Toolkit

The 15 week intervention involves delivery of patient education as well as clinical support.  Clinical staff involved in providing the components should be aware of best practices for heart failure, chronic obstructive pulmonary disease, vaccines, advance care planning, and associated clinical guidelines.

This section includes recommended preparation for frontline staff on how to use the DIVERT Scale and deliver the 8 components:

  • Needs Assessment - A suggested exercise to explore current human resources to best deliver components (RN, Pharmacy, Advance Care Planning, Care Coordinator) and use patient education materials consistent with local HF/COPD clinics and hospitals.

  • Curriculum Learning Passport - Details a comprehensive orientation for those RN/health professionals that will be implementing the 8 components.  A focus on HF/COPD clinical guidelines for chronic disease management, assessments, and pathophysiology is recommended.  Engage with HF/COPD clinic for shared staff education.

  • Pocket Guides/Clinical Practice - CORHealth/CCS and CTS pocket guides for health teams as a point of care resource.

  • Communication Supporting Tools - Intervention script offers components and teach-back.  Resources on SBAR communication technique are provided.

Find all resources required to implement the DIVERT program. Click the buttons below to view and download.

Organizational Preparation and Needs Assessment

Before implementing the DIVERT-CARE Trial we undertook a needs assessment and work flow process exercise.  The DIVERT Intervention is delivered in the home care sector and is intended to complement and align with health system initiatives in other sectors to promote continuity of care.  In this section you will find an example of the needs assessment from the Ontario site. 

Needs Assessment

User Guides

Training

For the intervention/practice change to be successful the health professionals/RNs involved in patient education require specific training and support.  We offered education on chronic disease management in Heart Failure and Chronic Obstructive Lung Disease delivered by Heart Failure Advance Practice RNs and Certified Respiratory Educators.  The Passport document includes HF/COPD specific preparation and additional training; DIVERT Scale, motivational interviewing, Advance Care Planning.

Registered Nurses delivering patient education were provided national level pocket guides and resources. 

Passport

Motivational Interviewing and Teach Back

 

SBAR

Advance Care Planning

 

Pocket Guides

 

Vaccine Recommendations

 

Patient Supporting Resources

The Zones are used to help monitor and detect fluctuations in symptoms.  The Zones with accompanying log sheets were part of patient education to be left with the patient.  We recommend using patient resources that are consistent with those provided by local acute care/specialist clinics.

Communication documents associated with coordinated care plan, ED transfer sheet, and SBAR communication have been adapted from Ontario resources, specific branding has been removed. 

Zone Sheets

Coordinated Care Plan

SBAR Communication

Care Pathways

Assessments