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Conducting Individualized Care and Discharge Planning Aniin - - PowerPoint PPT Presentation
Conducting Individualized Care and Discharge Planning Aniin - - PowerPoint PPT Presentation
Conducting Individualized Care and Discharge Planning Aniin www.HQOntario.ca How to Participate Today Open and close your Panel View, Select, and Test your audio Submit text questions Raise your hand www.HQOntario.ca 2 How
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How to Participate Today
- Open and close your
Panel
- View, Select, and
Test your audio
- Submit text
questions
- Raise your hand
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How to use this time well
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Presenter Disclosure
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Presenter(s)
- Julie Nicholls, Tracy Howson(HQO)
- Dr. Jocelyn Charles
- Dr. Kaplan
Relationships with commercial interests:
- Grants/Research Support: Not Applicable
- Speakers Bureau/Honoraria: Not
Applicable
- Consulting Fees: Not Applicable
- Other: Not Applicable
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Disclosure of Commercial Support
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- This program has received no commercial
- r financial support
- This program has received no in-kind
commercial or financial support
- Potential for Conflict(s) of interest:
- No speaker has received payment or
funding from any for-profit organization
- No organization has a product that will
be discussed in the program
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Some Helpful Resources: HQO Improvement Packages
Supporting Health Independence
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Transitions
- f Care
Chronic Disease Management
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Transitions of Care Improvement Package
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Individualized care planning
Health literacy
Risk assessment and follow-up care planning Medication Reconciliation
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Agenda
- What is Individualized Care and Discharge
Planning?
- What are the elements of care coordination?
- Hear from Drs. Charles and Kaplan and their
care coordination tool.
- Share resources available
- Raising the challenge of “What you can do by
next Tuesday”
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Individual Care Planning: What does it mean?
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Discharge Planning: Best Practices
Individualized pre-discharge planning should be a multi- component intervention, including some combination of the following:
- patient education;
- patient-centred discharge instructions; and
- coordination/communication with family physicians and
- ther appropriate community-based services.
- Ontario Health Technology Advisory Committee (OHTAC), April 2013
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Three Categories of Best Practices
- 1. Category 1: Pre-Discharge Practices
- 2. Category 2: Discharge Planning Processes
- 3. Category 3: Assessment for Post-Transition Risk and
Activation of Post-Discharge Follow Up
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Category 1: Pre-Discharge Practices
- 1. Pre-discharge planning is incorporated as a standard
- f care for complex patients admitted to hospital
- 2. Patients and caregivers are involved as partners in
the discharge planning process
- 3. Individualized comprehensive assessments and care
plans are developed for complex patients on admission
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Category 2: Discharge Planning Processes
- 1. Individualized discharge plans are developed on
admission for patients with complex needs
- 2. Protocols are established to ensure medication
reconciliation at key transition points
- 3. Families/caregivers are provided with information and
resources to support their transition
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Category 3: Assessment for Post-Transition Risk and Activation of Post-Discharge Follow Up
- 1. Standardized risk assessment tools are used to
assess and stratify complex patients at discharge
- 2. Appointments are booked with the patient’s primary
care provider
- 3. Complex patients receive a follow up phone call within
48 hours of discharge from hospital
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Additional System-Wide Goals
- 1. Adoption of a standardized discharge summary
template for use among all health care organizations that perform discharge planning.
- 2. System-wide implementation of designated supports
for complex patients in the post transition follow-up period.
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Provincial Activity in Support of Coordinated Care Planning
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Care coordination requires:
- Patient centred approach
- Care providers working together
- Ability to share information across the
continuum
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Care Coordination Requirements
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- Commitment to data quality, using standard
language – balanced with flexibility to share complex information
- Plain but precise language
- Comprehensive – include social determinants
- f health as well as physical and mental health
- Patient-driven
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A Reminder: How to Join the Conversation
- ALL participants are muted
- If at anytime you have a question or comments during
the presentation, you can ask by:
Typing a question into the Question Box
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Dial in by phone: 1-877-273-4202 2961738#
TYPE QUESTION HERE
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- DR. CHARLES & DR. KAPLAN
Developments From the Field
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- Dr. Jocelyn Charles
- Dr. David Kaplan
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Questions?
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HQO & bestPATH resources www.hqontario.ca/bestpath
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Key Resources
- bestPATH – Transitions of Care - Evidence Supported
Improvement Package (November 2012)
- Ontario Health Technology Assessment Series; Vol.
13: No. TBA, pp.1-73 (April 2013)
- Ontario Health Technology Advisory Committee
(OHTAC). (April 2013- draft publication). Optimizing Chronic Disease Management in the Community (Outpatient) Setting (OCDM)
- Quality Compass
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Until we meet again
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What idea can you use or implement by Next Tuesday?
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