Practice Support Program Chronic Disease Management LS

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Practice Support Program Chronic Disease
Management LS 2Thompson Region

• October 3, 2007

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Objectives for LS 2

• Progress to date
• Hear about your experiences so far
• Address your questions
• Understand baseline data
• Create an Action Plan for AP 2
• Gain your input around the next learning sessions
  for CDM and future modules
• Provide hands-on training on the Toolkit

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Progress to date?
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Have you

• Applied for Toolkit and the Practice Profile
  Analysis?
• Installed the Digital Certificate?
• Identified your patients?
• Started using flowsheets consistently?
• Entered your baseline data? (by Nov 15th)

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Sample Baseline Timeline
Baseline is the data collected to get
started.In AP1, review charts and create
flowsheets for all patients with the condition,
where they have data within the baseline time
period
AP12 Enter baseline data for all patients

• AP3 later
• Start making improvements
• Add baseline for new patients as they are IDd

AP Action PeriodLS Learning Session
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Reference Materials

• Baseline and Patient Inclusion Criteria for CDM
• Baseline Observation Dates and Date Ranges by
  Condition
• CDM Toolkit How to add a Patient Flow Sheet and
  Enter Baseline Data
• Sample Flow Sheets for
• CHF
• CKD
• COPD
• DM
• Hypertension/CVD/CKD Prevention
• COPD Flow Sheet Reference Tables
• CDM Toolkit User Guide (in your white binder from
  LS1)

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DM
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DM

• Inclusion Criteria
• Any patient with a previous diagnosis of DM.
• Exclusion Criteria
• Patients with impaired glucose tolerance,
  impaired fasting glucose, metabolic syndrome
• Patients with gestational diabetes.

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DM
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UKPDS Risk Calculator for Coronary Heart Disease
Risk forPatients with Type 2 Diabetes
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CHF
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CHF

• Inclusion Criteria
• Any person with a clinical diagnosis of CHF,
  currently being treated.
• Any person with an EF lt40 regardless of signs or
  symptoms.
• Exclusion Criteria
• Patients not meeting either of the inclusion
  criteria above.

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CHF
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CHF
Use of Heart Failure Medication in CHF Patients
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CHF
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Age-stand. incidence, prevalence and mortality
for CHF (VIHA)
CHF
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CKD
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CKD

• Inclusion Criteria
• Any person with an eGFR of 50 or less.
• Optionally Any person with a previous diagnosis
  of CKD regardless of eGFR. Note we recommend
  that for patients with an eGFR of 50 or more, you
  use the cardiovascular risk reduction
  (Hypertension/CVD/CKD Prevention) flowsheet if
  you plan to maintain a patient registry for this
  population.
• Exclusion Criteria
• Any person with an eGFR greater than 50 without a
  previous diagnosis of CKD.

Note we recommend that for patients with an eGFR
of 50 or more, regardless of a previous
diagnosis of CKD, you use the cardiovascular risk
reduction (Hypertension/CVD/CKD Prevention)
flowsheet if you plan to maintain a patient
registry for this population.
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CKD
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COPD
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COPD

• Inclusion Criteria
• Any patient with a spirometric diagnosis of COPD
  (FEV1 lt80 predicted and FEV1/FVC lt70).
• Any patient with a previous diagnosis of COPD
  where spirometry is not available or patient is
  unable to perform
• Exclusion Criteria
• Any patient with an FEV1 gt80 predicted pre or
  post bronchodilator.

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COPD
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Hypertension / CKD / CVD Prevention
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HTN/CVD/CKD Prev

• Inclusion Criteria
• All patients with hypertension (gt130/80)
• Also, optionally
• All patients on anti-lipid therapy
• Known smokers
• Known family Hx of CVD in the lt60 age group
• eGFR greater than 50
• BM1 gt27 and presence of obesity related disease
• Impaired glucose tolerance, impaired fasting
  glucose, metabolic syndrome
• Exclusion Criteria
• People with Diabetes ? use DM flowsheet
• People with CHF ? use CHF flowsheet
• People with CKD or eGFR of 50 or less ? use CKD
  flowsheet

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HTN/CVD/CKD Prev