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Careplan masterclass 2
- 1. Care Planning Masterclass – Part 2 - This session will begin at 6pm (WA), 7:30pm (NT, SA), 8pm (ACT, NSW, QLD, VIC, TAS) If using VOIP please use your headphones Teleconference: Toll-free: 1 800 194 290 Access Code: 267-203-043 Audio PIN: Shown after joining the training
- 2. Care Planning Masterclass - Part 2 - Presenter: Dr Tony Lembke Guest speaker: Ms Ros Rolleston Date: 8 April 2014
- 3. How to participate Open and hide your control panel Join audio: • Choose “Mic & Speakers” to use VoIP or you can • Choose “Telephone” and dial using the information provided Raise your hand to ask a question or Submit questions and comments via the Chat panel We will mute everyone to minimise background noise
- 4. Presenter – Dr Tony Lembke Guest speaker – Roslyn Rolleston,
- 5. Learning Objectives Review PNIP Examine cycles of care Develop patient centred assessment Establish patient agreed goals The 7CCs framework
- 6. PNIP http://www.health.gov.au/internet/main/publishing.nsf/Content/pnip Introduced in January 2012 to support an expanded and enhanced role for NiGP $25000:1000 SWPE for RN working 12.6 hrs/wk Rural and AMS loading from 15 – 50% $5000 to help practice become accredited
- 7. MBS Rebates http://www9.health.gov.au/mbs/fullDisplay.cfm?type=note&q=A37&qt=noteID&criteria=721 Annual Diabetes Cycle of Care 2517/21/25 = $36.30 – $103.50 Asthma Cycle of Care 2546/52/58 = $36.30 – $103.50 Mental Health Care Plan – GP time only 2700 series = $70.30 – $131.45
- 8. Practice CDM Process Team based, collaborative care Defined GP & GPN roles Patient identification Agree procedure & length of appointment Template selection Organisation of recalls
- 9. Setting the Scene 1 hour appointment Review file, load template Active listening, be attentive Body language Open ended questions Include patient in decisions
- 11. BMI BP, P & regularity, BGL, SpO2 Pathology Medications In the Beginning...
- 12. Patient Needs Assessment Rate health on scale 1-10 Main health concern Duration of illnesses Knowledge of illnesses
- 13. Nutrition Is your diet healthy Breakfast, lunch, dinner, snacks Fruit and vegetables Meats, bread & dairy Water, salt Processed foods, takeaways
- 14. Activity Activities enjoyed How active is your lifestyle Barriers to activity Mobility Specific exercise
- 15. Mental Health & Wellbeing Daily routine Sleep patterns Do you ever feel sad or alone Do you have any worries or concerns Substance use including smoking & alcohol Self harm, suicidality
- 16. Medications Concurrence Complimentary therapies Side effects Regular Pharmacist HMR
- 19. Cardiovascular Risk TC, LDL, TC:HDL Triglycerides LFTs Statin BP, P, BGL ECG
- 20. Renal Protection eGFR Microalbuminuria & ACR U/E/C, K+ ACE or ARB NSAIDS BP, BGL
- 23. Goal Setting
- 24. SMART Goals TRADITIONAL Specific Measureable Achievable Realistic Time frame CONTEMPORARY SMall Authentic Review Time frame
- 25. Stages of Change Pre-contemplation Preparedness Contemplation Action Maintenance Reflection
- 27. Goal Setting Patient agreed goals Maximum of 3 Simple – arrange appointments – walk the dog – lose 5kgs – play some golf
- 28. Patient problems / needs / relevant conditions Today's Assessment Review Assessment Knowledge and self management Nutrition Activity/Mobility Mental Health and Wellbeing BP BP: P: BGL: SpO2: BMI H: W: BMI: Smoking Alcohol Medications INR: HMR: Immunisations Cardiovascular Risk TC: LDL: TC:HDL: ECG: Renal Protection eGFR: Vision Preservation Peripheral Circulation Dentition Specialists
- 29. Team Care Members & Contact Details Required treatments and services Goals
- 30. In the End… Thank the patient for coming Congratulate them on becoming an active participant in their health care Invite patient to call if have any questions
- 31. 7CCs Framework
- 32. 7 Care Components of a Chronic Conditions Consultation http://bit.ly/7ccsccc
- 33. 1. Concerns Comprehensive Core Changes Concerns
- 34. Care Team and Communications Consultants Other Clinicians Chompers Chemist
- 35. Challenges Calories In Calories Out Ciggies, Coldies and Chardies Cool things Catnap
- 36. Conditions
- 37. Concurrence Charts Communications (PCEHR)
- 39. Calendar Calendar Check Up Charge
- 40. Summary CONCERNS identified, plans to deal with them Identified CARE TEAM, COMMUNICATIONS from them and to them are up to date Addresses core CHALLENGES and goals CONCURRENE of medications, SHS and hand held records
- 41. Summary (cont) Patients have everything they need before the next visit, and CONFIDENCE about what they need to do Schedule for CHECK UP for Preventative health, review date is on the CALENDAR, CHARGED appropriately http://bit.ly/7ccsccc
- 42. Presenter – Dr Tony Lembke Guest speaker – Roslyn Rolleston,
- 43. Next qiCommunity webinar Cardiovascular Risk Factors Heart Foundation Is being held on Weds May 14th 2014. • Check local guides.
- 44. is a space where you can come together to share ideas, challenges and resources. The discussion forums provide the ideal area for you to engage in conversation with colleagues across the country, ask for help or advice, celebrate success and lots more.
- 45. • Evaluation is important to us • Please complete the evaluation form that will appear after you log out EVALUATION FORM Thank you for your attendance Evaluation Forms
Notas del editor
- HousekeepingAgendaBriefly introduce topicInteracting and asking questionsFeel free to ask questions at any time by typing in the question pane. But duse to overwhelming amount of attendees, I will apologise now if we do not get to all of your questions. After the webinar we will collate all questions on the chat log and for the ones we have not answered refer them to Tony and Ros and send out the collated responsesTaping of the sessionThis session will be taped, edited and a podcast made and distributed via qiConnectHand over to Tony
- HousekeepingAgendaBriefly introduce topicInteracting and asking questionsFeel free to ask questions at any time by typing in the question pane.Taping of the sessionThis session will be taped, edited and a podcast made and distributed via qiConnectHand over to Tony
- ASGC-RA 15% - 25000-99999, 20% - 10000-24999, 25% remote centre - >5000, 40% - <1000050% - other remote <5000 & AMS
- Cycle of care not billable on samDACC $1, $20 PIP.DM SWPE when 50% DACC billed, $40 SIPACC @0.25 PIP, $100 SIP
- Team meetingQuality systems and governanceGeneric template
- What you are trying to do is build a relationship of trust so that the patient feels safe when I ask about theirSMBGL and they answer not as much as I should then probably havent done it for 2 yearsRange – if they answer 6-8 then they are probably not doing it regularly. Are they squirming?
- Assess knowledge & cognition concurrence, side effects, complimentary therapies, HMRPlace the scales between the patient and chair – is your weight stableDiscussion about accepted levels, increases health literacy and improves motivation for self managementRelate pathology to medications
- Always looking for opportunities for positive reinforcement
- Water, salt, fibre, full fat dairy, takeawayActivity not exercise – physical disabilitiesNeed for CNC, dietician, EP
- Stable on feet, falls prevention, mobility aids
- Lipids, LFTs, BP, ECGeGFR, urine microalbumin, ACE or ARB, BPCRP, FBC, Optometrist, Dopplers
- With your time management skills you have been able to identify the stage of change the patient is inChange is a process
- SMART goalsKISS – keep it short and simpleMotivational Interviewing
- 10997, 10987Hand over is gold, prevent the patient from bringing other issues into the care plan consult
- HousekeepingAgendaBriefly introduce topicInteracting and asking questionsFeel free to ask questions at any time by typing in the question pane.Taping of the sessionThis session will be taped, edited and a podcast made and distributed via qiConnectHand over to Tony
- is a space where you can come together to share ideas, challenges and resources. The discussion forums provide the ideal area for you to engage in conversation with colleagues across the country, ask for help or advice, celebrate success and lots more.Also if you are interested in hearing about a certain topic, please log it on the discussion forum.