1. 1 Developing an Office Approach Learning Session 2 1

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 2

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

4. 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 4

5. 5 Identify eligible patients-interim registry A.Categories 1.Case-finding-New patients per guideline-Simple spirometry 2.Case-finding-Dx COPD-no spirometry – simple spirometry /Diagnostic spirometry 3.Confirmed COPD (spirometry positive) B. Methodology to Identify Those Dx with COPD (#2 and 3 above): 1.Billing software (COPD Code: XX) 2.Paper chart review 3.EMR 4.Physician Profile Analysis Report 5

6. 6 Identify eligible patients-final registry-confirmed COPD 1.New patients with Dx confirmed by spirometry (Dx code: 496) 2.Dx COPD, no initial spirometry, Dx now confirmed with spirometry 3.Dx COPD, had confirmatory spirometry 6

7. 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 7