Chronic Disease Management in Primary Care

Quality and Outcomes

Gill Wakley, Ruth Chambers

• Publisher: CRC Press
• Year: 2018
• ISBN:
  9781315358390
• Edition: 1
• Topic: Medicine
• Subtopic: Medical Theory, Practice & Reference

Domiciliary care is a sensitive and complex subject. Can I obtain suitable care workers? Which organisations can I call on for support? What are the obligations placed on homeowners? If a relative wishes to remain at home do you know what to do? These are questions often asked by health professionals social workers and service users. This book answers such questions gives choices and shows how to implement decisions. It is essential reading for the new primary care organisations community practitioners primary healthcare teams practitioners in palliative care and geriatrics charities and volunteer groups.

1

Problem-based learning (PBL): how to do it

This chapter introduces you to the principles of problem-based learning (PBL). You will see how your primary healthcare team (PHCT) can use PBL to assist in improving chronic disease management in your practice. This includes practical ideas on how a PBL session should be run, what sort of outcomes you can expect and what pitfalls to avoid.

Why PBL is important

Problem-based learning was first developed in Canada, at McMaster University Medical School during the 1960s and has rapidly influenced medical and nursing education worldwide.¹ It encourages a move away from traditional didactic instruction to a more learner-centred approach to learning. It challenges you and the rest of your team to develop the ability to think critically, analyse problems, and find the most appropriate learning resources yourselves. As well as helping to address important learning relating to your work, PBL helps you to learn how to learn.

Problem-based learning is very enjoyable and will increase your motivation to change your clinical practice and behaviour.^2,3 This motivation is likely to be transferred into actual change, for instance in relation to prescription writing. Problem-based learning conforms to many of the principles that characterise effective adult learning, in that it:

• is linked to day-to-day practice
• is a group-based activity
• is flexible, and ‘personalised’ to your own situation
• reinforces learning, through review.

What is PBL?

In PBL the ‘problem’ is used as the stimulus for learning. In some ways this is the opposite of your previous experience, where you would be expected to already know something, and then to apply this knowledge to solve a test problem.

In PBL, the purpose of considering the problem presented is to allow discussion, and the identification of what is already known, and crucially, what is not yet known. The next step is to address the identified learning needs and share the new knowledge at a later meeting. Finally, the group considers how the new learning can be applied.

This sequence is described in Box 1.1.

Box 1.1: Sequence of problem-based learning

1. Problem is presented to group
2. Group discusses the information
3. Group establishes agreed ‘facts’
4. Group identifies what else it needs to know
5. Areas for learning are divided up within the group, and responsibility for carrying out the necessary learning and research is shared
6. Group meets again to review what has been learnt and how the learning can be used

The principles of PBL are.

• Problem scenarios do not test skills and knowledge.
• The problems are open-ended – there is no ‘correct answer’. As new information is gathered and shared, the group develops an understanding of the problem and the learning.
• Different groups will identify different learning needs.
• The group solves the problem for itself.
• The group must decide for itself how it chooses to address the learning issues it has identified.
• The process is complete once the learning has been applied in practice. Ideally, these changes in practice can be audited to reinforce and check on the nature of their application.

How do you do it?^{4, 5, 6 and 7}

Some preparation is needed. Ill-prepared attempts at PBL are likely to result in confusion and disappointment! The essential components are.

1. A group that is willing to learn together.
2. Someone to facilitate who understands the PBL process and can involve everyone in your team.
3. A PBL scenario that stimulates relevant discussion.

Planning checklist

Use the following checklist to help with your PBL planning.

Do you have time to do this?

A typical PBL session will take two to three hours to complete. You do not need to plough through a whole scenario if the team has identified enough learning issues to deal with earlier on in the case. The purpose of the PBL process is to engage your team in discussion, and to identify your collective learning needs. Then you can share, learn and plan for change.

Many practices will use protected learning time to carry out PBL so that all the team members can meet. Would this work for you? Does your primary care organisation (PCO) at least support you in this activity by for example providing emergency cover for the doctors, or could it? The time for PBL (like any other learning activity) needs to be properly protected – no ringing telephones, bleeps or other distractions!

Does everybody agree?

Most practice teams are complicated, diverse groups of people, who don’t necessarily all want the same thing at the same time! So take time at a preliminary meeting for the lead facilitator to explain what PBL is about, and make sure everybody understands how it is expected to work. Provided that everyone in the team is happy to give it a go, a trial run often helps – as it is fun and engaging.

Who is going to be involved?

Problem-based learning works best when the group includes a full range of your primary healthcare team. Everyone brings their own perspective which is one of the strengths of the technique. Ideally, a PBL group includes doctors, nurses, healthcare assistants, practice manager, administrative and domestic staff, as well as attached staff such as social worker, pharmacist, health visitor, physiotherapist, podiatrist and midwife. Anyone who works in the team can be involved! And don’t forget patients and their carers too.

Do you have a trained facilitator?

The facilitator should be familiar with techniques for running small groups successfully, as well as PBL principles. Is there someone in your team who can fulfil this role?

Is your group the right size?

Some people think the ideal group is around 8–12 people. However, PBL has been used successfully with groups slightly larger than this – up to 15. Anything larger and the group cannot function properly: some members of the group will not feel able to contribute, it will be difficult to hear what is being said, and there will be a tendency for the group to ‘splinter’ into smaller sections.

You could divide a larger group into two. You would then need two facilitators but the process will be much more effective and enjoyable. Both groups could use the same scenario and come together at the end to share their plans for learning.

Have you got the necessary equipment?

Each group will need a room large enough for everyone to sit in comfortably, without being disturbed. Get a flipchart, pens (that work!) and plenty of flipchart paper. Photocopy the problem case examples so that they can be handed out (one between two is probably enough) amongst the group members as you progress through the case. If you are facilitating watch the clock to pace the session.

Do you have a set of PBL scenarios?

This chapter includes a problem case example (see page 10) that you can use to get started, or you can turn to one of the other chapters. Further cases are available from other sources.⁸

… And remember:

• PACE YOURSELVES!

Prioritise the learning issues identified to ensure that you are tackling a manageable number. It is better to address a small number of issues well...

Table of contents

• Cover
• Title Page
• Copyright Page
• Table of Contents
• Preface
• About the editors
• About the contributors
• Acknowledgements
• Chapter 1: Problem-based learning (PBL): how to do it
• Chapter 2: Team-based learning
• Chapter 3: Assessing your learning and service development needs: effective chronic disease management
• Chapter 4: Organising chronic disease management to match the quality and outcomes framework
• Chapter 5: Diabetes
• Chapter 6: Hypertension
• Chapter 7: Hypothyroid disease
• Chapter 8: Asthma
• Chapter 9: Mental health
• Chapter 10: Coronary heart disease
• Chapter 11: Stroke and transient ischaemic attack (TIA)
• Chapter 12: Medicines management
• Chapter 13: Chronic obstructive pulmonary disease (COPD)
• Chapter 14: Epilepsy
• Chapter 15: Cancer and palliative care
• Chapter 16: Patient safety in your practice
• Appendix 1: North Staffordshire palliative care communication form
• Appendix 2: Cancer and palliative care: dealing with complex problems in advanced illness
• Index