Strategic Clinical Networks
1. Patient Education Resources (HF/COPD): Who, what, when, where, why, how?
Session Audio Recording May 15 2018
Learning Objectives:
- Recognize priority patient learnings
- Identify available Heart Failure/ COPD patient education resources
- Discuss the logistics of education resource availability
- Share site experiences
Pathway Pearls:
- Providers should use consistent messaging as patients transition from acute care into primary, community and home care. Simple, targeted, timely, and short education is essential for acute care inpatients.
- Ensure patient education resources are readily available
- Sustain COPD and Heart Failure patient education through ongoing front line staff education regarding effective, helpful, simple, teachable content and resources.
2. Proper Inhaler Use: Are you equipped to teach this?
Session Audio Recording May 17 2018
Learning Objectives:
- Review best practice standards
- Identify resources available for staff/patient teaching
- Instill confidence to teach inhaler use within frontline staff
- Share site learnings
Pathway Pearls:
- Use consistent education materials so providers, programs and care partners are consistent when they communicate with patients. Communicate important information regarding inhaler use and concerns with family, healthcare providers and primary care physician
- Reinforce education on proper inhaler technique at hospital discharge.
3. Optimizing Heart Failure/COPD Medication
Session Audio Recording May 24 2018
Learning Objectives:
- Identify resources providing best practice recommendations
- Discuss approach to optimizing HF/ COPD medications
- Share site experiences with medication optimization
Pathway Pearls:
- Suggested Resource Tools:
4. Heart Failure Action Plans: Teaching Patients Self-Care
Session Audio Recording May 29 2018
Learning Objectives:
- Review best practice standards
- Explain the Heart Failure Action Plan
- Teach patients how to use the HF Action Plan
- Share site approach to implementation of HF Action Plans
Pathway Pearls:
- Conduct routine educational blitzes to raise awareness and interest
- Include new patient care resources in the orientation package for new staff
5. LACE Index Scoring: What are teams doing?
Session Audio Recording June 5 2018
Learning Objectives:
- Review best practice standards
- Describe the LACE Index Scoring tool
- Discuss the logistics of completing the LACE Index Scoring tool
- Share Site challenges and solutions to LACE Score completion
Pathway Pearls:
- L – Length of Stay
A – Acuity of the admission
C – Co-morbidities
E – Number of Emergency Department visits in the last 6 months
- LACE helps to coordinate and transition patients from acute care to community.
- By using LACE, we’ve seen a reduction in the number of days patients spend in the hospital. Interventions associated with using LACE contribute to greater patient satisfaction post discharge.
- LACE helps identify high risk patients and adjust our care. The result is positive outcomes for our patients, families and care teams
6. Early Mobilization: Defining and Doing
Session Audio Recording June 6 2018
Learning Objectives:
- Review best practice standards
- Define Early Mobilization
- Identify available resources to facilitate early mobilization
- Share site learnings on how to promote early mobilization so staff are comfortable and confident
Pathway Pearls:
- Remind the patient - If you cannot breathe, you cannot function
- Monitor how the patient is doing by observing their ease or difficulty of movement
- Nursing students are passionate champions who are an excellent resource to care for, and work with, patients.
- Ideas to encourage movement:
- Home-made game accessories - (for example, wire hangers/with tubing to create racket, foam shaped bricks etc.)
- Games (e.g. Wii).
- Follow (or leverage) the patient’s interests (e.g. golf club, tennis racquet, writing, etc.)
7. Frailty Screening: Who, what, when, where, why & how
Session Audio Recording June 7 2018
Learning Objectives:
- Review best practice standards
- Identify recommended frailty screening tools
- Identify healthcare providers who could complete frailty screening
- Discuss Elder Friendly Care
- Share Site approaches to complete frailty screening
Pathway Pearls:
- The term “frailty” is not favorable, good to consider the language we use with patients and families
- If positive frailty screen (i.e., those who are designated as “significant frailty”), then seek to perform a full assessment and carry out a care plan
- Think beyond urinary tract infection for delirium. Most older adults have contaminated urine. Things to consider are dehydration, new meds, etc.
8. Discharge Planning: Smoothing transitions in care
Session Audio Recording June 12 2018
Learning Objectives:
- Review best practice standards
- Discuss challenges and solutions to improving transitions in care
Pathway Pearls:
- Coordinating care is integral to managing chronic disease
- Communication from acute care to primary care providers and home care staff is essential to supporting patients through transitions
9. Cognitive Screening for HF/COPD
Session Audio Recording June 12 2018
Learning Objectives:
- Review best practice standards
- Describe the difference between screen vs assessment
- Identify healthcare providers who could complete cognitive screening
- Share site implementation strategies
Pathway Pearls:
- Cognitive impairment impacts self-care capacity and increases risk of functional decline, re-hospitalization, and mortality
- Consistent screening and communication about cognitive status can identify patients who require further cognitive assessment in acute care
- The LACE Score or a Frailty Scale may assist to identify need for further cognitive screening or assessment
10. Discharge Management Plan (DMP): Taking a closer look
Session Audio Recording June 14 2018
Learning Objectives:
- Review best practice standards
- Review the Discharge Management Plan (DMP)
- Describe completion of the Discharge Management Plan (DMP)
- Share site implementation strategies
Pathway Pearls:
- Use the Discharge Management Plan (DMP) and the Admission to Discharge Checklist (ADC) to collect data and send it to provincial Data Analyst.
- For COPD: Recent guidelines support the use of COPD education only when combined with an action plan and case manager. Without such, the COPD education may actually be harmful.
- See patient online education resources are recommended (see above)
