Theme 5. Coordinating care to create better transitions
Presentation Details
- Date: 10/17/2016
- Concurrent Session B
- Time: 3:30pm – 4:15pm
- Room: Pier 4
- Style: Presentation (information provided to audience, with opportunity for audience to ask question)
- Focus: Practical (e.g. Presentation on how to implement programs and/or practices in the team environment)
- Target Audience: Clinical providers
Learning Objectives
- Identify key components of proactive or planned COPD management utilizing various members of the inter-professional team
- Learn how to design and implement a COPD management program within your office setting
- Understand how the EMR can be a tool for the identification, management and evaluation of COPD patient care
- Demonstrate an approach to care coordination and transition into primary care post COPD related ER visits or hospitalization
Summary/Abstract
The “INSPIRE” program is currently being implemented and therefore data collection is underway. We anticipate the following clinical outcomes:
- Improved MRC Dyspnea Scale and CAT (COPD assessment test) scores
- High patient satisfaction with care
- Increased rates of patients who are up to date with their vaccinations – influenza, pneumococcal
- 100% of patients receive a personalized COPD action plan and referral to smoking cessation resources
- Reduction in the number of yearly COPD exacerbations, ER visits or hospitalizations
- 90% of patients will be seen by team within 2 weeks of ER or hospital discharge related to COPD
Presenters
- Colleen Youngs, Primary Care Nurse Practitioner, RN EC, Bridgepoint Family Health Team
- Victoria Siu, Pharmacist, Bridgepoint Family Health Team