Health Links Leadership Community of Practice Feb 22, 2017 Hearing from Health Links IDEAS Teams on their experience implementing coordinated care management innovative practices Health Quality Ontario The provincial advisor on the quality of health care in Ontario www.HQOntario.ca
Today’s Agenda & Objectives • Review of Innovative Practices for Coordinated Care Management • Hear how IDEAS teams identified, planned and implemented care coordination management in their Health Link using innovative practices • Understand how quality improvement methods can be used to accelerate your Health Links work www.HQOntario.ca 1
PARTICIPATING IN THE WEBINAR • This webinar is being recorded. • ALL participants will be muted (to reduce background noise). You can access your webinar options via the orange arrow button. • Discussion period post presentation, please type your questions for the presenter after each presentation. • If you would like to submit a question or comment at any time, please use Question box feature. www.HQOntario.ca 2
WEBINAR PANEL Shannon Brett, Manager, Quality Improvement & Spread, Health Quality Ontario Stacey Bar-Ziv, Team Lead, Quality Improvement & Spread, Health Quality Ontario (Moderating Discussion) Shawna Cunningham, Quality Improvement Adviser, Health Quality Ontario www.HQOntario.ca 3
GUEST SPEAKERS HURON PERTH HEALTH LINK, LONDON MIDDLESEX HEALTH LINK Jeni Millian, Patient Care Manager, South West CCAC Paula Day, RN Thames Valley Family Health Team Llori Nicholls , RPN North Perth Family Health Team Heather Ross , Occupational Therapist, New Horizons Rehab MID EAST TORONTO HEALTH LINK (METHL) Kelly Clarke , Client Services Manager, Toronto Central CCAC Michelle Bather and Vicky Wen , Case Managers, General Internal Medicine Unit at St Michael’s Hospital Susan Anstice , Transitional Care Coordinator Mid East Toronto Health Link and Social Worker at WoodGreen Community Services www.HQOntario.ca 4
HEALTH LINKS LEADERSHIP COMMUNITY OF PRACTICE ‘Communities of practice can be defined as groups of people who share a concern or a passion for something they do and learn how to do it better as they interact regularly’ www.HQOntario.ca 5
INNOVATIVE PRACTICES www.HQOntario.ca
COORDINATED CARE MANAGEMENT http://www.hqontario.ca/Quality-Improvement/Our- Programs/Health-Links/Coordinated-Care-Management www.HQOntario.ca 7
COORDINATED CARE MANAGEMENT Summary of Innovative Practices www.HQOntario.ca 8
www.HQOntario.ca
shareideas.ca www.HQOntario.ca 10
UPCOMING DATES IDEAS application webinar: March 21 See IDEAS.ca for more details Upcoming IDEAS-QI Webinars www.HQOntario.ca 11
Mid East Toronto Health Link (METHL) Virtual Hub: Improving Identification, Referral & Care Co-ordination For Acute Care Patients With Complex Needs Project Sponsor : Ashnoor Rahim, Vice President WoodGreen Community Services IDEAS Applied Learning Project
Our IDEAS Project Team MID EAST TORONTO HEALTH LINK (METHL) Kelly Clarke MSW Michelle Bather RN Client Services Manager, Case Manager, St. Michael’s Toronto Central CCAC Administrative & Hospital General Community Resource Internal Medicine Expertise (SMH GIM) - Clinical Expertise Susan Anstice MSW, Victoria Wen , RN MSc Transitional Care Case Manager, Coordinator (TCC) - St. Michael’s METHL , Hospital General Clinical Social Worker, Internal Medicine WoodGreen (SMH GIM) - Team Lead & - Clinical Community Resource Expertise Expertise 13
Our Health Link Process Improving care transitions across health sectors through Coordinated Care Planning 14
Why this QI Process? Meet Mr. G.M. • Admission: 59 y.o. man; alcohol withdrawal, electrolyte imbalance, acute kidney injury • PMHx: depression, CHF, Type II diabetes, cirrhosis • Living in shelter, no community services 15
How Can We Improve? • Systematically identify patients eligible for Health Link • Identify the optimal time to approach patients • Connect patients to METHL Transitional Care Coordinator (TCC) in hospital Project Aim : By December 31, 2017, increase the percentage of identified SMH GIM patients referred to METHL who participate in a Coordinated Care Planning Case Conference within 30 days of discharge from 43% to 75% 16
Virtual Hub – Change Ideas Aim Primary Drivers Secondary Drivers Change Ideas Improve timely Use SMH Screening By February Increase identification of complex tool with all patients 3, 2018, care patients for HL referral Access admitted to GIM reduce to Care avoidable 30- Coordination TCC meets with Improve patient consent and day hospital patient pre-discharge; attachment process acts as single point of readmissions contact for patients Build patient and care team of St. relationships Patients receive Michael’s Health Link brochures Develop Hospital GIM Partnerships Improve patient experience/ who knowledge of Health Link participate Interview patients to understand Health in Availability of Primary care Link experiences Coordinated providers and PCP Care appointments CCP completed within Planning 30 days of discharge Coordinate care team with Mid Enhance communication to improve East Toronto Care Team patient transition across Health Link Collaboration Primary Care sectors (e.g. acute to appointment 7 days to 20% community) post D/C
PDSA Cycles Example: Screening Tool Cycle 1 Oct 24 Tests of change/ cycles for: 1)Screening Tool Do Plan 2) Screening Process Screen GIM Test SMH Pts with readmission SMH Tool Risk Tool 3) Patient Consent Process (2 weeks) 4) HL Referral Process 40% of screened Use SMH Tool patients eligible for - all new GIM Health Link admissions 5) Warm Handover to TCC Study Act
Patient Engagement and Consent Cycle 1 Nov 20 Plan Do Request Inform about Pt. consent CCP and Cycle 2 Dec 12 2d before Request Pt. discharge consent Plan Do Change to Pts. missed: Request Pt. Inform about requesting Difficult to consent CCP consent at predict d/c 1-2 d post & Request admission date admission Pt. consent Study Act Why fewer More pts. seen consenting? Less consented/ -presentation able to engage vs timing? Study Act
Results - Screening & Referral 11 SMH GIM Patients referred to Health Links 9 Number Patients Referred 7 Count 5 Median Baseline Dec 2015 - Sept 2016 3 PDSA 1 Oct 24 2016 1 Dec-15 Jan-16 Feb-16 Mar-16 Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 -1 Month 20
CCP Consent Rate SMH GIM Referrals October 2016-January 2017 TCC met patient Consent to CCP CCP Declined Consent Rate prior to (count) (count) (%) discharge? Yes 6 1 85% No 2 4 33% Total 8 5 61% * excludes “consent in progress” 21
Impact – Meet Ms. MC 34 y.o. woman • frequent suicidal ideation and diabetic ketoacidosis. • history of PTSD • spent the last 2 years at a Shelter • Identified with SMH Screening Tool • Met with METHL TCC while in hospital • CCP Case Conference completed within 30 days 22
Overall Learning SMH Screening Tool vs LACE Tool • Identifies Health Links appropriate patients on admission • Includes homelessness, mental health, family doctor • For CHF and COPD; to be revised for general GIM population Warm handover to TCC while in hospital • Support for change theory: patient more likely to consent Productive Range of Tension / Limit of Tolerance 23
Overall Challenges • Sustainability – screening and patient engagement create additional workload • Electronic information sharing – no single platform • Predicting discharge date 24
Next Steps Continue change ideas • Sustain/Improve processes underway • Additional change ideas including: CCPs completed within 30 days of referral, patient experience Spread to other settings? • Acute Care / Rehab Hospitals, other Health Links 25
Acknowledgements Thank you to the following people Without you this project would not be possible Yinka Macaulay, Toronto Central LHIN Ashnoor Rahim, WoodGreen Community Services Mary Eastwood, Mid East Sub Region Gayle Seddon, TC-CCAC Leighanne MacKenzie , St Michael’s Hospital Kim Grootveld , St Michael’s Hospital Joe Mauti, HQO Laura MacLagan, ICES METHL TCCs: Sandra Corrado, Xochil Amaya, Claire Bogomolny 26
Insert Team Photo Here Embedding CCP into the FHT Jeni Millian Patient Care Manager, SouthWest CCAC Paula Day RN TVFHT Llori Nicholls RPN NP FHT Heather Ross Occupational Therapist, New Horizons Rehab Project Sponsor: Huron Perth Health Links London Middlesex Health Links IDEAS Applied Learning Project
Utilization reports does not always capture right patient! CCP not GP not engaged being done ! in process ! Story: “Could it get any worse?” – Not on Med GPS – Multiple healthcare agencies – No family involved – Only trust GP and plastic surgeon Who could be more in need of a CCP, must involve GP team 28
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