1. An Overview of the Alberta Screening & Prevention Initiative Improvement Facilitator Training Session 1 Day 1

2. Objectives Overview of TOP The Origins of ASaP The ASaP Opportunity The Benefits of ASaP The ASaP Intervention Improvement Facilitator Support The Medical Home

3. Toward Optimized Practice Clinical Practice Guideline Program Clinical Process Improvement Program/s – Customized – Targeted initiatives

4. The Origins of ASaP National Context – Council of Federation Health Innovation Initiative Working Group – C – Change Cardiovascular Harmonized National Guideline Endeavour Alberta Context – Integrated clinics project – Pharmacy project – Worksite project – ASaP project in partnership with key organizations AHS TOP

5. The ASaP Partnerships A7

6. Why ASaP? Family physicians do an outstanding job of screening individual patients during focused screening visits. The challenge is more than one-third of patients simply do not “self-present.” The majority of these patients are attached to physicians Evidence says the most effective behavior change tool is an invite from their primary care provider and team to complete screening There are a number of physicians in Alberta who have tried opportunistic and/or outreach engagement of patients for screening – it works ! Methods are time and cost effective ASaP will bring those methods to PCNs for PCNs to provide to participating clinics A2

7. The ASaPOpportunity The ASaP Initiative is focused on supporting primary care providers ( physicians and nurse practitioners) and team members to offer a screening and prevention bundle to all their patients through enhanced opportunistic and planned outreach methods, targeting patients who do not present for screening care.

8. Maneuvers Menu for Adults ManeuverAge (years)Interval Blood Pressure18+Annual Weight18+Annual Height18+Once lifetime Exercise Assessment18+Annual Tobacco Use Assessment18+Annual Alcohol Use Assessment18+Annual Influenza Vaccination/ Screen18+Annual Pap Test Females 21 – 69 3 years Plasma Lipid Profile Males 40 – 74 Females 50 – 74 3 years CV Risk Calculation Males 40 – 74 Females 50 – 74 3 years Diabetes Screen One of: - Fasting Glucose - Hgb A1c - Diabetes Risk Calculator 40+3 years Colorectal Cancer Screen One of: - FOBT/FIT - Flex Sigmoidoscopy - Colonoscopy 50 – 74 2 years 5 years 10 years MammographyFemales 50 - 69 (74*)2 years A3

9. Practice Points ManeuverPractice Points Blood Pressure Use automated B/P cuffs when possible and complete more than one reading The evidence does not define an interval; recommends at “every appropriate visit” Height & Weight Height & Weight are useful when using risk calculators & determining osteoporosis risk. If patient is obese, see ACFP Tools for Practice 2011 Is any diet better for weight loss or preventing negative health outcomes? http://www.acfp.ca/Portals/0/docs/TFP/20111028_101605.pdf http://www.acfp.ca/Portals/0/docs/TFP/20111028_101605.pdf Exercise Assessment For evidence based intervention ACFP Tools for Practice 2009 Motivating Patients to Move: A Light at the end of the Couch? http://www.acfp.ca/Portals/0/docs/TFP/20111028_111954.pdf http://www.acfp.ca/Portals/0/docs/TFP/20111028_111954.pdf Canadian Physical Activity Guideline 2011: Recommend 150+ minutes per week, with bouts of 10 minutes of vigorous activity. No upper age limit; those over age 64 with poor mobility should perform physical activities to enhance balance and prevent falls. http://www.csep.ca/CMFiles/Guidelines/CSEP-InfoSheetsComplete-ENG.pdf http://www.csep.ca/CMFiles/Guidelines/CSEP-InfoSheetsComplete-ENG.pdf Tobacco Use Assessment Tobacco use includes all forms including smokeless tobacco Evidence recommends that tobacco assessment commence at age 12 years; evidence does not define an interval Alcohol Use Assessment The AHS Addiction and Mental Health Strategic Clinical Network recommends the use of the following approach taken by British Columbia for primary care physicians: http://www.bcguidelines.ca/pdf/problem_drinking.pdfhttp://www.bcguidelines.ca/pdf/problem_drinking.pdf Evidence does not define an interval Influenza Vaccination/ Screen Pneumococcal vaccination is recommended once for all adults 65+ years; available at time of influenza vaccination. Influenza vaccine recommended annually for Albertans of all ages (free of charge) Pap Test Some new guidelines recommend pap testing starting at age 25 years Remember to assess based on reported sexual activity and start tests once sexually active Evidence recommends 3 negative tests in 5 years, then every 3 years Plasma Lipid Profile Start males at age 40; females at age 50 or age 40 if post-menopausal Canadian Cardiovascular Society 2013: Recommends a 3-5 year interval for those with a Framingham risk score <5%, annual for those at higher risk. http://www.onlinecjc.ca/article/S0828-282X%2812%2901510-3/fulltexthttp://www.onlinecjc.ca/article/S0828-282X%2812%2901510-3/fulltext Cardiovascular Risk Calculation Highly recommended practice for determining CV risk using any accepted tool: Canadian CV Society recommends Framingham CV risk tool is embedded in all Alberta qualified EMRs Canadian Cardiovascular Society 2013: Recommends a cardiovascular risk assessment, using the 10-Year Risk provided by the Framingham model be completed every 3-5 year. Screen more frequently if at high risk. http://www.onlinecjc.ca/article/S0828-282X%2812%2901510-3/fulltext Diabetes Screen - Fasting Glucose OR - Hgb A1c OR - Diabetes Risk Calculator Recommended to use a Diabetes Risk Calculator (e.g. CANRISK, FINDRISC) Canadian Task Force on Preventive Health Care 2012: Does not recommend routine screening for Type 2 diabetes for adults at low to moderate risk of diabetes as determined with a validated risk calculator. http://www.cmaj.ca/content/184/15/1687http://www.cmaj.ca/content/184/15/1687 Colorectal Cancer Screen - FOBT/FIT OR - Flex Sigmoidoscopy OR - Colonoscopy FIT test proposed to be available fall 2013 Mammography *New guidelines recommend mammography for women to age 74 years Clinical Breast Examination not indicated in conjunction with mammography

10. Benefits of ASaP to Primary Care Providers & Their Teams Customized screening processes Patient panel processes and lists Enhance role of teams & EMR Improvement Tools & Resources A2

11. Benefits of ASaP to Primary Care Organizations Practice Facilitation Identification & Training EMR support Improvement Results reported for providers, clinic and PCO Access to QI training Tools and resources A2

12. How will this occur? Toward Optimized Practice will offer training, tools and resources to identified facilitators within primary care networks to support the screening and prevention improvements. Following training, primary care organizations will: – engage physicians to participate – offer practice facilitation to primary care providers and team members to support the development of customized processes at the primary care organization and/or clinic levels.

13. The ASaP Intervention Panel Identification Focused Improvement Build on Success Document process to ID patient/provider attachment Generate patient lists for screening Choose + document screening methods: opportunistic and/or outreach Choose + document screening maneuvers Define & document team roles & responsibilities Test small change (PDSA) Standardize processes Measure reliability of processes Apply for CME credits Identify other clinical improvement opportunities Baseline Chart Review & Current Screening Process Assessment 4-Month Follow Up Chart Review & Screening Process Assessment Sustainability Chart Review & Continued Follow-up Reviews 30 days 60 days Ongoing A6 13

14. Improvement Facilitator Training H4 14

15. PCN will be invited to Identify improvement facilitators who will be provided with the resources and mentorship to support clinics and primary care organizations implementing this initiative. Participate in planning and implementation activities to locally select changes to maximize screening and prevention methods and results. Participate in planning and implementation activities to support emerging communities of practice in facilitation and EMR use. Coordinate and deliver, with support, physician engagement events. Identify staff members who will receive resources, tools and methods to conduct standardized chart reviews.

16. Benefits of ASaP to Albertans Improve screening offers Improve early detection Progress toward patient-centred medical home A2

17. The Medical Home A9 What is the difference between a medical home and a medical hotel? In your home, someone cares about you even when you are not in their room.

18. Primary Care Sustainable Results for Active Participation in ASaP A10