ONE CLIENT - ONE TEAM
Primary Care and CCAC Working Hand inHand to Drive Integrated Service Delivery
April 13, 2016
The CCAC Sector…The CCAC Sector
Our Vision
Outstanding care- every
person, every day
Our Mission
To deliver a seamless
experience through the
health system for people in
our diverse communities,
providing equitable access,
individualized care
coordination and quality
health care
14 CCACs across Ontario providing
home care…
Serving over 630,000 clients of all
ages across Ontario annually…
By enabling them to stay safely at
home for as long as possible…
And helping them understand
other supports available to them…
Working hand-in-hand with
primary care, hospitals, long-term
care homes, and community
organizations.
A shared provincial vision and mission – supporting local needs.
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Toronto Central LHIN
An Urban Geography
•
Our community consists of 1.15 million residents
in the Toronto area
•
Highest rates of diversity and low income and
single parent families - urban population
• 20% of children live below poverty line
• 36% of households have low incomes
• 40% of Ontario’s homeless population live
in Toronto
• Incredible diversity with over 100 languages
spoken across the region
Partnering In A Complex System
Up to 1800 primary care
22 Hospitals,
41 long-term care homes
providers
74,000+ transitions,
operating at 99%
(13 Family Health Teams,
57% to other CCACs
occupancy
18 Community Health Centres,
and 700 solo-practice)
1
CCAC
100+
Community
Support Services
4 School
Boards
The Changing Complexity of Home Care
The Home and Community Care Sector has continued to invest in supporting more complex
clients at home for as long as possible…
The organization has seen
an +20% increase in
chronic and complex
populations
…This transformational shift requires continued and stable investment in community and
innovative service delivery models that improve quality and drive value
Toronto Central CCAC Strategy (2012-2016)
Opening Our Hearts,
Opening Our Minds
A strategy dedicated to client experience, quality improvement, and integration with a focus
on advancing the home and community care sector
V
Caring and
Empathy
A
L
Leadership
U
Excellence
E
Social
Responsibility
S
Human Dignity
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Toronto Central CCAC – What We Do
Connecting People to Care
Facilitating Supportive
Transitions
Supporting People in
Their Home
Respond to over 183,000 calls per
year through our Information and
Referral program
Support 74,000 clients to transition
clients home from hospital
Support 46,000 clients to remain at
home for as long as possible, wherever
home may be
Connected 14,000 unattached clients
to a Primary Care doctor or Nurse
Practitioner
Helped over 2,000 clients transition to
long-term care through placement
services
Support 5,000 children to receive
care at school
CARE COORDINATORS
CLINICIANS
CARE SUPPORT TEAM
Understanding what’s most
important to clients and
families, setting care goals,
organizing and navigating care
services, resource
management, and ensuring
quality of care
Nurse Practitioners,
Pharmacists, Advanced
Practice Nurses, and
Physicians working as part of
an integrated team and
delivering care to our most
complex populations
Including Placement Coordinators,
Information and Referral and Client
Care Support teams that help to
connect clients to services, help
get access to long-term care and
help to resolve client and family
concerns
Partnering to Deliver Care
Toronto Central CCAC – Our Programs
Toronto Central CCAC’s population-based model supporting what’s most important
to our clients…
PALLIATIVE CARE
Supporting over 2,700 clients to die
in the place of their choice with
dignity
ADULT SUPPORTIVE CARE
Supporting 1,200 adults & their
caregivers to manage their long
term conditions
SENIORS CARE
Intensive support to 20,750 seniors
and their caregivers to remain at
home with dignity
CHILD AND FAMILY
Helping 7,000 kids get the right
support in schools; 300 children who
have complex medical needs, and
1,100 children with post acute needs
5%
ACUTE, REHAB & TRANSITION
Providing 13,500 clients with
post acute and rehab care
URBAN HEALTH
Unique to TC CCAC, helping
1,700 marginalized clients with
mental health issues, or
homeless to access services & be
supported in their community
HOSPITAL TRANSITIONS
Supporting over 74,000
transitions from hospital and
over 2,000 transitions to longterm care
The Home and Community Care Sector, of which the CCACs are a
part of, currently makes up 5% of the provincial health care budget
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Toronto Central CCAC – Our Programs
Toronto Central CCAC’s population-based model supporting what’s most important
to our clients…
Recognition of Our Work With Partners
INTERNATIONAL
•
Our population-
Recognized as one of top 14 models of integrated care at the
World Congress on Integrated Care 2015
NATIONAL
based
•
National accredited best practice for Changing the Conversation
for client and family centered patient care (2015)
integration with
•
National Best Practice for care integration from the Canadian
Home Care Association 2014
primary care and
•
Accredited to national standards with recognition for leading
practices in integrated care & ethics by Accreditation Canada
other partners
has been
recognized
PROVINCIAL
• Ontario Minister's Medal for the highest achievement in quality
for our integrated palliative care program 2014
• Ontario Minister’s Medal Honour Roll for our integration for
complex older adults 2013
AT THE POINT-OF-CARE
•
Received proud partner award from Baycrest
From Form Follows Function To...
Form and Function in Tandem
FORM
Health System
Transformation
in Ontario
Patients First
FUNCTION
FUNCTIONAL INTEGRATION
2010
STRUCTURAL REFORM
2016
How We Thought About
Integration in this Environment
Our Starting Point – Failing Clients & Families
Failed handoffs
during transition
Multiple medications,
multiple pharmacies,
multiple prescribers
Poor service
coordination; a
maze of care
No integrated client
record and shared
planning
Many providers,
fragmented care
CCAC and primary
care working
independently
Provider-Centric
Through the Eyes of Clients and their Families
Our Point-of-Care Integration Strategies
OUR AIM
One Client, One Team
A health system strategy
and philosophy
A program
For clients and families to experience multiple parts of the health care system as one team
Driving two parallel strategies to create an enabling environment for functional, point-of-care integration
Integrated Client Care Programs for
Complex Populations
Primary Care Integration
OUR APPROACH
Understand the needs of clients and families through continuous engagement
Building meaningful relationships by always asking our partners...
Who are our common clients and how can we work together to better their care experience?
Putting client experience and quality at the forefront of every conversation
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Functional Integration with Primary Care and the
Health System
Point of Care Functional
Integration
Teams responsible for populations,
experience, outcomes, and value
The provincial environment and our local context are providing us with
the new levers to scale our primary care integration strategy
One Client, One Team
Functional Integration at the Point of Care: Building inter-sectorial,
inter-organizational, inter-professional teams at the point of care
One Client, One Team
Functional Integration at the Point of Care: Building inter-sectorial,
inter-organizational, inter-professional teams at the point of care
One Client, One Team
Functional Integration at the Point of Care: Building inter-sectorial,
inter-organizational, inter-professional teams at the point of care
Local Primary Care Integration Strategy
OUR GOALS
Stronger
Communication
Better Access and Support to
Primary Care for Clients with
Complex Care Needs
300
Implementation of
communication standards
through standardized tools
and e-health enablers
Joint visits and care
planning for the most
complex clients
Building Ethics Capacity
to Support Complex
Populations
Upward of 300 physicians using
newly launched physician
+ phone line for navigation and
resource support
71%
100%
95%
30%
93%
Of Primary Care Physicians
are connected to a CCAC Care
Coordinator
Connection to Family Health
Teams
Connection to Community
Health Centers (CHC)
Connection to solopractice physicians
Increase in helping unattached
clients find a doctor through
Health Care Connects
Integrated Community and Primary
Care Ethics Network and Program
• Partnership with UofT
Department of Family and
Community Medicine, the Joint
Center for Bioethics and the
Toronto Central LHIN
•
New curriculum for new
Primary Care grads
•
Building capacity for existing
primary care teams
Scaling Primary Care Integration Provincially
Connecting Care
Coordinators with
Primary Care
Providers
Better Communication
Better Access
The heart of our strategy is all about developing meaningful
Connections with primary care physicians……….
KEY ENABLERS
Communication and
Engagement
E-Health
Operational Tools
Performance
Indicators
Our Strategy in Practice
South East Toronto Family Health Team
CC
CC
One Client, One Team
2 CCAC Care Coordinators Aligned to Primary Care Practice
with shared caseloads for the most complex older adults who cannot access office-based
primary care
Enabling point-of-care integration for our most complex clients
1
2
3
4
Supporting older
adults to transition
home
Coordinated
Care
Planning
Remote Monitoring
and
Tele-Home Care
Supporting Planned
Admissions to
Hospital
Evaluating the Experience and
Outcomes of Our Clients
Evaluation Methodology
EVALUATION OBJECTIVES
1
Health Outcomes
2
Client Experiences
and Perceptions of
Health
Methodology
Comparison of effectiveness of two care models,
One Client, One Team and the comparator
program, Seniors Enhanced Care (SEC).
(a) Propensity scoring models are used to match clients
in both care models and ensure they are comparable
on a number of ‘baseline’ covariates. This ensures we
are comparing ‘like’ individuals
(b) Longitudinal models to explore the trajectories of
client complexity scores between the two care
models
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Partner Experience
Data Sources
•
•
•
•
•
•
Electronic and phone surveys with clients,
caregivers, and providers
In-depth phone interviews with clients and
caregivers across both care models
Focus groups with care providers
Key informant interviews with One Client,
One Team program management
Developmental video interviews with clients,
caregivers, and providers where appropriate
Retrospective analysis of client data from
the RAI-HC – Resident Assessment
Instrument for Home Care (i.e. complexity
scores, activities of daily living, cognitive
functioning
Evaluation of Health Outcomes
HYPOTHESIS
WHAT WE LEARNED
Decline of clients within the One Client, One
Team program is slower than those clients in
the comparator program
Multilevel longitudinal models confirm the above
patterns for each of the RAI-HC sub-scales:
-
Method of Assigning Priority Levels (MAPLe),
-
Activities of Daily Living (ADL) and Instrumental Activities
of Daily Living (IADL)
-
Cognitive Performance Scale (CPS) and Changes in Health
-
End-Stage Diseases and Signs and Symptoms (CHESS)
-
Aggregate RAI Score
If One Client, One Team adds value (above what is
offered by the comparator program), deterioration in
the RAI-HC (and sub-scales) measures in the One
Client, One Team sample will be at a slower rate than
comparable individuals in the comparator program.
Evaluation of Client Experience
HYPOTHESIS
If One Client, One Team adds value, clients and their
families will have a better care experience
characterized by increased trust and confidence in
their care team, a “one team” experience, and an
experience of care that is meeting their needs.
WHAT WE LEARNED
One Client, One Team
Comparator Model
Evaluation of Client Experience
HYPOTHESIS
If One Client, One Team adds value, clients and their
families will have a better care experience
characterized by increased trust and confidence in
their care team, a “one team” experience, and an
experience of care that is meeting their needs.
WHAT WE LEARNED
One Client, One Team
Comparator Model
Evaluation of Partner Experience
HYPOTHESIS
If One Client, One Team adds value, providers within
care teams will experience an integrated team with
team members they can rely on to work together to
address some of the most complex needs of clients and
their families
WHAT WE LEARNED
https://www.youtube.com/watch?v=uOWkE3U-wdw