Integrated Comprehensive Care Bundled Care Better, Faster, Cheaper - - PowerPoint PPT Presentation

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Integrated Comprehensive Care Bundled Care Better, Faster, Cheaper - - PowerPoint PPT Presentation

Integrated Comprehensive Care Bundled Care Better, Faster, Cheaper February 27, 2013 | Dr. K. Smith S T . J OSEPH S H EALTH S YSTEM (SJHS) SJHS IS ONE OF THE LARGEST CORPORATIONS IN C ANADA DEVOTED TO HEALTH CARE . O UR MEMBER


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Integrated Comprehensive Care – Bundled Care

Better, Faster, Cheaper

February 27, 2013 | Dr. K. Smith

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  • ST. JOSEPH’S HEALTH SYSTEM (SJHS)
SJHS IS ONE OF THE LARGEST CORPORATIONS IN CANADA DEVOTED TO HEALTH CARE. OUR MEMBER ORGANIZATIONS PROVIDE EXCELLENT, COMPASSIONATE CARE ACROSS THE CONTINUUM.
  • ST. JOSEPH’S HEALTHCARE,

HAMILTON

CHARLTON CAMPUS is a tertiary care teaching centre, which includes the regional kidney transplant centre, oncologic surgery and a large acute care hospital. KING STREET CAMPUS provides

State-of-the-art, stand-

alone facility including a Surgery and Satellite Dialysis Centre. WEST 5TH CAMPUS provides specialized tertiary mental health services for residents of Central South Region in Ontario.

  • No. of beds: 760
  • No. of Staff: 4,432

Annual budget: $500 M Established: 1890 www.stjoes.ca

  • ST. JOSEPH’S HOME CARE

SJHC provides a multitude

  • f services that respond to

community needs. Mandate is to help people including the frail, elderly, and disabled, lead more independent lives. This is done through nursing, personal and home support, and volunteer services, as well as our Constant Care, Palliative Care, Healing Touch, With Seniors in Mind, and Corporate Health Programs.

  • No. of beds: n/a
  • No. of Staff: 164

Annual budget: $10 M Established: 1921 www.stjosephshomecare. ca

  • ST. JOSEPH’S HEALTH

CENTRE GUELPH

  • St. Joseph’s Health Centre,

Guelph has been serving the Guelph and Wellington community since it first opened as a refuge for the sick, injured, frail and the indigent in 1861. Today it is Guelph's leading, fully accredited, non-for-profit provider of resident long term care, complex continuing care, and rehabilitation services.

  • No. of beds: 235
  • No. of Staff: 340

Annual budget: $30 M Established: 1861 www.sjhh.guelph.on.ca

  • ST. JOSEPH’S LIFECARE

CENTRE, BRANTFORD

SJLC is a multigenerational place of care, hope and

  • education. The new

concept of health care combines long term care with Brant County’s first hospice as well as a centre for research and

  • academics. The SJLC

commitment to the Mission and philosophy of providing compassionate care will never change.

  • No. of beds: 205
  • No. of Staff: 165

Annual budget: $11 M Established: 1955 www.sjlc.ca

  • ST. JOSEPH’S VILLA -

DUNDAS

SJV has built a new vision

  • f long term care; one that

understands that “there’s no place like home”. SJV staff embrace the mission; providing compassionate care with dignity and

  • respect. Over $70 million

in new buildings transformed the Villa and Estates into a modern home able to meet the needs of seniors and their families.

  • No. of beds: 452
  • No. of Staff: 306

Annual budget: $22 M Established: 1879 www.sjv.on.ca

  • ST. MARY’S GENERAL

HOSPITAL, KITCHENER

SMGH provides adult, acute care to people in Waterloo Region and

  • beyond. As home to the

Regional Cardiac Care Centre SMGH provides a full range of cardiac care including surgery, angioplasty, and pacemaker insertions. SMGH continues to meet the needs of the community, recently

  • pening a 100,000 sq.
  • ft. addition.
  • No. of beds: 160
  • No. of Staff: 921

Annual budget: $120 M Established: 1924 www.smgh.ca

SJHS TOTALS BEDS = 1,800 BUDGET = $683M

INTERNATIONAL OUTREACH PROGRAM

International Outreach has been bringing good intentions to life around the world since 1986. From Haiti to Uganda to Sudan, IOP partners with developing countries to provide training in current medical and nursing techniques, transport basic medical supplies, and make donated equipment operational. International Outreach is funded by the Sisters of St. Joseph of Hamilton, Canada and supported by member

  • rganizations and friends of St. Joseph's Health System. Projects are aimed at building capacity for sustainable programs; teams include physicians, nurses, biomedical engineers, and other healthcare personnel.
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Demonstrate the value of an integrated model of care

Patient centered model Follows the patient across the continuum of care

  • Acute care in hospital
  • Home Care in the community

Three client groups with broad applicability in Ontario (1,200 clients)

  • Hip and Knee Replacement
  • Lung Cancer Surgery
  • Chronic Diseases (chronic lung disease and heart failure)

Evaluation

  • Conducted by Program for the Assessment of Technology in Health (PATH)
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Integrated Care Coordinators

Team of 4 Integrated Care Coordinators

  • Directly coordinate the care of the patient acute care to community care
  • Expertly trigger interventions from both the hospital and community
  • Prevent readmissions
  • Prevent complications
  • Streamline the integrated continuum of care
  • Navigate the Health System WITH the patient
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Hip/Knee Replacement Surgery

Integrated Care Coordinator Home Care Team

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Client Value Statement

"Please help me fully understand my health challenges so that I can make informed choices about my care.” “I would like timely care when it is necessary, in the most suitable location.” “I want to be clear about what will happen next so I can prepare properly and try to worry less.” “Help support my recovery at home."

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Key Components of ICC

  • Integrated Care Coordinators
  • Partnership with a single service provider in the

community

  • Central contact number: access to the team (24/7)
  • Very engaged and committed team
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Key Components of ICC

  • Shared electronic health record
  • Flexibility in communication:
  • Skype, phone calls
  • Timely access to medical care
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Transforming the Way We Deliver Care

(Video)

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Edward

68 years old, Lives at home with his wife, in Brantford ON Diagnosed with Lung Cancer through the Lung Diagnostic Program at St. Joseph’s Healthcare Hamilton In August 2012 underwent Lung Cancer surgery at St. Joseph’s Healthcare Hamilton

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Edward

BEFORE

After 7 days in hospital, he is discharged home on Thursday

NOW

Saturday: His chest tube site is bleeding quite a bit, and he and his wife decide to go the Brantford General Emergency Room; they are sent home after a change in dressing. The CCAC Thursday evening: He is suffering from shortness of breath and right shoulder pain; His wife bring s him to the Brantford General Hospital ER for assessment He waits a few hours for an assessment and tests and is sent home ; The CCAC and home care providers are not aware of the visit After 5 days in hospital, he is discharged home on Thursday Saturday: His chest tube site is bleeding quite a bit, and he and his wife call the ICC central contact number; They speak with the Integrated Care Coordinator…

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Edward's Home Care Record

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Edward

BEFORE

After 7 days in hospital, he is discharged home on Thursday

NOW

Saturday: His chest tube site is bleeding quite a bit, and he and his wife decide to go the Brantford General Emergency Room; they are sent home after a change in dressing. The CCAC and home care providers are not aware

  • f the visit

Thursday evening: He is suffering from shortness of breath and right shoulder pain; His wife bring s him to the Brantford General Hospital ER for assessment He waits a few hours for an assessment and tests and is sent home ; The CCAC and home care providers are not aware of the visit After 5 days in hospital, he is discharged home on Thursday Saturday: His chest tube site is bleeding quite a bit, and he and his wife call the ICC central contact number; They speak with the Integrated Care Coordinator… The ICC sends the nurse in to assess the bleeding. A picture is sent to surgeon for review. The patient stays at home, with a follow up in the clinic in 2 days. All events are documented in the electronic record Thursday evening: He is suffering from shortness of breath and right shoulder pain; The Integrated Care Coordinator sends a respiratory therapist in the home for assessment, using an oximeter. A direct visit with the thoracic surgeon is scheduled immediately, with all his information provided to the physician.

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The Team’s Perspective

(Video)

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Results

Hip and Knee Replacements

  • Decreased length of stay and referrals to rehab
  • Decreased ER visits

Lung Cancer Surgery

  • Decreased length of stay: significant savings ($1,500+ per patient/client)
  • Decreased ER visits (9% versus 13%)
  • Reduction in hospital costs represents a 15%-23% savings per patient

Chronic Disease

  • Fewer ER visits after discharge
  • Fewer readmissions 30 days after discharge

Patient/client satisfaction is very high

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SJHH length of stay

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Average Cost Per Case

$0 $2,000 $4,000 $6,000 $8,000 $10,000 $12,000 $14,000 $16,000

CMG 112 Open Lung Resection CMG 114 Endoscopic Lung Resection CMG 320 Total Hip Replacement CMG 321 Total Knee Replacement

Average estimated direct costs

F2011/2012 Q1 F2012/2013

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A Client’s Experience

www.skype.ca

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Alignment With Other Initiatives

  • Quality Based Procedures/ HSFC
  • Apply learnings to the development of Health Links models
  • Seniors Strategy for Ontario: “Living Longer, Living Well”
  • HNHB LHIN Discharge Transition Bundle Project
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Potential Alignment with CCAC

  • Integrated care plan (hospital/home): patient specific outcomes
  • Integrated home care team delivering care
  • Entire bundle could be contracted to hospital/home care collaborative
  • Accountability for all cost: home care, readmits, ER visits

Client in Hospital Client at Home Integrated Care Coordinator Home Care Team CCAC Contract

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Additional Opportunities

  • 2. Test the model in a community hospital
  • St. Mary’s Kitchener
  • Chronic diseases (CHF/COPD)
  • Lung cancer surgery
  • 3. Evolve the model for Complex Cancer Surgery in Hamilton/LHIN HNHB
  • Alignment with Cancer Care Ontario
  • Cancer of the esophagus
  • Head and neck cancers
  • Urological cancers
  • 4. Vulnerable patients/clients with high length of stay, complex home care needs
  • Hip fractures
  • 5. Mental Health Programs?