Client Care Model Board Meeting April 25, 2012 Outstanding care - - PowerPoint PPT Presentation
Client Care Model Board Meeting April 25, 2012 Outstanding care every person, every day The Client Care Model The Client Care Model is a framework that standardizes how we define, work with, and are accountable for five client
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The Client Care Model is a framework that standardizes how we define, work with, and are accountable for five client populations. Each receive specific case management intensity, care planning and service that align with their care needs.
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Client Care Model concept (population-based model for delivering care) Impact from Regulations removing PSW caps: higher utilization & programs like Home First
May 2 0 0 9 Novem ber 2 0 0 9 May 2 0 1 1
CCM implementation begins at each CCAC according to local needs and capacity
Governm ent CCACs Provincial Local CCACs
CCAC Provincial Client Services Committee Analysis
Sustainability MOHLTC announces ALC / ER Wait Times priorities (i.e. Hospital Flow)
April 2 0 0 9 May 2 0 0 9 Septem ber 2 0 1 0
6 Proof of Concept sites test various populations and report evidence-based findings
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Clients w ere “our” clients Clients are “system ” clients
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disease management
care
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Outcom es
client dying in preferred place (Complex clients)
Stay for Community Independence clients
control and reduced social isolation for Complex clients
Satisfaction Costs
described feeling supported, especially during transitions
focused approach to Case Management
Case manager relationship (Complex)
services remained neutral
as per best practices (Short Stay)
Standards of Care Population Definition Anticipated Outcom es Case Managem ent I ntensity
Caseload Size
conditions
unpredictable
network
than one area
Sub-populations:
Example Client with CP , Arthritis, Diabetes, Depression, falls
home
families to achieve degree of stability in preferred care destination
Management
system navigation I nitial Contact < 72 hours I nitial Assessm ent < 7 days Re-Assessm ent RAI-HC every 3-6 months Follow -up ( General)
initial visit
month Follow -up post ED/ Hospital
(contact)
Visit) Follow -up post- CCAC discharge < 6 weeks
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Standards of Care Population Definition Anticipated Outcom es Case Managem ent I ntensity
Caseload Size
conditions
are stable & predictable
with support network
Sub-populations:
Example Client with Alzheimer’s Disease and no behavioural problems
home
families to achieve degree of stability in preferred care destination
structure that promotes self- reliance (e.g. ADL assistance to keep clients in their home)
Management intensity focused on helping client manage health condition(s) & preventing further decline I nitial Contact < 72 hours I nitial Assessm ent < 10 days Re-Assessm ent RAI-HC every 6 months Follow -up ( General)
1st month
Follow -up post ED/ Hospital
(contact)
(Home Visit) Follow -up post-CCAC discharge < 6 weeks
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Standards of Care Population Definition Anticipated Outcom es Case Managem ent I ntensity
Caseload Size
health conditions
independent living
network and/ or can be self-reliant
Sub-populations:
Independence Example Elderly client with difficulty bathing independently
maintain their health & well-being
management approach & linkages to community-based resources.
Case Management intensity
increased independence via effective pathways & system navigation I nitial Contact < 72 hours I nitial Assessm ent < 14 days Re-Assessm ent RAI-HC annually Follow -up ( General) Every 3-6 months Follow -up post ED/ Hospital
Supported Ind.
Stable at Risk Follow -up post- CCAC discharge < 30 days
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Standards of Care Population Definition Anticipated Outcom es Case Managem ent I ntensity
Caseload Size
education, care or support
return to independence
care trajectory Sub-populations:
Example Clinic client – wound care
acute/ rehabilitation needs to transition to self-care
Management intensity I nitial Contact < 72 hours I nitial Assessm ent By exception
Re-Assessm ent n/ a Follow -up ( General)
post admission
monthly as needed Follow -up post ED/ Hospital < 7 days Follow -up post-CCAC discharge < 7 days
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March 2 0 1 2
Client Categor- ization For Existing Clients
April 2 0 1 2
Develop CCM Team Structure
May 2 0 1 2
Expression of I nterest Process
June – Aug 2 4 th
Caseload Reassignm ent & Education
Aug 2 4 th
Go- Live Date
Sept – March 2 0 1 3
Phase Tw o: Monitoring, Evaluation & Revisions
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Community Case Managers to categorize at initial assessment Resource Case Managers to categorize once new chart received
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comfort / complacency shock / denial fear / anger negotiation depression / reality check curiosity / desire to know excitement / acceptance Adoption / evolution
Perform ance Tim e
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