Care Planning Masterclass– Part 2 -

This session will begin at 6pm (WA), 7:30pm (NT, SA), 8pm (ACT, NSW, QLD, VIC, TAS)

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Toll-free: 1 800 194 290Access Code: 267-203-043

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Care Planning Masterclass- Part 2 -

Presenter: Dr Tony Lembke Guest speaker: Ms Ros RollestonDate: 8 April 2014

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Presenter – Dr Tony Lembke

Guest speaker – Roslyn Rolleston,

Learning Objectives

Review PNIP

Examine cycles of care

Develop patient centred assessment

Establish patient agreed goals

The 7CCs framework

Care Planning

MasterclassPart 2

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

Care Planning

MasterclassPart 2

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

Care Planning

MasterclassPart 2

Practice CDM Process

Team based, collaborative care

Defined GP & GPN roles

Patient identification

Agree procedure & length of appointment

Template selection

Organisation of recalls

Care Planning

MasterclassPart 2

Setting the Scene

1 hour appointment

Review file, load template

Active listening, be attentive

Body language

Open ended questions

Include patient in decisions

Care Planning

MasterclassPart 2

Patient Centred

Assessment

BMI

BP, P & regularity, BGL, SpO2

Pathology

Medications

In the Beginning...

Care Planning

MasterclassPart 2

Patient Needs Assessment

Rate health on scale 1-10

Main health concern

Duration of illnesses

Knowledge of illnesses

Care Planning

MasterclassPart 2

Nutrition

Is your diet healthy

Breakfast, lunch, dinner, snacks

Fruit and vegetables

Meats, bread & dairy

Water, salt

Processed foods, takeaways

Care Planning

MasterclassPart 2

Activity

Activities enjoyed

How active is your lifestyle

Barriers to activity

Mobility

Specific exercise

Care Planning

MasterclassPart 2

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

Care Planning

MasterclassPart 2

Medications

Concurrence

Complimentary therapies

Side effects

Regular Pharmacist

HMR

Care Planning

MasterclassPart 2

Immunisation

Seasonal flu

Pneumococcal

Hep B

dTpa

MMR

Care Planning

MasterclassPart 2

Medical Guidelines

Cardiovascular Risk

TC, LDL, TC:HDL

Triglycerides

LFTs

Statin

BP, P, BGL

ECG

Care Planning

MasterclassPart 2

Renal Protection eGFR

Microalbuminuria & ACR

U/E/C, K+

ACE or ARB

NSAIDS

BP, BGL

Care Planning

MasterclassPart 2

Microvascular Protection

Vision

Feet

HbA1c

eGFR

BP

Care Planning

MasterclassPart 2

Further Investigations

FBE

CRP

Na+

B12

Vitamin D

Care Planning

MasterclassPart 2

Goal Setting

SMART Goals

TRADITIONAL

Specific

Measureable

Achievable

Realistic

Time frame

CONTEMPORARY

SMall

Authentic

Review

Time frame

Stages of Change

Pre-contemplation

Preparedness

Contemplation

Action

Maintenance

Reflection

Care Planning

MasterclassPart 2

Motivational Interviewing

Priority

Importance

Readiness

Confidence

Tools

http://www.healthchangeaustralia.com

Care Planning

MasterclassPart 2

Goal Setting

Patient agreed goals

Maximum of 3

Simple – arrange appointments – walk the dog

– lose 5kgs

– play some golf

Care Planning

MasterclassPart 2

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

Team Care Members & Contact Details Required treatments and services Goals

In the End…

Care Planning

MasterclassPart 2

Thank the patient for coming

Congratulate them on becoming an active participant in their health care

Invite patient to call if have any questions

7CCs Framework

7 Care Components of a Chronic Conditions Consultation

http://bit.ly/7ccsccc

1. Concerns

Comprehensive CoreChangesConcerns

Care Team and CommunicationsConsultantsOther CliniciansChompersChemist

Challenges

Calories InCalories OutCiggies, Coldies and ChardiesCool thingsCatnap

Conditions

Concurrence

ChartsCommunications (PCEHR)

Confidence and Chores

Calendar

CalendarCheck UpCharge

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 goalsCONCURRENE of medications, SHS and

hand held records

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

Presenter – Dr Tony Lembke

Guest speaker – Roslyn Rolleston,

Next qiCommunity webinar

Cardiovascular Risk FactorsHeart Foundation

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