Health Links COPD Change Ideas

Transcription

1 Health Links COPD Change Ideas Action Period #1 Grand Bend Area CHC South Huron Hospital Association CCAC Bluewater Area Family Health Team Please insert team photo Health Links Learning Collaborative

2 Our Aim Statement The South Huron Hospital, Bluewater Family Health Team, SW CCAC and Grand Bend Area CHC s approach to COPD is: Give priority to health promotion and illness prevention. Achieve person centred care and focus on selfmanagement approaches. Facilitate coordinated and integrated multidisciplinary care across services, settings and sectors. Health Links Learning Collaborative 2

3 Provide the most effective care using best practice and practice models that encompass the continuum of care. Work in partnership and collaboratively. Meet the needs of special population groups. Monitor Progress and adjust accordingly. Achieve significant and sustainable change Health Links Learning Collaborative 3

4 Change Ideas Each patient is provided with an education, information package when enrolled in the program and now part of that package is a reminder sticker. If you are admitted to hospital, please call the Better Breathing Team. We need to check on your lungs and medications. Health Links Learning Collaborative 4

5 Change Ideas All GBA CHC MDs are enrolled on LENS (London Hospital Electronic Notification System) to be informed of Admissions and Discharges from Thames Valley Hospitals. Primary Care Appointment is made in office or home within 7 days. Health Links Learning Collaborative 5

6 PDSAs Short objective of cycle: To teach the COPD patients about informing our team when they go to hospital to allow opportunities for teaching on inhaler usage, Action Plans and education on new inhalers as required. Test/Implementation Plan: Call all of the current active BBT patients to get a baseline of recent hospital admissions Health Links Learning Collaborative 6

7 Measures/Data collected Predictions: 1. An up to date list of patients with hospitalizations within the past 6 months 2. Patients will understand that our Better Breathing Team (BBT) and Primary Care Team (NPs/MDs) can support them before and after hospitalizations and work to prevent admissions and exacerbations Health Links Learning Collaborative 7

8 Data Collected After one month of LENS implementation with GBA CHC patients, 83% of High Needs patients discharged from Thames Valley Hospitals have had an appointment with a GBA CHC Primary Care Provider within 7 days of discharge. Health Links Learning Collaborative 8

9 Outcomes All patients that are active in our program will be called and their data will be entered into an Excel Spreadsheet that will be shared with the team regarding recent hospitalizations. Education regarding team notification of change in health status. Health Links Learning Collaborative 9

10 Learnings What worked Patients were delighted to receive a telephone call. They all described their breathing, coaching occurred on the phone call based on needs and they felt part of the team. What didn t work Explained that some admissions were not related to COPD and did not need to be reported. Some patients need a refresher on the team and our role to understand our goals in preventing admissions. Health Links Learning Collaborative 10

11 Learnings As well as COPD hospitalizations, we have been able to identify other chronic diseases and provide follow up with Primary Care or other GBA CHC Allied Health Programs eg. Falls prevention, exercise programs. Health Links Learning Collaborative 11

12 Next steps Each team member will educate patients on admission history or ED visit reporting This data will be entered into the spreadsheet for the team list as record of admissions/changes. Patients with recurrent admissions will be identified for a Coordinated Care Plan and team approach to managing their health. Annual data review of admissions and completed CCP s will demonstrate team effectiveness and changes in team approach if required. Health Links Learning Collaborative 12

13 Next Steps Continuation of LENS program. Hold once per month COPD clinic at BAFHT GBA CHC Respiratory Therapist to hold Spirometry to re-inforce best practices in spirometry testing to ensure consistent spirometry test results. Sharing of Coordinated Care Plans with CCAC Build Experienced Based Design (EBD) into Care Planning. Health Links Learning Collaborative 13

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