1. Developing an Office Approach
Learning Session 2

2. Office re-design for proactive shared care
Need to understand work flow and processes as they exist and improve --> MOA is the expert
CDM Office System:
Registry
Clinical tool for care management and monitoring (e.g. Flow sheet; Action-exacerbation plan)
Recall
Analysis: Run charts

3. Office re-design for proactive shared care
Communication
Referral  Consultation
New ways of working - e.g. telephone
Handoffs: Discharge, Re-Referrals

4. The patient registry
A list of all patients with a particular condition
e.g., COPD, Heart Failure
Based on registry, can set up system to organize care and monitor patients’ progress (e.g. using flow sheets)
Can recall patients per the patient registry

5. Identify eligible patients-interim registry
Categories
Case-finding-New patients per guideline-Simple spirometry
Case-finding-Dx COPD-no spirometry – simple spirometry /Diagnostic spirometry
Confirmed COPD (spirometry positive)
B. Methodology to Identify Those Dx with COPD (#2 and 3 above):
Billing software (COPD Code: XX)
Paper chart review
EMR
Physician Profile Analysis Report

6. Identify eligible patients-final registry-confirmed COPD
New patients with Dx confirmed by spirometry (Dx code: 496)
Dx COPD, no initial spirometry, Dx now confirmed with spirometry
Dx COPD, had confirmatory spirometry

7. Physician profile analysis
Secure and confidential report
Practice demographics
Complexity of patient population
Identifies potential gaps in care
Comparison to BC patients as a whole
Highlights your chronic disease patients
Diabetes, Hypertension, CHF, COPD, kidney disease