Sustaining the Lung Health Program

Sustaining the Lung Health Program
Heather Hadden BSc Phm, R Phm ,Teach Certified
Marnie Martin BScN ,RN,CRE
Credit Valley Family Health Team
Respiratory Health Forum (OLA)
Jan 31 2013
Jan 31 2013
Who are we?
Our Mission of Excellence:
High
g Standard Interprofessional
p
Primary
y Care + Family
y Medicine Teaching
g
2 sites
11,000 patients
15 IHPs
10 Physicians
18 Admin staff
20 Family Practice Residents
Multiple CDM and Preventative Care Programs
Goals/Objectives
•
To introduce the CVFHT Lung Health program‐ Breath for Life
Breath for Life
To introduce the CVFHT Lung Health program
(Patient education in Asthma, COPD , screening/follow up Spirometry)
•
To illustrate the integration of the PRIISME, QIIP(HQO) and OMSC program
To illustrate the integration of the PRIISME QIIP(HQO) and OMSC program
in the development of the Breath for Life program
•
To illustrate the integration of Health Professionals as team members in the To
illustrate the integration of Health Professionals as team members in the
program •
To show outcomes of the program
To show outcomes of the program
•
To highlight the success of CVFHT Smoking Cessation Program
•
To present real cases that illustrate collaborative team integration and success
•
To discuss our future direction with Quality Improvement
To discuss our future direction with Quality Improvement “
hf
if ”
“Breath for Life”
An collaborative integrated team approach to Screening Spirometry, Asthma and COPD Education and Smoking Cessation Counseling The CVFHT Lung Health IHP Team
Heather Hadden‐Program Lead
Pharmacist, Teach Certified Smoking Cessation Counselor
D J
Dr James Pencharz‐
P h
P
Program Lead Physician L d Ph i i
Marnie Martin ‐Asthma Lead
RN, BScN, Certified Respiratory Educator
Gord Canning‐COPD Lead
Nurse Practitioner
Mary Glenen‐Calder, RN & Pam Mareemootoo, RN
a y G e e Ca de ,
& a
a ee ootoo,
smoking cessation counselors
Acknowledgement
Acknowledgement:
Catherine Harrison NP‐initial Program Lead, CV FHT Lung Health Program Why Do We Need a Lung Health program?
Link to you tube House puffer video
Link to you tube House puffer video http://www.youtube.com/watch?NR=1&v=21TL94NEzvg&feature=endscreen
In The Beginning…..
GSK PRIISME (Jan 2010‐Jan 2012) ‐ funding QIIP (HQO) Asthma and COPD (Sept 2010‐Dec 2011)
Diagnosis/identification/clarification through EMR
Ottawa Model for Smoking Cessation (Oct 2011)
STOP Study (Oct 2011) ‐ Free NRT study
PRIISME
Education
‐CRE (Two 3‐4 day RESPTrec courses on Asthma and COPD followed by exams and final CRE exam ‐RN and NP) ‐TEACH (5 day course(CAMH/U of T)‐Pharmacist)
Liaise CVH C di P l
CVH Cardio‐Pulmonary Dept (COPD/Asthma Training/Mentoring)
D
(COPD/A h
T i i /M
i )
Training
Medication seminars from PRIISME
Medication seminars from PRIISME
Research
Trial and purchase of Spirometer (PDSA)
rial and purchase of Spirometer (PDSA)
EMR
May 2010‐
y
new computer system (CliniCareÆ
p
y
(
Optimed‐Acurro)
p
)
Adaptation of EMR – develop templates, flow sheets, macros (ongoing PDSA’s) Program Development (QIIP)
• Asthma/COPD (thru QIIP) (2 physicians rosters initially)
• Education around entering ICD9 code in EMR
/ p
) identifying of y g
• ((accurate extractable data/reports)‐
patients • PDSA‐ list of patients‐contact‐ mail out questionnaire, phone follow up, booked for spirometry and assessment
• Education ‐residents (Core presentations)
• Internal Referral Process
• Spread to entire clinic
CV FHT Lung Health Brochure
Services Provided
- Asthma Education
- COPD Education
- Smoking Cessation Counselling
- Lung function testing (spirometry)
- Medication management of asthma
and COPD
Our Team
In partnership with your family doctor
include:
- Certified Respiratory Educators
- Family Practice Nurses
- Nurse Practitioner
- Pharmacist
Breath for Life
program
For professional information about Breath for Life
please contact:
General Information
Gord Canning
Nurse Practitioner
For our patients with Asthma or COPD
Marnie Martin
RN, BSN
Certified Respiratory Educator
Credit Valley Family Health Team
2300 Eglinton Ave. W Suite 105
Mississauga, Ontario
L5M 2V8
Phone: (905) 813-1100 ext 5468
Or visit our website:
www.cvfht.ca
Accessing Our Services
™
A program initiated and sponsored by GlaxoSmithKline
Y
Your
ffamily
il d
doctor can refer
f you to the
h
Credit Valley Family Health Team Breath for Life
Please contact us at (905) 813-3850
Referrals‐ Front Desk Tear Off
Patient Name: ________________________________
Primary Care Provider: _____________________
Please provide this to the front desk to facilitate
booking of your future appointments.
appointments
Inter­professional Health Care Providers Purpose of Visit
Chiropodist
Dietitian
Pharmacist
Registered
Nurse
Social Worker
FHT Programs IVR
Counselling
Diabetes Team:
Smoking
Cessation
7-9 am
9-12 pm
1-5 pm
6-9 pm
New Consult
Spirometry
Insulin Start
Asthma Education
Refresher Course
Other:
COPD Education
Walking to Wellness
‘Healthy You’ weight loss
Procedure: _____________________________________
Follow up with Primary Care Provider: _______________
Date
Breath for Life Flowchart
Asthma 1st/2nd visit (RN)
Referral to Breath for Life program Previous dx or p
suspected asthma/COPD Screening spirometry Smoking hx respiratory symptoms positive CLHT p
Create box neg spirometry refer to MD for f/u Intake assessment 1st visit (1hr) •
•
•
•
•
•
•
Spirometry (pre/post) *consider PFT if methacholine challenge g
needed (after consulting with MD/NP) Intake assessment sheet Macro in ACCURO Identify patient centered goals Inhaler technique Discuss Action plan Book f/u visit Provide feedback to referring practitioner Smoking Cessation discussed at every visit Revised; August 2, 2012. Prepared by Catherine Harrison RN(EC), MSc •
•
•
•
•
•
•
•
•
Education Assess control Allergen/trigger avoidance Self monitoring Medication use/inhaler tech A
Assess need for referral> MD, df
f
l MD
pharm, smoking cessation Review action plan Document on asthma flow sheet Provide feedback to referring practitioner Credit Valley Family Health Team PRIISME™
Breath for Life Asthma/COPD poor control
control Pharmacological management Consult Periodic Visit •
•
•
•
•
MD/NP Pharmacist Poor control •
•
•
•
•
•
•
•
•
•
•
Assess control/action plan Spirometry Plan peak season review
Plan peak season review and management plan Annual Visit COPD 1/2nd visit (NP) Education/ Self‐management What is COPD/pathophysiology Breathlessness Fatigue
Psychosocial Nutrition Sleep Review recent exacerbation Action plan Consider end of life/identify POA Immunization Referral to IHP
f
l
(d
(dietitian/social /
l
work) if risk Referral to respirology if FEV1<50, or >2 exacerbations in 6 months Refer to pulmonary rehab if MRC is >3 (when appropriate) Medication and exercise review with pharmacist as needed Scheduled follow­up •
•
Unresponsive to usual care or action plan
or action plan
Consult with MD (primary provider) •
Spirometry Evaluate progress to date, goals, future care needs Provide feedback to referring
referring practitioner/specialist Initiate referral to appropriate specialist (paeds/resp) or for urgent/emergent> refer to ER
Usual care Poor control Initial Assessment COPD/Asthma
1st and 2nd visit Asthma
Determining Asthma Control
Asthma Visit Template
Initial Asthma Education Visit
SUBJECTIVE
SUBJECTIVE:
seen by Dr on / 2011 for .[previous|no previous] documented Dx asthma.
[no|hx of] ED visits for respiratory issues. [0|hx of] hospitalizations for respiratory issues. [has never taken|history of prescribed] Prednisone.
[No spirometry|Spirometry done] in past.
Family History: [pos|neg] family history: mother; , father: for [asthma|eczema|environmental allergies|food allergies].
past.
Allergies: [never|has been] allergy tested in the past. pos for [cats|dogs|horses|pollen|ragweed|dust|mold|feathers]
Smoking Hx:[smoker|non smoker|ex smoker] PPD for years, quit .
Past Medications: include [flovent|advair|symbicort|ventolin|flonase|avamys|singular]
Past Medications: include [flovent|advair|symbicort|ventolin|flonase|avamys|singular]
last taken days ago with [good|minimal] effect.
Comorbidities: pre exiting or hx of [none|sinusitis|rhinitis|GERD|obesity|anaphylaxis|eczema|depression|anxiety].
Irritant Triggers identified [none|changes in weather|cold weather|outdoor pollution|chest infections|exercise|emotions|stress|fumes or chemicals|perfumes or air fresheners|second hand smoke|wood smoke|school related exposure].
k | h l l d
]
Occupation: occupational related asthma symptoms [none|started at work|started in timing with a specific incident|worse at work|s/s less on days off or holidays]
Environmental controls: presently in place; [air conditioning|<50% relative humidity in home|q 3‐6 month furnace filter change|central vac or hepa filter|certified pillow and mattress covers|hot wash linens weekly|no pets in home|hardwood or tile floors]. suggested; [air conditioning| <50% relative humidity in home|q 3‐6 month furnace |
|
|
filter change|central vac or hepa filter|certified mattress and pillow covers|hot wash linens weekly|no pets in home|hardwood or tile floors].
TODAY:
– denies [sob|chest tightness| cough|sputum|wheeze].
– [post nasal gtt|denies post nasal gtt] with [nil|clear|yellow|green] drainage.
– sinuses [not|feel] inflamed . [able to|unable to] sleep through night with no resp s/s.
OBJECTIVE:
O2 t %
O2 sat % on room air. RP BPM. i RP BPM
lungs [GAEB|rt wheeze|lt wheeze|decreased a/e to bases|rt basal crackles|lt basal crackles|bilateral basal crackles].
No contraindication to spirometry. Informed verbal consent received.
Spirometry [completed|deferred]
p
y[
p
|
]
POST (Ventolin 4 puffs, 15 min)
FVC % ( % change)
FEV1 % ( % change)
FVC/FEV1 0. ( LLN)
ASSESSMENT/PLAN:
[normal|abnormal] spirometry. may need to redo when pt has symptoms or Bronchial Challenge for Dx.
Asthma def, meds, med delivery techniques and Asthma Action Plan reviewed and literature provided.
pt to take and Ventolin [diskus|MDI] q4h prn.
saline rinses suggested.
f/u with Dr in weeks and for 2nd asthma ed visit.
Asthma Flow Sheet
1st or 2nd COPD Visit COPD Flow Sheet
Determining COPD Level Follow Up Visits Measurements of Improvement Initially:
• St George’s‐Questionnaire (QOL)‐pre (COPD)
• Junipers Questionnaire (Asthma)
• 1 year follow up St George’s/Juniper
• GSK Final report (2 years) • Patient Satisfaction Survey‐ very positive Presently:
• collaborating with CVH for daily reports of patient ER visits
• Patient education on availability of FHT care (evening/Sat Patient education on availability of FHT care (evening/Sat
clinics, NP RN phone availability, Residents on call) • Developing system to alert q 3, 6 or 12 month f/u • Ultimate measure of decreased ER visits
Quality of Life‐Outcome SGRQ Average
44
43
42
As SGRQ # decreases‐
QOL increases 41
40
39
38
37
36
35
Intake
1 Year
1 Year
Where QIIP took us
Increased • referrals to Spirometry and Diagnosis of Asthma/COPD
• diagnosis and smoking status entered in EMR
• education Sessions (Asthma and COPD)
• Flu and Pneumococcal Vaccine Rates
• referrals to Smoking Cessation
Better control/Improved QOL of Asthma and COPD patients
Breath for Life Stats
April 2011‐Dec 2012 250
200
180
200
160
140
150
COPD visits
120
Asthma visits
100
Spirometry
100
80
60
40
50
20
0
0
Smoking cessation
Community Integration
Credit Valley Hospital Pulmonary Rehab
Credit Valley Hospital Pulmonary Rehab
‐10 week 2 ½ hr twice weekly Movin’ On
‐Partnership with City of Mississauga‐1 ½ hr class twice P t
hi ith Cit f Mi i
1½h l t i
weekly ‐currently 1 centre‐‐Æ expansion
‐21 pts‐
21 pts 1 year memberships
1 year memberships
PRIISME‐ Breathe Better‐Live Better
PRIISME
B th B tt Li B tt
‐partnership with City of Mississauga(2 community centers) and Town of Milton and Oakville
centers) and Town of Milton and Oakville
STRETCH!
CVFHT Smoking Cessation Program http://www youtube com/watch?v=fEXpaXsg6fc
http://www.youtube.com/watch?v
fEXpaXsg6fc
Fletcher Curve
OMSC Pre survey of Smoking Interventions by MD’s (5A’s) (July 2011)
Educated all staff, Residents and IHP re OMSC Program (Oct 2011)
Developed Smoking Cessation Screener
Canada Lung Health Test (CLHT) back of screener/ drop down in EMR
Documentation of Smoking Status in EMR (Goal 100%)
Documentation of Smoking Status in EMR (Goal 100%)
+CLHT referred to spirometry
Developed Drop down for OMSC Smoking Cessation Consult
Increased : ASK Rate (Goal 100%)
Advise Rate (Goal 80%)
Referral to Smoking Cessation Program
Referral to Smoking Cessation Program Patients seen by Smoking Cessation Counselor (Goal 60%)
Quit rate Smoking Status Screener (SSS)
CLHT
Moving Forward
Flag all patients charts that do not have Smoking Status in Lifestyle Section IP d
I‐Pad questionnaire‐
ti
i to be completed on check in
t b
l t d
h ki
Are you a smoker /Ex smoker/Non smoker?
How old are you?
CLHT for all those > 40 yrs & smoker or Ex smoker
Data populates the EMR under lifestyle and CLHT and flags any + answers
for screening spirometry
Documentation of Smoking Status
l
Goal 100%
Is the % of Rostered Pts >16 yrs Smoking Status entered into EMR increasing? 80
70
60
50
40
30
20
10
0
Aug Sept Oct Nov Dec Jan Feb Mar April May June July Aug Sept Oct Nov Dec Jan 2011 2011 2011 2011 2011 2012 2012 2012 2012 2012 2012 2012 2012 2012 2012 2012 2012 2013
Pts Screened for COPD with CLHT
Goal 100%
Is % of Smokers and Ex‐smokers Over 40 yrs old screened with CLHT increasing ?
d ith CLHT i
i ?
80
70
60
50
40
30
20
10
0
Aug Sept Aug Sept Oct Oct Nov Nov Dec Dec Jan Jan Feb Feb Mar Mar Apr Apr May May Jun Jun Jul Jul Aug Aug Sep Sep Oct Oct Nov Nov Dec Dec Jan Jan
2011 2011 2011 2011 2011 2012 2012 2012 2012 2012 2012 2012 2012 2012 2012 2012 2012 2013
Ask Rate
Is our ASK Rate 100%?
100
90
80
70
%
60
50
40
30
20
10
0
Holidays/Illness
Oct Nov Dec Jan Feb Mar April May June July Aug Sept Oct Nov Dec Jan 2011 2011 2011 2012 2012 2012 2012 2012 2012 2012 2012 2012 2012 2012 2012 2013
Advise Rate Is the Advise Rate 100%?
100
90
80
70
%
60
50
40
30
N R id t A i
New Residents Arrive
Vacation 20
10
0
Oct Nov Dec Jan Feb Mar April May June July Aug Sept Oct Nov Dec Jan 2011 2011 2011 2012 2012 2012 2012 2012 2012 2012 2012 2012 2012 2012 2012 2013
Ready to Quit
100
90
80
70
New Program
%
60
50
40
30
20
10
0
Oct Nov Dec Jan Feb Mar April May June July Aug Sept Oct Nov Dec Jan 2011 2011 2011 2012 2012 2012 2012 2012 2012 2012 2012 2012 2012 2012 2012 2013
Assist‐Referral
Is our Assist (referral) rate 100%?
100
90
80
70
%
60
50
40
30
20
10
0
Oct Nov Dec Jan Feb Mar April May June July Aug Sept Oct Nov Dec Jan 2011 2011 2011 2012 2012 2012 2012 2012 2012 2012 2012 2012 2012 2012 2012 2013
Smoking Cessation Sessions Attended Do 60% of patients Attend the Smoking Cessation?
120
100
80
60
Goal 60%
Goal 60%
40
20
0
Oct 2011
Nov 2011
Dec 2011
Jan 2012
Feb 2012
Mar 2012
April 2012
May 2012
June 2012
July 2012
Aug 2012
Sept 2012
Oct 2012
Nov‐12 Dec‐12 Jan‐13
CVFHT Quit Rates
OVERALL QUIT RATE CV FHT 80
70
69
60
59
40
30
10
59
66
65
67
61
60
60
60
53
50
20
60
63
69
30
32
35
National Quit Average 50%
23
17
15
17
13
0
April May June July Aug Sept Oct Nov Dec Jan Feb Mar April May June July Aug Sep Oct Nov Dec Jan 2011 2011 2011 2011 2011 2011 2011 2011 2011 2012 2012 2012 2012 2012 2012 2012 2012 2012 2012 2012 2012 2013
Integrated Team Work
Cases Examples of CVFHT in Action
Case #1
Case #1
PT RH 51 y.o. male Smoker + CLHT
Saw MD‐ Ask, Advise, Assist
Walked over to Smoking Cessation Counselor
Gave patient smoking cessation package‐ brief intervention
Returned next day‐ prescribed Champix Followed up closely‐ Day 1,4,8,15,30,60,90
Patient is now 6 months quit Referred to Spirometry
Spirometry negative
Integrate Team Work
Case #2
PT L.B. 47 y.o. Female Smoker
+CLHT
MD f
MD referred to Screening Spirometry due to +CLHT
d S
i S i
d
CLHT
+ Spirometry –irreversible obstruction
Education Session COPD‐ prescribed Spiriva 1 capsule 18 ug daily Referred to Smoking Cessation Counselor
Entered in STOP study—NRT Patches and Inhalers (28 mg x 4 weeks, 21 mg x 8 weeks, 14 mg 4 weeks , 7 mg x 4 weeks) g
g
)
Currently quit x 9 months Integrated Team Work
Case #3
PT M.E. 62 y.o. Female Ex Smoker
Had diagnosis of COPD on chart
N
No meds for COPD
d f COPD
No recent Spirometry Came in for repeat Spirometry
Spirometry was abnormal but not consistent with COPD
Referred to Respirologist for PFT’s Looking into the Future
• Expansion to French Site‐ Smoking Cessation, Lung Health • Moving towards our goals
p
g
p
• Improving tools for follow up
• Brainstorm meetings at 1 yr anniversary OMSC
IMD‐education/instruction
education/instruction details
details
• IMD
• E‐mail reminders‐ pts re follow up
IPE – partnering with Residents partnering with Residents
• IPE • Inter collaboration with professionals (Respirologists)
Moving Forward…..QI QI Project
Breath for Life Team‐
Heather, Marnie, Dr Pencharz, Gord (NP), Louise Smith (executive director), Faten Mitchell Master Student U of T QI (HQO),Nadia and Merlika (administrative assistants)
(administrative assistants) Weekly Meetings‐ 2 hrs ***L ki
***Looking at our COPD program through a different lens***
t
COPD
th
h diff
t l ***
‐Develop a process map of our current program from start to finish
(Identify –each process, decision points, input or output of data, documentation, delays, unclear step, connecting steps, waste)
If you can’t draw a picture of your process, you can’t improve anything.”
Dr. W. Edwards Deming
Process Map Symbols
Start
Process Step
D
Document
www.HQOntario.ca
Decision
Point
Stop
Process Map
Identifying Gaps
5 Why’s
Further Examination
Identify problems with COPD patient transitions
Internal transitions, Patient communication, Specialists, Hospital, CCAC
‐Internal transitions, Patient communication, Specialists, Hospital, CCAC
Create a statement that summarizes the problems
“The current state of transitions show areas of inconsistency and non‐
predictability. Due to lack of standardization there is often ineffective di t bilit D t l k f t d di ti th
i ft i ff ti
communication leading to potential gaps in patient care resulting in team members confusion and frustration”
Who Are Our Patients?
27 COPD pts in program 2011
27 COPD pts in program 2011
Incr to 39 pts in program 2012 ? 76 pts had ICD9 code‐4912 ? 76
h d ICD9 d 4912
? 75 pts issued a RX for Spiriva (with no COPD ICD9 code)
1st PDSA cycle – to discover all COPD patients in CVFHT
Computer list run of all patients with Computer
list run of all patients with
‐ ICDP Code COPD
‐ Billings for AECOPD, bronchitis, emphysema ‐ On Spiriva
O S ii
‐ On LABA or ICR/LABA combination
‐ Had spirometry in past
C0PD Master List
650 patients identified (assigned #
(assigned #’ss to weight each identifier and to weight each identifier and
650 patients identified patients listed ranking in highest to lowest score indicating highest chance of having a COPD diagnosis)
Screened each patient with chart to determine if COPD Based on clinical definition of 1) + Spirometry FEV1/FVC ratio < 0.7
Based
on clinical definition of 1) + Spirometry FEV1/FVC ratio < 0.7
or 2)Respirologist Diagnosis of COPD
Noted ICD Code in EMR under Diagnosis if not already done
Noted if being seen by Respirologist
Noted last Spirometry
Noted severity (mild, moderate or severe)
Removed COPD Diagnosis if not appropriate diagnosis
Removed COPD Diagnosis if not appropriate diagnosis
More PDSA’s
Current 135 patients with COPD diagnosis (ICD9 code)
(44% increase from 76)
(44% increase from 76)
How many should be in our program?
How many should be in our program?
PDSA Cycle #2‐
PDSA
Cycle #2‐ Phoned all COPD patients to return for Phoned all COPD patients to return for
repeat spirometry in not done in past 2 years
PDSA Cycle #3‐ Open more COPD/Spirometry Visits into schedule schedule
Further PDSA’s
ER visits of CVFHT COPD pts
Worked with IT at CVH to develop a daily list of all CVFHT patients who went to ER on a given date(s). Determined if these patients were COPD
Followed up with all CVFHT COPD patients seen in ER to determine if could have been avoided
Developed intervention plan for these patients to avoid ER visit
Translation to other Disease states and improved access Developing an Aim Statement
Brainstormed several possible Aim Statements
Final AIM Statement: “The CVFHT QI COPD team will reduce ER visits for id tifi d COPD ti t b 50% f
identified COPD patients by 50% from _____
to ______ by June 30, 2013”
Baseline Data will be obtained from Nov 1 2010 Oct 31 2012
Baseline Data will be obtained from Nov 1 2010‐
Oct 31 2012
Develop Primary and Secondary Drivers
p
y
y
Primary Driver‐ Outcome Measures‐”How will we know that a change is an improvement?” Secondary Driver‐ Change Concepts Secondary Driver‐
Change Concepts
CVFHT COPD Driver Diagram
Primary Drivers
PD1‐ COPD registry of confirmed patients
PD2‐ Patient Engagement
PD3‐ Prescreening Spirometry and Follow up Spirometry
PD4‐ External Liaisons (Referrals, Respirologists, Pulmonary F ti L b CCAC C
Function Lab , CCAC, Community Pharmacist)
it Ph
i t)
PD5‐ 24 /7 COPD patient support
PD6‐ Standardization
PD6
PD7‐ Internal Communication
These PD’s were evaluated and graded – to obtain priority Secondary Drivers
SD1‐ Communication with physicians
p y
List of potential COPD patients
Chart review SD2‐ Access
Follow up Physician Engagement
Health Literacyy
SD3‐ Calling and booking Spirometry
Spirometry Protocol Harmonize with the hospital
a o e t t e osp ta
CLHT
SD4‐ Develop relationships with Respirologists
Develop relationships with PFT providers
Develop relationships with PFT providers
Referral process‐forms etc SD7‐ Education for providers
Documentation of flow sheet ICD9 Code
Documentation
of flow sheet ICD9 Code
ER visit list Primary Driver PDSA
PD1‐COPD registry (ICD9 Code in EMR)
SD1‐list
SD1
list of potential COPD patients
of potential COPD patients
driven by Smoking Status Screening & CLHT for smokers/ex‐smokers >40 yrs Identified that SSS needs to be 100% IPAD‐ survey given at registration
will run PDSA cycles
will run PDSA cycles Future Improvement Numbers/Stats versus Information‐ important to use relevant real time data to drive the information
Outcome Measures (run chartsÆcontrol charts)
Telling a Story g
y
Relationships of Change Translation to other Chronic Disease Models
Translation to other Chronic Disease Models
Key Point:
Key
Point:
Importance of integrated inter professional teamwork
Questions/Comments
Contact:
[email protected]
[email protected]
Questions?
Thank you for your time