Languages
Pages
Legal
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 headphonesTeleconference:
Toll-free: 1 800 194 290Access Code: 267-203-043
Audio PIN: Shown after joining the training
Care Planning Masterclass- Part 2 -
Presenter: Dr Tony Lembke Guest speaker: Ms Ros RollestonDate: 8 April 2014
How to participateOpen 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
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
Is being held on Weds May 14th 2014.•
Check local guides.
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.
• 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
Top Related