(s) Measures perceived confidence.

The Pre- and Post-Confidence Surveys are anonymous instruments and are to be included in the participant manuals. Survey items will be subject-specific to area of training and identical items will be appear on both Pre- and


26

Post-Survey for same module. Instrument(s) not to exceed 10 items. The Pre-Confidence Survey is to be completed immediately prior to module commencement. The Post-Confidence Survey is to be completed immediately after the module. The Post-Confidence Survey will be combined with Participant Satisfaction survey. Instruments are to be collected by the trainer and forwarded to the evaluator for data collection.

Performance Change Survey • Self-reported changes in

behaviour/performance

The Performance Change Survey is an anonymous instrument and will be forwarded to all participants in each module 3 months after module completion. Survey items will be subject-specific to area of training. Instrument not to exceed 10 items. A return envelope will be provided for participants to return survey to the evaluator for data collection.

Behavioural change

Enablers/Barriers to Change Interview Interviews conducted with a sample of participants from each province to examine enablers and barriers to change.

Interviews conducted 3 months after module completion. 15 participants in training modules from each province to be recruited and interviewed by telephone. Maximum 60 interviews across provinces.

Change in organizational practice (Impact)

Perception of Organizational Change Focus Group Focus group conducted in each

Focus groups conducted at 6


27

province with sample of participants in training module. Interview Interviews with a practice site administrator from each site in each province in which a primary health team has been established.

months following training completion. Participants invited to comment on perceived and actual changes in interprofessional teamwork in primary health care practice. Maximum of 12 participants per focus group per province. Interviews conducted at 6 months following training completion. Administrators invited to comment on perceptions of change in interprofessional teamwork in primary health care practice. Maximum of 50 interviews across provinces.


28

Figure 1 BBTI Training Module Evaluation Design


29

Appendix B Pre-Training Confidence Survey

Self-Assessment

Participant Code No. _____

The following statements describe some abilities that are related to primary health care. Please rate your confidence in these areas on a scale of 1 = Low to 5 = High.

Confidence Ability Low High

1. Defining collaboration accurately.

1 2 3 4 5

2. Summarizing the underlying principles of

collaboration.

1 2 3 4 5

3. Utilizing the correct primary health care terminology.

1 2 3 4 5

4. Applying a collaborative approach to your work

1 2 3 4 5

5. Summarizing the elements required to be a

collaborative practitioner.

1 2 3 4 5

6. Applying your understanding of roles and scope of

practice to your own work situation.

1 2 3 4 5

7. Defining a target population.

1 2 3 4 5

8. Describing collaborative practice.

1 2 3 4 5

9. Identifying the role of collaborative practice in primary

health care.

1 2 3 4 5

Are there other areas in which you would like to enhance or develop your abilities for working in a collaborative practice?


30

Post-Training Confidence Survey Self-Assessment

Participant Code No.____

The following statements describe some abilities that are related to primary health care. Please rate your confidence in these areas on a scale of 1 = Low to 5 = High.

Confidence Ability

Low High

1. Defining collaboration accurately. 1 2 3 4 5

2. Summarizing the underlying principles of collaboration.

1 2 3 4 5

3. Utilizing the correct primary health care terminology.

1 2 3 4 5

4. Applying a collaborative approach to your work

1 2 3 4 5

5. Summarizing the elements required to be a collaborative

practitioner.

1 2 3 4 5

6. Applying your understanding of roles and scope of

practice to your own work situation.

1 2 3 4 5

7. Defining a target population.

1 2 3 4 5

8. Describing collaborative practice.

1 2 3 4 5

9. Identifying the role of collaborative practice in primary

health care.

1 2 3 4 5

Are there other areas in which you would like to enhance or develop your abilities for working in a collaborative practice?


31

Participant feedback Survey

Please identify your profession/role: Your Practice/Work Location (Site/Community):

Module Title: Training Location: Date:

Strongly Disagree

Disagree Neutral Agree Strongly Agree

1. This training module addressed my learning needs in this area.

1 2 3 4 5

2. The information which was provided was applicable to my practice/work.

1 2 3 4 5

3. My participation in this training module has enhanced my knowledge and skills in this area.

1 2 3 4 5

4. My participation in this module will influence my practice/work in the future.

1 2 3 4 5

5. The trainer was knowledgeable of the subject matter being presented.

1 2 3 4 5

6. The trainer presented the information in a clear and concise manner.

1 2 3 4 5

7. The trainer was enthusiastic and responsive to participant’s learning needs.

1 2 3 4 5

8. There was opportunity to interact with other participants.

1 2 3 4 5

9. There was opportunity to interact with the trainer.

1 2 3 4 5

10. The facilities were comfortable and conducive for learning.

1 2 3 4 5

11. The module was well organized. 1 2 3 4 5 12. I would recommend this training

module to others. 1 2 3 4 5


32

13. What did you like about this training module?

14. What changes or improvements could be made? 15. What aspects of your practice/work do you intend to change as a result of participating in

this training module? a. b. c.


33

APPENDIX C SELF-ASSESSMENT: HOW AM I DOING?

Please take a moment to reflect on the characteristics of an effective collaborative practitioner. The following table may be used as a self-assessment to monitor your progress as you participate in this course. Use a scale of 1 – 5 where 1 is a skill or attitude that requires a significant amount of work and 5 is a skill or attitude you have fully mastered. If you are uncertain about your understanding of a skill before or after the workshop, enter “Don’t Know” or “DK” beside the skill. First, complete the Pre-workshop Assessment by filling in the left-hand or “Pre-Workshop Rating” column for each question. We will return to complete the right-hand or “Post-Workshop Rating” column at the end of the module. Characteristics of an Effective Collaborative Practitioner Pre-Workshop

Rating Post-

Workshop Rating

1. Do you utilize various staff members for their particular

expertise?

2. Are you able to define those areas that are distinct in

your role from the role of other team members with whom you work?

3. Do you view part of your role as supporting the role of others with whom you work?

4. Do you work through conflicts with your colleagues in an effort to resolve them?

5. Do you believe that working as a team leads to outcomes that we could not achieve alone?

6. Do you go through a process of examining alternatives when making decisions with your colleagues?

7. Do you help your team members to address conflicts directly with each other?

8. Are you optimistic about the ability of your colleagues to work with you to resolve problems?

Post-workshop questions:

My strengths as a collaborative practitioner include: Things I would like to work on include:


34

APPENDIX D Collaboration in Practice Exercise

Sample Guidelines / Protocols

The following Collaborative Practice Clinical Guidelines / Protocol for Diabetes, Depression, and Hypertension and blank template (Diabetes) are provided as samples for use in negotiating the roles and responsibilities of health providers on your team. As such, the specific disease or illness can be replaced with any issue or problem your team has an interest in for the purpose of coming to some understanding about who does what, when it comes to dealing with a particular client/patient population you serve. The health care providers listed on the template and guidelines are also intended to be changed or adjusted so they are based on the actual providers who participate on your team, and may include family physicians, registered nurses, pharmacists, mental health therapists, dietitians, occupational therapists, physiotherapists, social workers, a relevant community organization and others, as appropriate. For example, you may have a health care professional that is not listed on the outline. If that is the case, please add another column. If a health care professional is included on the list, but not part of your team, remove them from the list. If someone from your team is missing from the negotiation process, leave them on the list and include a statement about what role / responsibility you expect that person to carry out. If you have clients or community members present, add columns to reflect their roles and responsibilities. When using the templates back at your worksite, please consider involving a client/patient as a team member in the process of negotiating roles and responsibilities.

SAMPLE

35

COLLABORATIVE PRACTICE GUIDELINES / PROTOCOL Guideline : Diabetes Care (Non-pregnant adults)

Approval Date:

Page:1 of 3

Goal of Care- To improve Glycemic control to achieve: A1C to- ˜7.0% , Fasting BG/preprandial PG- 4.0-7.0 mmol/l, 2hr postprandial PG- 5.0-10.0 Administrative Staff

Family Physician Care

Registered Nurse Care

Diabetic Educator

For: Management of patient scheduling, organizing chronic disease (CD)clinic day, bringing the CD team together for review of patients scheduled, could be the team manager for specific CD team

For: all initial, ill and unstable diabetes conditions, and annual physicals & written referral to physician specialists as required/ requested

For: follow-up of stable diabetes patients, initial education & identification of psycho- social concerns, q3/months & prn as required/ requested

For: all patients newly diagnosed with diabetes? referrals for education/advice as required/requested

Initial Visit -Collect demographic data -Place into the chronic disease register -Note idiosyncrasies (days, times etc.) related to CD day scheduling. -Gather patient medical-CD files for team review of patients scheduled for next CD clinic day. -Schedule patients for lab work (ensure results available for review during next visit) -Reminder calls to patients of appointments. -Recording data for program evaluation. -Advising clinicians of patient problems related to known hardships for families. (No money to purchase medications/ treatments prescribed)

Initial Visit S- history O-physical, Wt., BP, A-medical diagnosis P-Baseline Lab.work: A1C, Random BG, Fasting BS, Microalbuminuria, Lipid profile, if 8 Te/Tg, U/A, Cr, -medication -diet advice -screening for sexual dysfunction -referral to: nurse if stable for f/u; -written referral to: endocrinologist- prn opthalmologist- annually urologist - prn nephrologist - prn cardiologist - prn gastroenterologist - prn

Initial Visit S-concerns re: medication, side effects, diet, # of hypoglycemic events, social issues. O-Assess-ADLs, QOLs, social needs, -Weight, B/P, U/A, Foot exam -A1C q3/12 & plasma glucose PG as recommended by Diabetes Educator. A-identify problems P-refer as needed to: CF. physician prn & annually w Dentist prn CDECentre initially & prn CFoot care clinic prn CPsychosocial services prn CHome care prn CExercise program (ECG stress test prn) etc. -Assess: DEC teaching re insulin admin. & Glucometer use etc., compare BG meter readings with lab measurements of simultaneous venous FBG prn & at least annually. -ketone testing during periods of acute illness. -provide sample meal plan with suggested substitutions until seen by dietitian (i.e. AJust the Basics@ free CDA tool)

Initial Visit Education patient & family re: -diabetes & complications etc. -use of equipment to self-assess progress (CDA / pharmacies are compensated to teach BG monitor use, not usually DEC) -diet -exercise, -encouragement * Perhaps referral if target A1C not attained within 6-12 mos.

SAMPLE

36

etc. -emotional, social, economic concerns. -next appointment, -complete tracking form & record problems/ interventions/visit in medical record.

Administrative Staff Follow-up Visits

Family Physician Follow-up Visits

Nurse Follow-up Visits (or phone)

D.Educator Follow-up Visits (or phone)

-Collect changes to demographic data -Note new idiosyncrasies (days, times etc.) related to CD day scheduling. -Gather patient medical-CD files for team review of patients scheduled for next CD clinic day. -Schedule patients for lab work -Reminder calls to patients of appointments. -Recording data for program evaluation. -Advising clinicians of patient problems related to known hardships for families. (No money to purchase medications/ treatments prescribed) etc.

-referral from nurse -as needed following acute illness -q3/12 & prn for unstable diabetes conditions -annually for stable diabetes conditions -annually- Microalbuminuria, Cholesterol & TSH -specify metabolic targets with client and team

S- problems & concerns O-review BS readings & meal plan, # of hypoglycemic events, ADL issues (old & new), QOL issues, Social/ emotional/ spiritual concerns, medication adjustment w/ client -assess: understanding of disease and treatment etc., use made of suggested or prescribed referrals made from practice, A- identify problems, P- provide support & encouragement, verification of concerns, re-enforce useful information, -next appointment, -record problems & visit in medical record.

As needed for specific concerns

SAMPLE

37

Endocrinologist Care Opthalmologist Care Nutritionist/Dietition Care For: prn for assessment & treatment advise re complications of diabetes

For: prn and annually to assess for diabetes retinopathy, est. appropriate monitoring intervals

For: assessment of nutritional intake prn on referral & for specific dietary problems

Initial Visit S-Patient>s concerns O-History & physical A-confirmation of Family Physician assessment, complications, P-Advise to patient & Family Physician re: -medication, -diet -prevention of complications

Initial Visit Baseline data re vision and signs of diabetes related retinopathy and other visual complications

Initial Visit S- meal problems, wt. control, hypertension, hyperlipidemia, & combination conditions O- assess nutritional state, shopping / food prep. needs, economics issues re food/shopping preferences etc. P-educate to prevent hyper-/hypo-glycemia and to intensify diabetes control (carb counting, diet)

Endocrinologist Follow-up

Opthalmologist Follow-up

Nutritionist/Dietition Follow-up

-f/u re complication, prevention,

Type 1 - annually Type ll - q 1-2 years -prn for acute

concerns

-prn for acute concerns

Glossary of terms- A1C-glycosylated haemoglobin (reflects glycemia over 120 day life span of erythrocytes) Postprandial PG- 2 hr. Post dinner SMBG- self-monitoring of blood glucose FPG or Preprandial PG- fasting or ac dinner Resources: 2003 Clinical Practice Guidelines, CDA 2003 Clinical Practice Guidelines. S = Subjective (what the patient/client tells you); O = Objective (what you see/hear/smell); A = Assessment (based on S & O); P = Plan (based on S, O & A)

SAMPLE

38

COLLABORATIVE PRACTICE GUIDELINES / PROTOCOL Guideline: Depression

Approval Date: Revised Date:

Page: 1 of 3

Goal of Care- 9in symptoms, 9unnecessary contacts with health care system Personal goal- met & maintaining self-management of depression

Administrative Staff


Registered Nurse

LPN

Mental Health Staff

For: Management of patient scheduling, organizing chronic disease (CD)clinic day, bringing the CD team together for review of patients scheduled, ? team manager for specific CD team

For: Diagnosis, medication, refer for education about depression & care process, shared care, or referral for counselling, explains compliance. -?Manager of depression Program

For: Explains planned treatment options/goals, engage client to determine goal & self management, assess ability to self-manage, counsel or referral, encourage compliance with medication, counselling -?Manager of depression register/clinic

For: assisting team to provide a plan of care for the client & family, & maintaining the registry

For: Takes referrals from health centre, takes part in team management for client, communicates strategies for behavioural modification & follow-up, educates team,

Initial Visit -Collect demographic data -Place into the chronic disease register -Note idiosyncrasies (days, times etc.) related to CD day scheduling. -Gather patient medical-CD files for team review of patients scheduled for next CD clinic day. -Schedule patients for lab work -Reminder calls to patients of appointments. -Recording data for program evaluation. -Advising clinicians of patient problems related to known hardships for families. (No money to purchase

Initial Visit S - Self-identifies depression, or if client symptoms indicate possible depression. O - History, physical exam, assess response to recognition tools (attached); Assess suicide risk.; A -medical diagnosis using PHQ scores to determine if depression is minor, mild, moderate or severe (see attached); -Additional diagnosis; P - Tests to rule out other diseases/ conditions; -Treat according to severity of depression, i.e. watchful waiting, counselling, medication, hospitalization, or combination;

Initial Visit S - Verbalizes reason for attending & confirms reason for referral, O - History, physical/observation, active listening, assess suicide risk, - Assess degree of depression using PHQ-9, & type of f/u needed, -Assess ability to self-manage care, -assess support system, housing, financial issues, QOL, ADLs A - Identify problems to be addresses now & in f/u, P - Consult if suicide risk high, if depression severe, - Engage client in setting personal goals, family needs/goals, -Explain treatment/care process, -Education re depression, -Plan f/u (see attached suggested schedule f/u visit), community support systems, educational, pleasure

Initial Visit -Administer & score PHQ-9 questionnaire, -share educational resources with client, answer questions, -Explain the care process & what client should expect,, -Review side effects & when a clinician should be contacted, -schedule follow-up visits & establish a system for maintaining compliance & monitoring response to treatment i.e. transportation, phone, e-mail, fax etc.

Initial Visit -According to referral request, -Assess degree of depression (see attached), -assess suicide risk -consult or refer if suicide risk high, if medication response inadequate. What does hospital / community-based service look like? How does it fit?

SAMPLE

39

medications/ treatments prescribed) etc.

-F/u by self, other clinician (see attached suggested schedule f/u visit)

activities.

Administrative Staff Follow-up Visits


Nurse Follow-up Visits

LPN Follow-up

Mental Health Staff Follow-up

-Collect changes to demographic data -Note new idiosyncrasies (days, times etc.) related to CD day scheduling. -Gather patient medical-CD files for team review of patients scheduled for next CD clinic day. -Schedule patients for lab work -Reminder calls to patients of appointments. -Recording data for program evaluation. -Advising clinicians of patient problems related to known hardships for families. (No money to purchase medications/ treatments prescribed) etc.

Use planned visit approach day before visit: review goal of treatment, review medical care, self-management goals, problem-solving & follow-up plan. S- Response to ATwo question screen@, other complaints/concerns O- assess appearance, mood, response to counselling, medication, -assess self-management ability & progress to meeting personal goals, -assess compliance to treatment, -review test results with client & observe response, assess suicide risk, A- Response to treatment, medication, re-assess degree of depression, P- Further testing to rule out other diagnosis, -Consult or refer if required, -Medicate as needed -f/u according to response to treatment.

Use planned visit approach day before visit: review goal of treatment, review medical care, self-management goals, problem-solving & follow-up plan. S- Response to ATwo question screen@, other issues, concerns, O- assess appearance, mood, response to counselling, medication, -assess self-management ability & progress to meeting personal goals, -assess compliance to treatment -assess compliance to treatment & referral to community programs, -assess understanding of test results, -assess support system response, -Assess QOL & ADL -Assess suicide risk A- Response to treatment, medication, re-assess degree of depression & response as needed, P- Consult or refer if response to treatment inadequate or degree of assessed depression has increased, -Re-affirm personal goals, -Re-affirm treatment procedure -encourage compliance & self-management, -f/u visit according to response to treatment (see attached suggested

Use planned visit approach day before visit: review goal of treatment, review medical care, self-management goals, problem-solving & follow-up plan. -Repeat PHQ-9, -Assess compliance to referrals, medication, progress toward achieving personal goals, other contacts with health care system, -Encourage compliance, -degree of engagement in pleasure/sporting activities, -Arrange f/u visit according to plan.

Uses planned visit approach before visit: review goal of treatment, review medical care, self-management goals, problem-solving & follow-up plan. -assess suicide risk -assess support system response -assess pleasure activities

SAMPLE

40

schedule f/u visit), & Agut@ feeling Medical Internist/Specialist

Other- Community Programs

Other-

For: Consultation, commit to working with health centre collaborative, as consultant, educator, evaluator of referrals,

For: In collaboration with region- organize group activities, education, public education, self-help groups, school health fairs, teacher education, sporting activities, addictions

Initial Visit -According to referral request, History, physical, -Assess previous treatments & response, -Assess suicide risk -Recommend treatment to family physician, or follow-up by self

Identify community need for education related to specific issues to address understanding of depression, causes, support systems, barriers to effective care,

Medical Internist/Specialist Follow-up

Follow-up

Other Follow-up

-As requested by family physician, client;

Evaluation of effect of public education on self reporting of depression, attendance at public activities, queries related to depression & care process,

* ATwo Question Screen@- Questions: In the past month have you often been bothered by: 1. Little interest or pleasure in doing things. 2. Feeling down, depressed or hopeless. If client answers yes to either consider asking more detailed questions i.e. PHQ-9. Resource: -The MacArthur Initiative on depression & Primary Care at Dartmouth & Duke, Depression management Tool Kit, V1.1 July, 2003. -Health Disparities Collaboratives, Changing Practice Changing Lives, Depression. S = Subjective (what the patient/client tells you); O = Objective (what you see/hear/smell); A = Assessment (based on S & O); P = Plan (based on S, O & A)

SAMPLE

41

COLLABORATIVE PRACTICE GUIDELINES / PROTOCOL Guideline : Hypertension

Approval Date:

Page: 1 of 3

Goal of Care- To maintain/ reduce blood pressure to 129/84 mmHg (normal 120/80) Personal Goal -

Administrative Staff Family Physician Care

Nurse Practitioner Care


LPN Care

Pharmacists Care

For: Management of patient scheduling, organizing chronic disease (CD)clinic day, bringing the CD team together for review of patients scheduled, could be the team manager for specific CD team.

For: Diagnosis, all hypertensive urgencies/emergencies, all at risk of Coronary heart disease (CHD), all Grade D (major organ involvement), annual f/u physicals & referrals from nurse, written referral to physician specialists as required/ requested.

For: Shared care for diagnosis procedure, f/u hypertension, education, lifestyle, referral for weight control, referral, monitoring, education, of adults 19 years and older.

For: Follow-up of clients diagnoised, and receiving treatment for non major organ hypertension involvement & according to management plan, , education & identification of psycho- social concerns, support, weight control,

For: Group care, organizing hypertensive clinic & education sessions

Initial Visit -Collect demographic data -Place into the chronic disease register -Note idiosyncrasies (days, times etc.) re CD day scheduling. -Gather patient medical-CD files for team review of patients scheduled for next CD clinic day. -Schedule patients for lab work (ensure results available for review during next visit) -Reminder calls to patients of appointments. -Recording data for program evaluation. -Advising clinicians of patient problems related to known hardships for families.

Initial Visit S- History, -review medication (prescribed & other), alcohol & tobacco use, O-Physical, Wt., BP, A-Begin investigations to explain [ BP P-Baseline Lab.work: CBC, blood chemistery, fasting Lipid profile, fasting BS, ECG, -medication -diet advice, -referral to: NP assist with diagnosis protocol; RN, if stable for f/u; -written referral to specialist- if drug therapy ineffective, poorly tolerated, or contraindicated, pregnancy & prn

Initial Visit S- History, medication (prescribed & other), O- Physical including meticulously measure BP of all clients with risk factors for CHD, diabetes, CHF, renal disease, certain cultural heritages (African), Wt., U/A, CBC, blood chemistry, fasting BS, fasting lipid profile, ECG, Investigation of hypertensive episode i.e. repeat BP measure twice in same visit if initial reading abnormal. If still [consult with physician, (home self monitoring if necessary), f/u x 3-5 visits at monthly intervals before making final diagnosis (Follow guidelines for diagnosis). A- Identify needs/problem P- Refer to MD: if pregnant, child, -Consult if BP remains [ after 3rd

Initial Visit S-Concerns re: diagnosis, diet, social issues,medication, side effects, exercise, personal goal. O-Assess- Weight, meticulous B/P measurement, U/A, ADLs, QOLs, emotional/social needs, A-Identify needs P-Refer as needed to: CShort term plan to meet personal goal CFamily physician prn & annually, CPsychosocial services prn CExercise program etc. CDietitian referral, -complete tracking form & record problems/next visit -interventions/visit in medical record.

Initial Visit As agreed by team to meet objectives of the Health Centre hypertensive program.

Initial Visit

SAMPLE

42

(No money to purchase medications/ treatments prescribed) etc.

reading, dietician/social services as needed, exercise program, -Education -next visit & record keeping

-next visit monthly if on hypertensive medication (arrange with f/u for health problems i.e. diabetes, CHF etc.) & -Charting

Administrative Staff Follow-up

Family Physician Follow-up

Nurse Practitioner Follow-up

Nurse Follow-up

LPN Follow-up

??? Follow-up

-All urgent/emergent hypertensive episodes. -Client self referral -referral from nurses -as needed following acute illness/ episode -annually

Visit 2: S- Confirm personal goal, issues/ concerns, , O- Wt., BP., U/A, appearance, emotional & social issues, review self BP readings, A- If BP still8repeat history & physical P- arrange diagnostic test ? In consultation with FP. Visit 3: S- Confirm personal goal, issues/ concerns, , O- Wt., BP., U/A, appearance, emotional & social issues, review self BP readings, review diagnostic test results, A- If target organ damage & BP >140/90 consultation re confirmation of essential hypertension & treatment; If no target organ damage but BP>180/105 consult re confirmation & treatment of essential hypertension (see exceptions for clients with diabetes, renal disease [individual goal 130/80, proteinuria >1g/day [then individual goal 125/75]). P- Encourage compliance with treatment & lifestyle changes. -plan visit 4. Visit 4: Address concerns, measure

S- Confirm personal goal, issues & concerns O- Appearance, B/P, Wt., U/A, review self BP readings, physical activity, ADL issues (old & new), QOL issues, Social/ emotional/ spiritual concerns, -assess: understanding of disease and treatment etc., use made of suggested or prescribed referrals made from practice, A- Identify problems, P- Provide support & encouragement re lifestyle i.e. smoking, exercise, weight control etc., verification of concerns, re-enforce useful information, -Follow-up as requested by physicians in investigate of hypertensive episode. -next appointment, -record problems & visit in medical record.

As agreed to by team to meet objectives of the Health Centre hypertensive program.

SAMPLE

43

BP, re-enforce lifestyle changes. Visit 5. As visit4. If BP>140/90then diagnosis is confirmed, treat for essential hypertension, If BP<140/90 & no organ damage review annually.

Medical Internist/Specialist

Dietician

????

For: Consultation for assessment & treatment advise re hyperlipidemia treatment

For: Consulted for weight control, low sodium, protein, sugar, fat,

Initial Visit Family physician referral request S-Patient>s concerns O-History & physical A-confirmation of Family Physician assessment, complications, & medication P-Advise to patient & Family Physician re: -management -medication, -diet -prevention of complications

Initial Visit S- meal problems O- willingness to comply, A: Assess nutritional state, shopping k/h, food prep. needs, economics issues re food/shopping preferences etc. P-to address problems -Report to person who made referral,


Dietitian Follow-up

Resource: Clinical Practice Guidelines, Guidelines Advisory Committee, (http://gacguidelines.ca/articles.pl?sid)

SAMPLE

44

COLLABORATIVE PRACTICE GUIDELINES / PROTOCOL Guideline: Diabetes Template

Approval Date:

Page: 1 of 3

Goal of Care- Personal goal-

Administrative Staff



Diabetic Educator

For:

For:

For:

For:

Initial Visit S- O- A- P-

-Initial Visit S- O- A- P-

SAMPLE

45

Administrative Staff Follow-up


Nurse Follow-up Visits (or Phone)

Diabetic Educator Follow-up Visits (or Phone)

Use planned visit approach before visit: gather medical files, file all reports (Lab. etc.), bring team together for quick (10-15 mins.) review of scheduled/other patients. Call to remind patients.

Use planned visit approach day before visit: review goal of treatment, review medical care, self-management goals, problem-solving & follow-up plan. S- O- A- P-



SAMPLE

46

Medical Internist/Specialist Other- Community Programs Nutritionist/Dietitian Care For: Consultation, commit to working with health centre collaborative, as consultant, educator, evaluator of referrals,

For: In collaboration with region- organize group activities, education, public education, self-help groups, school health fairs, teacher education, sporting activities, addictions

For: Assessment of nutritional intake prn, on referral, and for specific dietary problems.

Initial Visit -According to referral request, History, physical, -Assess previous treatments & response,

Initial Visit Identify community need for education related to specific issues to address understanding of depression, causes, support systems, barriers to effective care,

Initial Visit


Community Programs Follow-up

Counsellor Follow-up

Resource:

Health & Medicine

Collaboration In Practice