In the chronic care team at the Ferndale clinic we are currently ramping up the pilot of the shared care plan. Slow but sure and always headed forward. We think we can, we think we can, we think we can....
Berdi has made efforts with some diabetic patients and it appears that quite often either there is little interest or it really isn't as urgent a need for them as it could be for others. In thinking about what might be a good first target group, the idea was raised to work with the population with HF. There appears to be a few benefits to this approach.
- We are going to have to identify these patients later to enter into the HF registry anyway, so by identifying them now, we can obtain our target population and also lay some ground work for future HF registry implementation (list of patients).
- The specialist on the care team for HF patients very often (not always) is part of NCC which is a pilot site. This will allow us to see the flow of the shared care plan from both ends as we have access to NCC.
- And these patients appear to be a group that may be more receptive because they have a greater need for a tool like the Shared Care Plan (SCP).
Once our list is finalized we plan on pulling the charts and labelling them like charts are labelled for Diabetes in the FCN clinics (this was implemented when the DM registry was put in place before P2). We have two labels being generated - A hot pink label for HF and a neon green label for SCP.
Kaye Palmer is getting a list from Nancy Stothart and from Sally who is the FCN care manager for CHF with group health's program and people with either of those two will automatically be flagged without a confirmation required. She is also looking into reporting on IDC9 code within their data and trying to flush out the right patients. Once a list has been generated we were going to look to the PCP to confirm the diagnosis before labelling the charts etc. Jeanmarie and Brian are confirming the ICD9 codes used by systems dynamics and in NCC's implementation of the HF registry to confirm we are all talking about the same patients.
Discussions with Lori Nichols and Dawn Gauthier triggered some question as to whether the registry input might be used to help with the initial volume of SCPs to be created. The hope was that the demographic information already entered for the registry could be 'scooped' for the first pass 'mass SCP creation' for those patients. They are looking into this and to date it appears this would be fairly simple once the patients have "c" accounts for the registries. Jeanmarie estimated that perhaps even within 3 weeks we might have the registry patients entered and confirmed and at that time we could isolate those patients within NCC that have a PCP in Ferndale and start from there.
Heads were also put together to try and simplify the process in the clinic for outputting medication list information from the SCP. Dawn is going to make some modifications to the printing to have it default to no sections checked but also add an option for the entire plan, currently each section has a checkbox and the default is that they are all checked. Every little improvement for the clinic will help in the final implementation. I believe there needs to be a way, as Lori had already commented previously, that we can somehow replace our medication list flowsheet in the charts at the clinics with the meds section of the SCP. This would involve having it print differently. I look forward with anticipation working with Dawn and crew on the single medication list implementation. That is obviously extremely interwoven into the Shared Care Plan success in the clinics.
Still advocating computers in the rooms as soon as possible....
