{"id":132,"date":"2014-01-08T18:27:23","date_gmt":"2014-01-08T18:27:23","guid":{"rendered":"http:\/\/afibreno.thecicc.com\/?page_id=132"},"modified":"2015-06-29T18:21:24","modified_gmt":"2015-06-29T18:21:24","slug":"132-2","status":"publish","type":"page","link":"https:\/\/afibreno.uhnopenlab.ca\/?page_id=132","title":{"rendered":"Site Management"},"content":{"rendered":"<p><a href=\"http:\/\/afibreno.uhnopenlab.ca\/wp-content\/uploads\/2014\/03\/kori_patient-e1395081875112.gif\"><img loading=\"lazy\" decoding=\"async\" class=\"alignleft size-full wp-image-302\" src=\"http:\/\/afibreno.uhnopenlab.ca\/wp-content\/uploads\/2014\/03\/kori_patient-e1395081875112.gif\" alt=\"AFCP pharmacist and patient\" width=\"300\" height=\"171\" \/><\/a>The goal of the AFQCP is to\u00a0<b>optimize<\/b>\u00a0care for AFIB patients.\u00a0 It is key that all of the components are maintained during the process.\u00a0It will be tempting during \u2018real life\u2019 running of the clinic to model it after existing clinic structures.\u00a0 However, the goal is to actually change the system of care \u2013 not just to try to \u2018add\u2019 AFIB to an existing clinic.\u00a0 The average time for us to assess, educate and engage our patients in their own care plan is about 90 minutes for a new patient \u2013 quite different from most clinics in the current system of care.\u00a0 The important components of our program are:<\/p>\n<p><strong>Comprehensive management<\/strong><\/p>\n<p>As AFIB often has a number of associated conditions (CHF, HTN etc) we take responsibility to include strategies to optimize care for these conditions, in addition to the patient\u2019s AFIB, in our Care Plan for the primary care team<\/p>\n<p><strong>Timely access<\/strong><\/p>\n<ul>\n<li><strong>From ED to clinic :<\/strong>\u00a0Our goal was to see patients within 5 business days of referral.\u00a0 In reality, given the episodic nature of acute AFIB, there were occasions when we were outside of this window.\u00a0 In addition, many patients rescheduled their own initial visit.\u00a0 In these cases, we would screen for any newly initiated anticoagulation and ensure that the patient had access to more immediate care (for INR testing in new warfarin starts for example).<\/li>\n<li><strong>To cardiac diagnostics and specialist consultation:<\/strong> (See our \u201cpartnerships\u201d under <a href=\"http:\/\/afibreno.thecicc.com\/?page_id=167\">Construction Crew<\/a>)<\/li>\n<li><strong>To an AFIB clinician when needed:\u00a0<\/strong>To support patients, particularly with acute symptoms or urgent questions, they were given access to a 1-855 number to be connected with a clinician.\u00a0 We had an average of 2-3 calls per week, some that directly prevented an ED visit according to the patients.<\/li>\n<\/ul>\n<p><strong>Patient Education and Engagement<\/strong><\/p>\n<p>Our goal was to ensure that by the end of each visit, the patient and family had a good understanding of their AFIB issues, how to manage them, what we were doing to help them and what the next steps in their care looked like.\u00a0 This requires time spent engaging the patient in their care, creating mutually acceptable goals and ensuring they have an understanding of the time it may take to reach those goals<\/p>\n<p><strong><a href=\"http:\/\/afibreno.uhnopenlab.ca\/wp-content\/uploads\/2014\/01\/sitemanagement_circleofcare.gif\"><img loading=\"lazy\" decoding=\"async\" class=\"alignleft size-full wp-image-322\" src=\"http:\/\/afibreno.uhnopenlab.ca\/wp-content\/uploads\/2014\/01\/sitemanagement_circleofcare.gif\" alt=\"sitemanagement_circleofcare\" width=\"240\" height=\"209\" \/><\/a>Care coordination and responsibility<\/strong><\/p>\n<p>The AFQCP needs to play a care coordination role as well \u2013 to ensure clear transfer of information to the patients Primary care team as well as to liase with other members of the patient\u2019s circle of care.\u00a0 The AFQCP team\u2019s responsibilities are clearly communicated via the Care Plan<\/p>\n<p><strong>Early transition to Primary Care<\/strong><\/p>\n<p>This new model is intended to TRANSITION patients safely from acute care to their Primary Care team with support.\u00a0 As such the goal is to ensure that once the initial assessment and diagnostic testing is completed and the patient is stable with a clear plan of care, that the patient gets transferred back with the 1-855 link to enable either the patient or the primary care team can reconnect the patients back to the AFQCP seamlessly.<\/p>\n<p><strong>Clear communication<\/strong><\/p>\n<p>This is accomplished via a standardized Care Plan structure and a commitment to provide that plan to the patient\u2019s Primary care team within 48 hours of each visit, including any pertinent test results. View <a href=\"http:\/\/afibreno.thecicc.com\/wp-content\/uploads\/2014\/01\/AFQCP-Care-Plan-v1_07_29_13_FORM_READER_WC-logo.pdf\">Provider Care Plan<\/a> &gt;&gt;<\/p>\n","protected":false},"excerpt":{"rendered":"<p>The goal of the AFQCP is to\u00a0optimize\u00a0care for AFIB patients.\u00a0 It is key that all of the components are maintained during the process.\u00a0It will be tempting during \u2018real life\u2019 running of the clinic to model it after existing clinic structures.\u00a0 However, the goal is to actually change the system of care \u2013 not just to [&hellip;]<\/p>\n","protected":false},"author":1,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"open","ping_status":"open","template":"page-full.php","meta":{"_exactmetrics_skip_tracking":false,"footnotes":""},"class_list":["post-132","page","type-page","status-publish","hentry"],"_links":{"self":[{"href":"https:\/\/afibreno.uhnopenlab.ca\/index.php?rest_route=\/wp\/v2\/pages\/132","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/afibreno.uhnopenlab.ca\/index.php?rest_route=\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/afibreno.uhnopenlab.ca\/index.php?rest_route=\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/afibreno.uhnopenlab.ca\/index.php?rest_route=\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/afibreno.uhnopenlab.ca\/index.php?rest_route=%2Fwp%2Fv2%2Fcomments&post=132"}],"version-history":[{"count":17,"href":"https:\/\/afibreno.uhnopenlab.ca\/index.php?rest_route=\/wp\/v2\/pages\/132\/revisions"}],"predecessor-version":[{"id":412,"href":"https:\/\/afibreno.uhnopenlab.ca\/index.php?rest_route=\/wp\/v2\/pages\/132\/revisions\/412"}],"wp:attachment":[{"href":"https:\/\/afibreno.uhnopenlab.ca\/index.php?rest_route=%2Fwp%2Fv2%2Fmedia&parent=132"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}