Agassiz Community Health Centre

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Agassiz Community Health Centre

• Self- Management Process

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The Team Approach
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Patient makes appointment with physician
Physician sees patient and identifies Dx of
CHF -Identifies need for on-going monitoring and
education
Referral to Nurse Clinician
Physician explains need for follow-up and
education and introduces role of nurse clinician
Either personal introduction or legible plan in
chart
Informal consultation between Physician and Nurse
Clinician always available
Nurse Clinician sees patient -Reviews role and
partnership with Physician -Introduces idea of
CHF on-going self-management with support from
health care team -Brief overview of S S of CHF
and when to report to clinic or ER -Initiate plan
for daily weights
Patient follows up with Nurse Clinician within
one month(sooner if new meds/unstable)
for -Ongoing education (Na, H2O,
activity) -Assessment of S S of CHF -Review
daily weights establish goal -Determine
frequency of follow-up and review care in terms
of internal policies (blood work, medication
titration, etc)
Patient makes appointment for follow-up with
Physician and/or Nurse Clinician
Referral to other HCPs -Dietitian now
on-site -Pharmacist to start soon
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Whats Missing

• A formal process for the team to review each
  patient in terms of the CPGs
• Plan Heart Failure days for each Physician
• Team members will meet ahead to develop care plan
• Physician will be available when other HCPs meet
  with patients
• Team will meet after to review and re-evaluate
  care plans
• Patient satisfaction questionnaires to be
  developed/obtained

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Keeping it in Perspective