What is the purpose?
The purpose of the Alberta Screening and Prevention Plus (ASaP+) Change Package is to assist primary care clinics in adopting a suite of evidence-based screening maneuvers that allow providers to communicate and address the risks associated with modifiable factors. Discussing modifiable factors with patients may increase opportunities for brief intervention and supporting patients in positive health changes.
What is the aim statement?
By a specific date, the clinic team will increase the offers of support for patients with modifiable risk factors by a specific percentage.
What is the outcome measure?
The percentage of patients with documented screening receiving brief intervention within a specified interval.
What constitutes the balancing measure?
Ensuring ASaP screening rates do not decline while implementing ASaP+.
What do I need to do before proceeding?
These are the prerequisite change packages that should be reviewed:
Panel Processes Change Package Summary Relational Continuity Change Package Summary Care Planning Change Package SummaryHigh Impact Changes
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Improve the patient experience
Potentially Better Practice
Create opportunities that allow for routine, nonjudgmental conversation about modifiable factors.
Process Measures
The number of patient surveys completed in the clinic.Tools
Patient's Medical Home Guide to ASaP+ ASaP+ Health Checklist for Providers ASaP+ Health Checklist Patient Form
Potentially Better Practice
Integrate modifiable factors management into collaborative care planning
Process Measures
The number of care plans completed with a positive modifiable factor.Tools
Care Plan Template with Prompt
Potentially Better Practice
Develop a personalized approach that supports patient understanding about modifiable factors.
Process Measures
The number of patient surveys completed in the clinic.Tools
Patient's Medical Home Guide to ASaP+ ASaP+ Health Checklist for Providers ASaP+ Health Checklist Patient Form -
Optimizing the EMR for modifiable factors
Potentially Better Practice
Use EMR data to identify and support:
- Point-of-care reminders and EMR workflows are used to enable proactive approach to modifiable risk factors
- Panel based measurement and monitoring of modifiable factors
Process Measures
The number of patients screened for each modifiable factor.
The number of patients eligible for care planning (positive modifiable factors).
Tools
EMR Resources and Measurement Measures Form with Guide - ASaP+ -
Standardize documentation
Potentially Better Practice
Establish standardized documentation of modifiable factors in the EMR.
Process Measures
EMR Audits
Tools
EMR Resources and Measurement ASaP+ EMR Data Entry Assessment Tool -
Coordination of the team in the medical home
Potentially Better Practice
Test and implement a process that bundles opportunistic screening of modifiable factors.
Process Measures
Documentation of screening processes.
Tools
Patient's Medical Home Guide to ASaP+
POTENTIALLY BETTER PRACTICE
Develop action plans with patients to support care planning.
Process Measures
The number of care plans completed with a positive modifiable factor.
Tools
Care Plan Template with Prompt HealthChange Methodology
POTENTIALLY BETTER PRACTICE
Establish clear roles and responsibilities and a shared mental model for your medical home team.
Process Measures
Documented roles and responsibilities of the team members.
Tools
Patient's Medical Home Guide to ASaP+ Rationale and Evidence - ASaP+ -
Coordination of care in the medical neighborhood
Potentially Better Practice
Develop relationships with PCN, community and zonal resources that support patients to make positive health changes related to ASaP+ modifiable factors.
Process Measures
The improvement team generated a community and PCN resources list.
Programs and Resources Quick Referral List
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