Primary Health Care – COPD Program Update

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Primary Health Care – COPD Program Update


Primary Health Care RQHR is pleased to share their progress on improving services for patients with COPD (Chronic Obstructive Pulmonary Disease).

2015-16 Goals

  • Improve services to all patients with COPD in each of the 6 PHC Networks by training and connecting existing resources
  • Ensure that all PHC providers have an opportunity to participate
  • Identify and support leading practices in the diagnosis, education, rehabilitation and management of COPD in the community

2015-16 Key Actions

  • Prevention - Smoking Cessation
    • Frontline staff, and a client with COPD who smokes, participated in a Kaizen Event October 7 and 8, 2015 to establish standard work for supporting clients to quit smoking.
    • Urban: The Urban Aboriginal Home Care Team will be the initial starting point for this work, which will be expanded to all PHC staff in the Central Network. Once the North and South East Networks are settled in their respective new teams, we will also look to expand this work to them as well.
    • Rural: A subsequent meeting with Acute Care and PHC staff will be had to discuss the best way to reach the target population.
  • Establish Spirometry Testing in each Network
    • A kaizen event was held to establish standard work and supplies for 6 new mobile spirometry kits. Staff is being trained to perform spirometry testing in each RQHR PHC Network and in private Physician offices.

Central Network

1 new spirometry kit has been deployed to Meadow PHC site and 1 to Four Directions. 2 staff are trained in spirometry testing and a 3rd will be trained in February 2016.

Once capacity for spirometry in each of the 6 Networks is expanded, we may need to look at how many spirometers are deployed in each Network.

The Pulmonary Function Lab is offering spirometry testing at Dr. Patel’s Medical Clinic on Dewdney Avenue from November to December on a trial basis.

North Network

Arlene Rogers from Touchwood Qu’Appelle has been periodically offering spirometry services at Northgate Medical Clinic. This will occur until the new PHC Nurse is trained in February 2016 to perform spirometry tests and a new mobile spirometry kit is deployed to the North Network.

The Pulmonary Function Lab is offering spirometry testing at Rochdale Medical Clinic from November to December on a trial basis.

South East Network

The Pulmonary Function Lab is offering spirometry testing at Rochdale Medical Clinic on South Pasqua from November to December on a trial basis.

Touchwood Qu’Appelle Network

1 new mobile spirometry kit has been deployed for use in Fort Qu’Appelle and Balcarres. A 2nd new spirometer will be deployed in Lestock on November 5th. 3 staff are trained to deliver spirometry tests.

Twin Valleys and Prairie East Networks

1 new spirometry kit has been deployed to Grenfell. It will be rotated between Grenfell and Moosomin once a PHC Nurse is hired and trained in Moosomin to provide this service. 1 staff memberhas been trained in Twin Valleys.

RPIW 91 is occurring the week of December 7, 2015 to establish a process for navigating all spirometry referrals to the trained providers in each Network.

Spirometry Interpretation

51 Practitioners have been trained across the 6 PHC Networks on spirometry interpretation and 30 Practitioners are scheduled to participate in another course on October 31st.

Dr. Hansia and Dr. Williams are developing a spirometry interpretation peer support program, comprising peer support and CME Journal Club components.

2 Rural Nurse Practitioners are trained in spirometry interpretation have been connected with a peer support in Urban.

Community Pulmonary Rehab and General Education for Providers

  • 4 existing RQHR staff are previously certified to provide COPD education. 7 more staff, including Nurses and Physiotherapists across all 6 PHC Networks, will become certified in October. As new staff is hired, they will continue to be enrolled in certification.
  • The existing COPD Rehab Program education modules will be video-taped in January 2016 to provide COPD Educators with resources. The COPD Rehab Program has found a new home at Pioneer Village.
  • October 27-30, a kaizen event was held to design a community based version of the COPD Rehab Program to provide additional options to COPD Educators and their clients. It is being hosted at the Eagle Moon Health Office.
  • Clients can be referred to the existing Live Well with Chronic Conditions program and support group. Clients who have not received a diagnosis of COPD or COPD clients who have completed pulmonary rehab may be able to access existing Forever in Motion programs.
  • 6 staff on the Urban PHC Response Team, 2 Nurses from the Aboriginal Home Care Team and 2 Nurse Educators from Rural have taken a ½ day session that will help them support clients with existing COPD Action Plans.
  • Approximately 50 Home Care Nurses from Urban and Rural have received a 1 hour course in COPD medications. There is a plan to train the remaining 50 Home Care Nurses and incorporate the training into initial orientation for Home Care Nurses and Rural LTC and Acute Care Nursing orientation.

Improve Information Flow from Acute Care to Community

  • Community Practitioner follow-up within 7 days after an acute care stay is important to prevent a subsequent acute care visit. In RQHR, 7 day follow-up for COPD Patients who visit acute care occurs 30-40% of the time.
  • RPIW 86 looks to reduce lead time and defects in information flow from ER to Community (i.e. Pink Sheets) to support better community follow up.

Oxygen Availability

  • Primary Health Care is exploring how to engage NHIB to provide Personal Oxygen Concentrators, which allow clients with COPD greater mobility outside their homes. They would also like to eliminate the need for uncomfortable blood gas testing for oxygen coverage and renewal and instead move to oximeter print outs.