Collaborative Pathway

Learning Session 1 (3.5 hours): / Action Period 1
Minimum Requirements / Learning Session 2 (3.5 hours):
/ Action Period 2
Minimum Requirements / Learning Session 3 (3.5 hours):
Comorbidity
Introductions(20, include 10 for discussion)
  • Opening remarks from family physician,
  • Housekeeping, overview to PSP
  • Module expectations with a poll/table discussions. Include Action Period Requirements.
Patient Story or Video Clip (15)
Core Content
  • COPD 101(25)
  • Guidelines
  • Local data for the community
  • Gap in care and system of care
  • Local respiratory services (15, including 10 didactic + 5 questions)
  • COPD-6 training (30, 10 didactic + 20 trying it out)
  • QuitNow (5)
  • Integrate into the workflow discussion – COPD (10)
Break (15)
  • Heart Failure 101 (40)
  • Guidelines
  • Local data for the community
  • Gap in care and system of care
  • Local HF clinic services (20, including 10 didactic + 10 questions)
  • Integrate into the workflow discussion – HF (10)
Action Planning Expectations (5)
  • Reinforce deliverables: including average time spent for COPD 6 per patient
  • Action Period funding, support, requirements
  • Engage MOA in data collection – e.g. fax back weekly and registry

Planning for the action period including evaluation (20): /
  1. Registry
  2. Total ______patients on COPD registry and on __HF registry
  3. Casefinding and testing with COPD-6 device – Minimum 6 patients.
    Document FEV1 per patient visit.
  4. Referred for Ejection Fraction or Brain Natriuretic Peptide (BNP) Diagnostic testing - Minimum 2 patients.
/ Introduction, Sharing AP review, set stage for next AP, success and lessons learned (35)
Patient Story or Video Clip (10)
Core content:
Medication for both COPD and HF (60, 40didactic + 20 discussion)
  • MOA break out: office flow, support smoking cessation, PSM, resources, education around HF, Ebsworth Scale, sleep apnea
Break (15)
PSM Support
  • COPD and AECOPD Management (30, 20 didactic + 10 questions)
  • Heart Zones and other PSM tools (30, 20 +10 questions)
  • Smoking cessation (10, 5 didactice + 5 questions)
Sharing the care with the specialist and referral process– maybe Partners in Care
Planning for Action Period 2, including evaluation (20): /
  • Smoking cessation interventions with patients – 6 patients
  • COPD Patients with an exascerbation plan – 3 patients
  • HF patients who bring self-management goal logs – or who have been Rx ACE/ARBs or Beta Blockers – 2 patients
  • Review medications for COPD and HF patients
  • Try outa practice change with a respirologist /cardiologist/ internist regarding the referral and consult process
/ Intro (5)
- handout evaluation form at beginning or at break.
Sharing success and lessons learned – HF and COPD (60):
Co-morbid Patient Story: (10)
Core material:
  • Comorbid patients (60, 40 didactic + 20 discussion )
  • How to differentiate between HF and COPD
  • Comorbidity management
  • Sharing the care with the specialist, referral and resources (15, 10 didactic + 5 facilitated discussion)
  • Optional:End of Life HF/COPD – e.g. palliative sp
Break (15)
Planning for Sustainability (30, 15 didactic + 15 discussion):
Wrap up (30 – mostly evaluation)
MOA: tools for HF patients

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