TSWF Metabolic CPG AIM Form Training May May-Aug 2020 Form Version “Medically Ready Force…Ready Medical Force” 1
Dis isclaimer Content shown is from an AHLTA Training System (ATS) and does not contain actual patient data. “Medically Ready Force…Ready Medical Force”
Recent Changes The following group of slides reflect changes made to all CORE compatible forms. The specific training slides for this form follow the change slides. “Medically Ready Force…Ready Medical Force”
CORE Compatible Updates Updated the Hepatitis C screening recommendation on the 'Preventive Services Recommendations-All Patients' Ribbon. The new recommendation: 'The USPSTF recommends screening for hepatitis C virus infection in adults aged 18 to 79 years.' “Medically Ready Force…Ready Medical Force” 4
CORE Compatible Updates Updated the wording in the 'Self-Reported Level of Functioning' row on the PHQ-9 OLD NEW “Medically Ready Force…Ready Medical Force” 5
CORE Compatible Updates Updated 'Pain Treatment history' section on the Exit CCP tab “Medically Ready Force…Ready Medical Force” 6
CORE Compatible Updates Updated 'Chronic Pain' ribbon label to say 'Pain Management Care Plan' and verbiage updated within section. Also changed the 'Pain care agreement on file’ to 'Pain Care Informed Consent on File’ “Medically Ready Force…Ready Medical Force” 7
Objectives Metabolic Training Objective: Identify the clinical workflows, screeners and tools available in the TSWF Metabolic AIM form as they relate to the VA/DoD Clinical Practice Guidelines Metabolic Learning Objectives: At the conclusion of today’s activity, the participant will be able to: • Understand the documentation requirements found on the HPI tab (patient intake/Med Rec/Preventive Services) • Understand the use of various screeners (Travel/Audit-C/Tobacco use/Annual Questions/Learning Assessment/Military Specific Screening) • Describe the usefulness of the focused Review of Systems and Physical Exam elements • Demonstrate the purpose and use of the Obesity and Metabolic Disorders Chronic Care Plans • Understand what information can be found on the various reference-only tabs found on the form “Medically Ready Force…Ready Medical Force”
Why Use a TSWF CPG AIM IM Form? • Integrates recommendations from VA/DoD CPGs (Diabetes, Hypertension, Dyslipidemia, and Obesity/Overweight) • Provides easily accessible references for clinical decision- making & patient education • Improves continuity of care and healthcare outcomes • Standardizes documentation • Implementation form use was associated with Increased prescribing of medication (statins, aspirin, ACE-I) that decrease morbidity/mortality in diabetics “Medically Ready Force…Ready Medical Force” 9
Workflow Key Points • Clinical Support Staff (CSS) completes CORE or TSWF Metabolic CPG Form Screening Sections • Provider takes ‘ownership’ of the CSS note • Provider loads the Metabolic form if indicated • Provider reviews and completes the note • CPG based forms are compatible with CORE and can be used interchangeably “Medically Ready Force…Ready Medical Force” 10
Navigating th the TSWF Metabolic CPG AIM IM Form “Medically Ready Force…Ready Medical Force” 11
Selecting th the Proper Template Select from either your drop-down list of favorites or via Navigator Select TSWF Metabolic-CPG “Medically Ready Force…Ready Medical Force” 12
TSWF Navigator Select TSWF Navigator Then select the Metabolic Disorders CPG form “Medically Ready Force…Ready Medical Force” 13
HPI/PFSH/CCP Tab TSWF Navigator takes you to the most current version of the form “Medically Ready Force…Ready Medical Force” 14
HPI/PFSH Tab Medication Reconcil ilia iation Text field to input name * Primary Opioid of patient’s Primary provider means that a patient Opioid Provider* has an agreement in Support staff updates place that medication list (and authorizes a checks box verifying single provider completion) to write or renew Provider completes prescriptions for opioid ‘provider use only’ section medications. “Medically Ready Force…Ready Medical Force”
HPI/PFSH/ CCP Tab Maj ajor In Interventions Remin inder Summary of interventions that have a positive impact on morbidity and mortality “Medically Ready Force…Ready Medical Force” 16
HPI/PFSH/CCP Tab Lif Lifestyle le Emphasis is • BMI > 30 should prompt these questions: • Reduced calorie diet plan? Yes or no • Behavior change? Yes or no • Exercise? Yes or no “Medically Ready Force…Ready Medical Force” 17
HPI/PFSH/CCP Tab Lif Lifestyle le Emphasis is (c (cont.) If “no”, secondary questions open automatically: • Reduced calorie diet plan in past year? Yes or no • Behavior change program in past year? Yes or no • Exercise program in past year? Yes or no Identifies lifestyle factors that need to be addressed “Medically Ready Force…Ready Medical Force” 18
HPI/PFSH/CCP Tab Comprehensiv ive Car are Plan lans • Pre-populated text is a starting point • Content is derived from CPGs or subject matter experts • Text can be edited as needed “Medically Ready Force…Ready Medical Force” 19
HPI/PFSH/CCP Tab Lin Links to o References Link to Diabetic Foot Exam “Medically Ready Force…Ready Medical Force” 20
HPI/PFSH Tab Open the ribbon to show more details “Medically Ready Force…Ready Medical Force”
Screening Tab Travel Sc Screening/Infectious Di Disease Travel l Sc Screen If appropriate or according to local protocol, complete pre-travel counseling and Infectious Disease Travel Screen Note: blue clinical clues about various diseases “Medically Ready Force…Ready Medical Force”
Screening Tab Links to resources on tobacco cessation “Medically Ready Force…Ready Medical Force” 23
Screening Tab Annual l Questions/Health Lit Literacy These questions need to be completed annually. If more than 12 months have elapsed since last updated, uncheck the red “ X ” to reset the questions to current requirements. The Single Item Literacy Screener (SILS) for assessing health literacy is in the Annual Questions field. If patient’s response is either “often” or “always,” conduct a more thorough assessment (see next slide). “Medically Ready Force…Ready Medical Force” 24
Screening Tab Healt lth Lit Literacy/Mil ilit itary-Specific If the SILS response is either “often” or “always”, further assessment of the patient’s health literacy is documented here along with an action plan if indicated. A link to REALM-SF is provided, but any appropriate assessment can be used. “Medically Ready Force…Ready Medical Force” 25
BH/Other Screening Tab De Depression Sc Screening Note clinical clue on the Depression Screening “Medically Ready Force…Ready Medical Force” 26
BH/Other Screening Tab Additional Screeners include: GAD-2, GAD-7, TBI and Epworth Sleepiness Scale “Medically Ready Force…Ready Medical Force” 27
ROS Tab ROS and PE are color-coded according to recommendations in the respective CPGs “Medically Ready Force…Ready Medical Force” 28
PE Tab ROS and PE are color-coded according to recommendations in the respective CPGs “Medically Ready Force…Ready Medical Force” 29
PE Tab Psych Links to resources on detection of cognitive impairment “Medically Ready Force…Ready Medical Force” 30
Exit/CCP Tab Se Self Car are an and CCPs “Medically Ready Force…Ready Medical Force” 31
Exit/CCP Tab Additional Ri Ribbons • Patients who have multiple chronic conditions may require additional documentation • Document/update additional chronic care plans (CCPs) here “Medically Ready Force…Ready Medical Force” 32
Dia iabetes Reference Tab “Medically Ready Force…Ready Medical Force” 33
Dia iabetes Reference Tab “Medically Ready Force…Ready Medical Force” 34
HTN (V (VA/D /DoD) ) Reference Tab “Medically Ready Force…Ready Medical Force” 35
HTN (V (VA/D /DoD) ) Reference Tab “Medically Ready Force…Ready Medical Force” 36
HTN (J (JNC-8) Reference Tab “Medically Ready Force…Ready Medical Force” 37
HTN (J (JNC-8) Reference Tab “Medically Ready Force…Ready Medical Force” 38
Dyslipidemia Reference Tab “Medically Ready Force…Ready Medical Force” 39
Dyslipidemia Reference Tab “Medically Ready Force…Ready Medical Force” 40
Obesity Reference Tab “Medically Ready Force…Ready Medical Force” 41
Fin inal Thoughts • TSWF AIM forms/templates support the PCMH concept • TSWF AIM forms support care aligned with CPGs • Support staff are vital to effective template use • You may find CCPs difficult to start but easier to maintain; they offer a useful ongoing summary of relevant information copied forward for easy updating “Medically Ready Force…Ready Medical Force” 42
TSWF Resource Material The TSWF repository for training/educational materials and updates: www.tswf-mhs.com/ “Medically Ready Force…Ready Medical Force” 43
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