South West Health Links
Welcoming Remarks
Tuesday, March 31st, 2015
Stratford, Ontario
Kelly Gillis
Housekeeping
•
Introductions and Icebreaker
•
Presentations and resource materials are available online
• Provided with copies of agenda, bio brochure, and
learning placemat
•
Question and answer periods will follow presentations
•
Networking/breaks from 1055 to 1105 and 1430 to 1435
•
Lunch break from 1200 to 1245
Presenters
Kelly Gillis has no potential for conflict of interest with this presentation
Sue McCutcheon has no potential for conflict of interest with this presentation
Dr. Gord Schacter has no potential for conflict of interest with this presentation
Mary Atkinson has no potential for conflict of interest with this presentation
Michelle Penfold has no potential for conflict of interest with this presentation
Barabara Major-McEwan has no potential for conflict of interest with this
presentation
Cheryl Pfaff has no potential for conflict of interest with this presentation
Jennifer Croft has no potential for conflict of interest with this presentation
Lisa Mardlin-Vanderwalle has no potential for conflict of interest with this
presentation
Presenters
Kim Van Wyk has no potential for conflict of interest with this presentation
Sally Boyle has no potential for conflict of interest with this presentation
Dr. Rob McFadden has no potential for conflict of interest with this presentation
Dr. Rob Annis has no potential for conflict of interest with this presentation
Dr. Cathy Faulds has no potential for conflict of interest with this presentation
Miranda Ross has no potential for conflict of interest with this presentation
Emily Stoll perceives no conflict of interest with this presentation but has worked
with or consulted for: Pfizer by educating primary care providers on EMR use
Presenters
Maria Savelle has no potential for conflict of interest with this presentation
Melanie Sabino has no potential for conflict of interest with this presentation
Gina De Souza has no potential for conflict of interest with this presentation
Jennifer Mills-Beaton has no potential for conflict of interest with this presentation
Peter Papantonis has no potential for conflict of interest with this presentation
Disclosure of Commercial Support
GBHS INSPIRED team has received financial support through the CFHI
collaborative in the form of an educational grant.
Potential for conflict(s) of interest:
GBHS INSPIRED team: Jane Wheildon, Val Fleming, Angela Schmidt,
Shaundra Anderson
Management of Potential Bias
• The presentations will manage potential bias by
ensuring that data and recommendations are
presented in a fair and balanced way.
• The presenters will speak to a full range of
products that can be used in this therapeutic
area.
What is the current state of Health Links across
the South West LHIN?
How will Health Links improve health?
Identify local and system
barriers and work to
mitigate
Use all existing resources
to assist in implementing
the coordinated care plan
Identify people who are having
to use Emergency and Hospital
admissions to manage their
health
Develop Individual
Coordinated Care Plans
Share information across
providers to enable
coordinated care planning
South West Health Links
•
Quality improvement initiative
•
Health Links is about physicians, specialists, hospitals and
community providers working together to more
effectively coordinate local health care services for
people who need them the most
What do we want to accomplish through the
Learning Collaborative?
•
Spread best practices by creating an opportunity to share
experiences within and across teams
•
Accelerate improvements and achieve results within the
Health Links model
•
Build teams’ capacity for quality improvement and
develop leaders for change
What is a Learning Collaborative?
•
Improvement method developed by the Institute for
Healthcare Improvement (IHI)
•
Provides opportunities for interdisciplinary teams to
come together to share experiences and learn with, and
from, each other over a short-term period
•
Consists of structured learning sessions and actionoriented trainings
Learning Objectives
•
Create collaborative/coordinated care plans
• Including how to identify patients that would benefit from a
coordinated care plan
•
Access free resources
• To assist patients and professionals with chronic disease
management
• To help to build knowledge, skills and confidence
•
Improve outcomes for patients with COPD using a cross-sector
collaborative approach
Partners in the Learning Collaborative
•
Patients / Clients / Residents / Families
•
Each Individual Health Link
•
Health Link Leadership Collaborative
•
South West LHIN
•
Health Quality Ontario
•
Partnering for Quality
•
South West Self Management Program
•
South West Primary Care Network
Today’s Agenda (Morning Highlights)
•
Welcome & Introductions
•
Coordinated Care Planning
•
Why self-management? Improving Patient Health,
Together
•
Improving Outcomes of Patients with COPD
•
Huron Perth Health Link Data
Today’s Agenda (Afternoon Highlights)
•
INSPIRED Approach to COPD care
•
Applying a Quality Improvement Approach to COPD
• London Family Health Team
• Stratford Family Health Team
•
Application of Quality Improvement Approach
Acknowledgements
•
Sue McCutcheon
•
Sally Boyle
•
Amber Alpaugh Bishop
•
Rachel Labonte
•
Mary Atkinson
•
Rachel Stack
•
Michelle Penfold
•
Gina DeSouza
•
Dr. Gord Schacter
•
Sarah Emms
•
Dr. Rob Annis
•
Jennifer Mills-Beaton
•
Lisa Mardlin Vandewalle
•
Peter Papantonis
•
Catherine Shackelton
•
Julia Hill
South West Health Links
Health Links & Quality
Improvement
Sue McCutcheon, Program Lead, Health Links
Health Links and Quality Improvement
•
Making changes that will lead to better individual
outcomes, stronger health system performance and
enhanced professional development
•
Draws on the combined and continuous efforts of all
stakeholders – individuals and their families, health care
professionals, researchers, planners and educators – to
make better and sustained improvements
Quality Improvement Framework
Reference: Health Quality Ontario http://www.hqontario.ca/quality-improvement
The Problem
People who are frequently
visiting the emergency
department or being
admitted to the hospital are
not having their healthcare
nor wellbeing needs met in
a sustainable way.
Aim of Health Links
South West Health Links Aim Statement
‘To reduce avoidable healthcare utilization in
order to better meet the needs and support
individuals and families with the greatest
health care needs in the South West LHIN.’
How will we know that we are making a
difference?
1. Reduced Emergency Department Visits
2. Reduced Hospital Admissions
The Problem – Local
Huron Perth and London Middlesex Health
Links Business Plans identified:
• Care providers often working independently
with the goals of the patient not well understood
across the system
• Identified higher than average hospitalization of
people with COPD and CHF
Testing a Solution: Coordinated Care Planning
•
…now ready to spread
Further Testing of Specific Interventions to
include in the Coordinated Care Plan when
working with people who have COPD
•
Many specific interventions tested
•
What interventions regarding COPD need further testing
within the Coordinated Care Plan model?
Ideas for Improvement
Cross-Sector Collaborative
Coordinated Care Planning
•
How will you spread the
Coordinated Care Planning
Process?
•
What new change ideas or
clinical interventions do
you want to test to
coordinate care better for
people who have COPD?
South West Health Links
Health Links and Primary Care
Dr. Gordon Schacter
Primary Care Lead, South West LHIN
Why Health Links? The Case for Change
•
People who are frequently at the emergency department
or admitted to the hospital benefit more from health
care that is delivered a coordinated and sustainable way.
•
5% of the population accounts for 66% of health care
costs in Ontario.
•
Health Links brings everyone together to develop a
coordinated care plan. The plan uses the patient’s goals
for their health and wellbeing.
Why Coordinated Care Plans?
•
The Quebec Experience
•
Coordinated care - 200 patients
• Improved sense of wellbeing and quality of life
• fewer visits to the emergency department (72%
reduction)
• fewer hospital admissions (83% reduction).
How Can Health Links Help Patients?
•
Community-based support is increased and coordinated
across many partners.
•
It helps reduce use across the system.
•
For primary care, Health Link helps make it easier to
coordinate community-based supports for those patients
who need additional services.
Patient Story - John
•
84 year old, Widower,
lives alone in an
apartment in London
•
COPD, (120 p/y smoking
history),
•
Hyperlipidemia, Restless
Leg Syndrome
John – Chronology Oct 2013-Oct 2014
•
7 hospital admissions for
COPD exacerbations
•
On Home O2 since May
2012
•
2nd Admission dx with
bacterial endocarditis –
IV antibiotics for 6 wks
at home
•
FEV1 31%
•
Still smoking 5 cigs per
day.
Multiple ER visits
without hospital
admissions (? 40)
•
Meds: Spiriva, Advair,
Crestor, Ramipril, ASA
and Sinemet qhs
•
John
•
Only family is Brother in
law.
•
Brother in law found him
Oct 2013 on floor
confused precipitating
admission for COPD
exacerbation (O2 sat 78%
when EMS arrived).
•
CCAC Rapid Response
RN involved after 3rd
admission, got blister
packs for meds set up
with pharmacy.
•
O2 Company involved.
Found him smoking with
oxygen on and threatened
to remove his oxygen.
John
•
Had seen 5 Internist and
3 Respirologists through
7 admissions
•
Family Physician was
seeing him on home
visits.
•
As a result of his
admissions has both a
General Internist and a
Respirologist following
him for COPD as out
patient.
•
Both Brother in Law and
Family MD had
numerous discussion
regarding placement but
refused.
•
DNR order at home on
file after 4th admission
Huron Perth Health Link
Breaking Down the Barriers
with
Health
Links
Our Journey from There to Here
Mary Atkinson
Project Manager, Huron Perth Health Link
Huron Perth Health Link
Two Areas of Focus
•
Building the virtual infrastructure
•
Readying for the future
Huron Perth Health Link
Building the virtual infrastructure
•
Business Plan
• Guiding document for overall Health Link structures, processes,
and activities
•
Terms of Reference
• Guiding principles
• Commitment & accountabilities of partners and rules of
engagement
• Roles & functions for partners
• Huron Perth Health Link Mandate
Huron Perth Health Link
Guiding Principles
•
•
•
•
•
•
•
•
Person centred
Collaborative
Sustainable
Realistic
Integrated
Evidence based
Blame free
Evaluated
Huron Perth Health Link
Building the virtual infrastructure (cont’d)
•
Steering committee
• Governance and oversight
• Liaise with system partners – voice of Huron Perth Health Link
•
Project resources
• Project Manager & Project Coordinator
• Responsible for progress of working groups
• System partners
• Implementation of the working group activities
Huron Perth Health Link
Health Link Quality Improvement Model
The 5 quality improvement areas
will help to close the gaps in
achieving the best care and
outcomes for our patients.
The key enablers form the base
of our model to support the
change in how we deliver care.
Frail Seniors
and
Adults with
CHF & COPD
i)
ii)
iii)
Cultural Change
Human Resources
Enabling Technologies
Huron Perth Health Link
Project Working Groups
•
After hours and weekend services
•
Patient education
•
Volunteer Support
•
Primary care visit post discharge from hospital
•
Affordable transportation
Huron Perth Health Link
Project Working Groups (cont’d)
•
Coordinated care planning
• The heart of Huron Perth Health Link
• Sub-project working groups:
• IDEAS Team – coordinated care planning process
• Patient Navigation – dynamic model based on
patient relationships with providers
Coordinated Care Plans – Early Results
•
Compared pre- and post-care conference use of ED and
hospitalizations:
•
• Trend to decrease utilization by patients
Monitoring patient experience:
•
• Feeling respected throughout process and level of
confidence in managing their care
Monitoring provider experience:
• Breaking down of communication silos – know who to
call
Huron Perth Health Link
Building for the future
•
Planning for spread to all providers in a sustainable
manner
•
2-prong plan
• Develop capacity at organizations’ leadership to
champion the continued work
• Develop capacity at the front line
• Champion leaders at the front
• Knowledge spread and expertise to build front line capacity
Huron Perth Health Link
Huron Perth Health Link Contacts
Mary Atkinson
North Perth Family Health Team
[email protected]
Lisa Mardlin-Vandewalle
Project Manager
[email protected]
Catherine Shackleton
Project Coordinator
[email protected]
London Middlesex
London Middlesex Health Link
Michelle Penfold
Project Manager, London Middlesex Health Link
London Middlesex Health Link - Background
•
Thames Valley Family
Health Team is the lead
agency for the London
Middlesex Health Link, and
is accountable to the South
West LHIN.
•
The Health Link will
identify, coordinate, plan,
develop and implement
solutions collaboratively
with acute, primary,
community health and
social service agencies.
London Middlesex Health Link - Key
Characteristics
London Middlesex Health Link - Population Focus
In London Middlesex, the initial population focus will be:
• Frail seniors
• Adults with a disease of the circulatory system
(including Hypertension, Coronary Artery Disease, Angina,
Congestive Heart Failure, Atrial Fibrillation/Flutter,
Peripheral Vascular Disease, and Stroke)
• Chronic Obstructive Pulmonary Disease (COPD)
London Middlesex Health Link – Identification
Process
The Health Link will review how individuals use the health care
system (over 12 months) to identify those who have:
• 3+ Emergency Department (ED) visits
• 2+ hospital admissions
• 3+ sectors of the health system accessed
“Complex” patients may also benefit from a Coordinated Care
Plan completed by his/her Health Link team:
• multiple chronic diseases;
• mental health issues/addictions; and/or
• palliative care needs
London Middlesex Health Link - 2013-2014 data
London Middlesex Health Link - Utilization
In 2013/14, the 880 patients with high care needs in the London
Middlesex had:
•
•
•
•
•
•
1 - 10 different health service providers (average – 2.4)
4 - 108 emergency department visits (6,734 ED visits, average 7.7)
Acute inpatients: discharged between 2 - 20 times (3,707 acute
inpatient discharges, average – 4.2)
Inpatient rehabilitation: discharged between 0 - 3 times (82
inpatient rehabilitation discharges, average – 0.09)
Adult inpatient mental health: discharge between 0 - 12 times
(84 inpatient mental health discharges, average – 0.1)
83% of those who meet HL criteria are on CCAC service (727/880
patients)
London Middlesex Health Link: Collaborating
Partners
London Middlesex Health Link - Collaborating
Partners
•
•
•
•
•
•
•
•
•
Addiction Services of Thames
Valley
Blackfriars Family Health
Organization
Cheshire London
•
(representing SWCSS Council)
•
Four Counties Family Health
Tea
City of London
London Family Health Team
Health Zone NP Clinic
London Health Sciences Centre
London Intercommunity Health
Centre
McCormick Home
(Long Term Care Home Network)
•
•
•
Middlesex Hospital Alliance
Southwest Ontario Aboriginal
Health Access Centre
South West Community Care
Access Centre
South West Local Health
Integrated Network
(Primary Care Co-Leads)
•
•
St. Joseph’s Health Care London
Thames Valley Family Health
Team
London Middlesex Health Link – others
engaged
• Alzheimer’s Society
• Heart and Stroke Foundation
• Behavioural Supports Ontario - SW
• Middlesex London EMS
• Canadian Mental Health
Association – Middlesex
• Middlesex London Health Unit
• Centre for Studies in Family
Medicine
• City of London
• Dale Brain Injury Services
• Health Quality Ontario
• Ontario Lung Association
• Participation House Support
Services – London and Area
• Partnering for Quality Program
• Schulich School of Medicine &
Dentistry, Department of Family
Medicine
London Middlesex Health Link - Project Update
November 2014 Business Plan approval
January 2015 Project Manager hired
February 2015 Care Coordination Facilitator hired
Terms of Reference approved
Communication strategy identified
Implement communication strategy
Approval to begin Working Group
March 2015
recruitment (Coordinated Care Planning;
Physician and NP Advisory Council; &
Patient and Family Advisory Council)
Business Analyst projected start date
April 2015
LHIN reporting begins
London Middlesex Health Link: Contact Details
Judi Fisher
Executive Director
Cheshire Homes
519-439-4246 x226
Michelle Penfold
Project Manager
London Middlesex Health Link
519-473-0530, x126
[email protected]
[email protected]
Susan Clements
Care Coordination Facilitator
London Middlesex Health Link
519-473-0530, x127
[email protected]
Huron Perth Health Link
A Quality Improvement Approach to
Developing Health Link Coordinated
Care Planning for Huron Perth
Cheryl Pfaff, Jennifer Croft, Barbara Major-McEwan
Lisa Mardlin-Vanderwalle
Kim Van Wyk
Agenda
1) IDEAS Project: Developing the Health Link
Coordinated Care Planning Process
• Rob Annis, NPFHT; Jennifer Croft, ONE CARE; Barb MajorMcEwan, NHFT; Cheryl Pfaff, CCAC
2) Coordinated Care Planning Process in Huron and
Perth: Current State and Looking Forward
• Lisa Mardlin Vandewalle, NPFHT
3) Coordinated Care Planning: An Individual’s
Perspective
•
Kimberly Van Wyk, Clinton FHT
IDEAS Project: Developing the Health
Link Coordinated Care Planning
Process
We Would Like to Acknowledge
•
Project Sponsors: Kelly Gillis, South West LHIN; Rose Peacock,
South West LHIN; Mary Atkinson, North Perth FHT; Lisa Mardlin
Vandewalle, North Perth FHT
•
IDEAS Quality Improvement Advisor: Joe Mauti
•
Employers: North Huron Family Health Team, North Perth Family
Health Team, ONE CARE Home & Community Support Services,
South West CCAC
•
Early Adopter Champions: Dr. Rob Annis (North Perth FHT),
Patti Rosehart (CC – CSS), Jaynie Nicholson (CC - SW CCAC),
Kim Van Wyk (ED – Clinton FHT), Wendy Dunn (NP- NP FHT), Dr.
Russell Latuskie (NP FHT)
What is IDEAS?
•
Improving & Driving Excellence Across Sectors (IDEAS)
is a provincially funded/applied learning strategy
designed to support the health care system achieve
progress on Ontario’s system priorities
•
The IDEAS Quality Improvement team, sponsored by
the South West LHIN and North Perth FHT, was
leveraged to take the lead on developing and testing the
Coordinated Care Planning process
•
The team included representatives from: the South
West CCAC, North Perth FHT, North Huron FHT and
ONE CARE Home & Community Support Services
QI Tools/Methods Used
•
Driver Diagram
•
5 Why’s
•
PDSA’s
•
Process Mapping
•
Team Meetings
•
Building upon established networks
Driver Diagram
Our Aim Statement
Overall Project Aim of the HPHL:
•
To decrease healthcare utilization (ED Visits &
Inpatient days) by frail elderly and those with COPD &
CHF by 10% by March 31, 2015
IDEAS Project Aim:
•
85% of identified complex patients with a coordinated
care plan will be ‘confident’ or ‘very confident’ that they
can reach their identified goals
Change Ideas
•
Information Sharing: Sharing paper coordinated care plan
i.e. via, Yammer, Health Partner Gateway, fax, Dropbox,
Health Chat, monthly conference calls, etc.
•
Involved Stakeholders: Coordination of logistics to facilitate
involvement.
•
Standardized Care Delivery: Standardize pre-conference
assessment tools i.e. geriatric, CCAC, etc. (Not tested within
the scope of the IDEAS project)
•
A Positive Patient Experience:
• Sample patients with “did you feel respected”?
• Process to capture and understand patient’s goals.
• Sample patients to understand their confidence level in
reaching their identified goals.
Process Map
PDSA Learning
Change
Idea
Information
Sharing
Involved
Stakeholders
and Positive
Patient
Experience
# Cycles
What Was Tested?
Findings
Yammer
1
Using medium to share
Coordinated Care Plan (CCP)
Privacy Concerns
HPG
1
Using medium to share CCP
Limited Access
Fax
1
Using medium to share CCP
Adequate Medium
Key Contact
1
Assigning key contact for each
TBD
FHT to coordinate communication
Coordinator
2
Assigning a Central Coordinator
to facilitate scheduling and
communication of Care
Conference
Tools needed to
guide process
Case
conference
1
Having regular Care Conferences
with appropriate stakeholders
Consistent time
difficult to schedule
Involved Stakeholders and Positive
Patient Experience: Cycle #1
•
Purpose: To test regular care conference meetings with primary
care, CCAC, CSS and patient/caregiver to develop and/or monitor
the care plan.
•
Predictions: We predicted that a core group of participants (the
care team) would be identified, would understand their roles and
responsibilities and would attend care conferences on a predetermined schedule.
•
Results: It was difficult for physicians to identify a common
standard meeting time each month. The care team confirmed that
communication before the care conference was confusing and
inconsistent. It was also unclear to the care team what their role
and responsibility would be before, during and after the care
conference.
Cycle #2
•
Purpose: To test the establishment of a key contact for each
Family Health Team (FHT) to coordinate communication prior to
the care conference (pilot North Perth FHT).
•
Predictions: We predicted that one person from the NP FHT could
act as the “key contact” and that this person would be responsible
for ensuring thorough pre-conference communication with care
conference participants.
•
Results: NP FHT was not able to identify a contact with the
available time to support a coordinator role. A standardized preconference communication tool and planning checklist were
created to assist with coordinating any care conference but not fully
implemented.
Cycles #3 & 4
•
Purpose: To test the use of a “Admin/Logistical Support” to
facilitate the scheduling of the care conference, facilitate the
meeting, and ensure that the care team is aware of their roles
and responsibilities.
•
Predictions: We predicted that one person could act as the
“Admin/Logistical Support” and effectively coordinate the care
conference ensuring all participants were in attendance,
facilitate the care conference and ensure that all tasks,
including role of “care navigator” were assigned/completed by
the care team.
Cycles #3 & 4
•
Results: Cycle 3 - Delayed approval for the “Admin/Logistical
Support” resulted in an incomplete test. The care team was
informed of details; however, clarification was required from most.
The delay in implementation resulted in some inefficiencies for
those team members involved in pre-work. The “Care Navigator”
was not clearly identified due to the meeting running over the time
allotted. The acting “Admin/Logistical Support” spent 1.5 hours
preparing for the care conference.
•
Results: Cycle 4 - Attendees were informed and contacted with
necessary details prior to the care conference. The work load was
heaviest for the physician and FHT Executive Director (acting as
“Admin/Logistical Support”). A “Care Navigator” was identified. The
communication tool and checklist assisted in ensuring all tasks
were completed. The “Admin/Logistical Support” spent
approximately 2 hours in preparation, including the creation of a
consent form.
Cycle #5
•
Purpose: To test one organization to act as both
“Care Navigator” and “Admin/Logistical Support”.
•
Predictions: We predicted that one organization
could act as both the “Admin/Logistical Support” as
well as the “Care Navigator” and that this format
would help achieve informed attendance, ensure
that roles and responsibilities were clear and that
tasks were completed in a timely fashion.
•
Results: With appropriate supports in place, one
organization can act as both “Care Navigator” and
“Admin/Logistical Support”.
Involving Stakeholders
•
When health care providers work as a team, the patient
receives better, more coordinated care
•
Care Conferences provide opportunities for patients/families
and their care providers to design a care plan together
ensuring they receive the care they need
•
For the patient, it means they will :
• Have an individualized, coordinated plan which includes
the patient’s personal goals as well as services that may
be needed to achieve their goals
• Have care providers who are supporting the patient and
ensuring that the plan is being followed
• Have a care provider they can call who knows them, is
familiar with their care needs and can help
The Care Team
•
In Huron Perth, the Care Team consists of a
minimum of: the Primary Care Physician,
Community Support Services and Community Care
Access Centre
•
When applicable, this team can also include
specialists, front-line health care workers and nonmedical community support agencies
•
In all cases, the patient is the center of this team
The Role of Community Care
Access Centre
•
Gets people the care they
need to stay well, heal at
home, and stay safely in their
homes longer
•
When home is no
longer an option,
they help people make
the transition to other
living arrangements
Community Support Services
Primary Care Physician
•
A Primary Care Physician has a well-established
and trusting relationship with the patient
•
They understand the patient and their medical
history better than most and can help navigate the
medical system
•
They can provide the history and medical
perspective during the Coordinated Care Planning
process
•
They are active members in the patient’s care
before, during and after this process has ended
Communication Tool
Care Conference Checklist
The Checklist
1) Identification
•Work continues to be done to ensure that Health Links
patients are appropriately identified and in a timely manner
2) Engagement
•The role of the Care Navigator is to engage with the Health
links patient
• explain Health Links, obtain consent, outline purpose of
Care Conference and prepopulate plan
• 2 weeks prior to Care Conference
The Checklist
3) Care Conference Planning
•
Set up Care Conference and invite Care Team and
others as identified by patient
•
Share Care Plan with Care Team
•
Review plan and develop plan during preconference teleconference
•
1 week prior to Care Conference
The Checklist
4) Collaborative Care Conference
•
One hour maximum
•
Review purpose of Care Conference
•
Use patient-centered approach and open-ended
questions
•
Most appropriate Care Navigator identified and
follow-up appointments confirmed and recorded in
Care Plan
The Checklist
5) Service Provision & Follow-up
•
Service plans are initiated immediately
•
Care Navigator contacts patient 2 weeks post Care
Conference:
•
Reinforce action items from Care Conference
•
Ensure referrals have been made/services initiated
•
Collect indicators
•
Update Care Plan
The Checklist
•
Using clinical judgment, Care Navigator continues to
check in on patient
•
Updating and sharing Care Plan when applicable
•
If deemed necessary for patient to transfer to
another Care Navigator, the transfer is based on
deliberate and intentional transfer of information
• Warm hand off occurs
A Care Plan Example – Before CCP
•
Elderly patient with multiple co-morbidities including
CHF and COPD
•
Lives alone in house and manages ADLs
independently
•
29 ED visits and 10 hospital admissions during April
1, 2013 to March 31, 2014 including recent hospital
discharge
•
Receiving ongoing care by Primary Care Physician,
services through CCAC and informal family supports
•
Identified as “person with high care needs” during
identification process
A Care Plan Example – During CCP
•
CCP developed in collaboration with patient and
Care Team and patient goals became focus of the
Care Conference
•
It was important to patient to “get out and walk
more”. The patient also wanted to find more suitable
housing i.e. accessible
•
Care Team worked together to develop a service
plan that assisted patient in meeting their goals
•
With patient permission, Huron County Housing
contacted and worked with Care Team to identify
plan
A Care Plan Example – After CCP
•
Care Navigator contacted the patient 2 weeks
following the Care Conference
•
Patient happy to report that they are walking
frequently with the assistance of their service
provider nurse
•
Still awaiting more accessible housing – CCAC will
initiate OT services when in new home
•
Care Navigator will contact patient monthly and Care
Team continues to communicate all changes to
patients condition/goals and adjusts plan as
necessary
Family of Measures
Overall Huron/Perth Health Links Project Measures:
•
Rate of Emergency Department visits by complex
patients with a coordinated care plan
•
Rate of Inpatient Days for complex patients with a
coordinated care plan
•
Hospital Readmission Rate of complex patients with a
coordinated care plan
Outcome, Process, Balancing
What is being measured?
% of complex patients with a care plan who
are ‘confident’ or ‘very confident’ that they
can reach their identified goals
Why is it being How is this indicator
measured?
defined?
Frequency
Perception of effectiveness
of care plan
# patient confident/very confident/#
patients with care plan
2 weeks follow-up
# of pre-care plan visits by the identified
To determine effectiveness
complex patient to the ED in the last 6 months of care plan
# of pre-care plan visits by the
identified complex patient to the ED
in the last 6 months
Monthly
# of pre-care plan inpatient days by the
To determine effectiveness
identified complex patient in the last 6 months of care plan
# of pre-care plan inpatient days by
the identified complex patient in the
last 6 months
Monthly
# of post-care plan visits made by the
To determine effectiveness
identified complex patient to the ED in the last
of care plan
6 months
# of post-care plan visits made by the
identified complex patient to the ED
in the last 6 months
Monthly
# of post-care plan inpatient days by the
To determine effectiveness
identified complex patient in the last 6 months of care plan
# of post-care plan inpatient days by
the identified complex patient in the
last 6 months
Monthly
% of completed goals on the care plan by the
review date
To determine effectiveness
of care plan
% of completed goals by date
assigned/total number of identified
goals
Monthly
% of patients who responded “Yes” to the
question: “Did you feel respected”?
To determine effectiveness
of the case conference
process
# of patients who responded
“yes”/total number of identified
patients with a case conference
The total cost of getting all people in one room *Obtained via Focus Group
2 Week Follow-up
Results/Impact – Inpatient
Days
Results/Impact – ED visits
Results/Impact – Patient & Stakeholder
Satisfaction
•
Patient “confidence” in achieving identified goals had been
collected post Care Conference and at 2 week follow-up
• Limited data – average 3-4 out of 5 (1-5 scale)
•
Four patient interviews were conducted - feedback from patients
informed iterations of the process and tools
•
Two focus group sessions conducted with early adopter providers
which included front line health care providers and physicians
•
Purpose was to gain the patient/family/stakeholder perspective
regarding the Care Conference process
•
All feedback valuable in highlighting areas of improvement
Overall Learning/Challenges
•
•
Tools/checklists to guide communication/activities
before/during/after care conference are essential to
ensuring process is effective for care team and patient
Working within the confines of predefined project
• Difficult to feel connected as starting part way through project
• Sub group of a much larger working group
•
•
During the process patients were not appropriately
identified/defined – HPHL continues to work on this
Provincial solution to share care plan was not yet
available
Overall Learning/Challenges
•
We were creating a new process vs. improving an
existing process within a health care system that is
not structured to work this way
• Must wait for feedback/data/improvements
•
The “care navigator” needs to be identified early in
the process and a relationship needs to be
established so the patient develops trust in the
process
Overall Learning/Challenges
•
What we learned was that a person/organization
must assume role of “coordinator” to ensure
information about patient and care conference is
communicated to care team in a timely/effective
manner and to ensure follow up activities occur
•
Each member of care team must know their role as
coordinator, navigator, or participant and fulfill their
responsibilities within that role for the care plan to be
effective.
Overall Learning/Challenges
•
A care team should consist of multiple care providers to
be effective; however, the key players have consistently
been the family physician, Community Care Access
Centre and Community Support Services.
•
Health care professional’s schedules (i.e. vacations,
weather, etc.) and large geographies can impact the
ability to test process in a timely fashion.
•
Different cultures across the health care system create
challenges to working in a more integrated way (e.g.
open, looser structures versus highly structured
organizations)
Coordinated Care Planning Process in
Huron and Perth: Current State and
Looking Forward
Current Care Planning Process
•
Potential individual is identified by any provider
•
Provider & family physician have a conversation about
whether individual would benefit from HL Coordinated
Care Planning
•
Navigator is identified
•
Navigator meets with the individual to initiate care planning and
discuss who should be invited to conference
•
Care Conference is held with the individual and family/support
person, family physician and all relevant providers
•
Coordinated Care Plan is completed and shared
•
Ongoing follow up, reassessment, communication
Bold text indicates evolution of care planning process since the IDEAS team work
Current “Package” of Coordinated
Care Planning Documents
1. Handout for individual “What is Health Links”
2. Huron Perth Health Link Patient Identification
3. Complex Needs Screening Tool
4. CCP Care Conference Process Map
5. Navigator Framework
6. HL Coordinated Care Plan Template
7. “My Plan for Future Situations”
8. Coordinated Care Plan User Guide
9. CCP Care Conference Checklist
10. CCP Care Conference Communication Tool
11. HPHL Consent to Share Personal Information
HealthLink
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last verified
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Communication Tool
Communication Tool
•
The document used to communicate conference details
to all care team members and to collect Health Link
measures
•
Completed by the provider who has identified an
individual who would potentially benefit from a Health
Links coordinated care plan (CCP)
• For those individuals who will have a CCP completed
AND those individuals for which the CCP is not
deemed necessary
•
The completed Communication Tool is faxed to the HL
project management team
Communication Tool Components
• Logistical details of the care conference and contact
information for all care team members
• Individual consent for experience interview
• Measures
Current Measures
•
Initial identification source of the individual with high care needs
(e.g. primary care, RIDS, CCAC, CSS, hospital)
•
Support status (e.g. coordinated care plan, alternative level of
support)
•
Number of CCPs completed
•
Number of providers involved in CCP conference
•
Rate of unscheduled ED visits pre- and post-care conference
•
Rate of acute inpatient discharges pre- and post-care conference
•
Average length of stay in acute care pre- and post-care conference
•
Average confidence scores for people with a CCP
•
Average respect scores for people with a CCP
•
Average support scores for people with a CCP
•
Average satisfaction scores for providers involved in the CCP
process
NOTE: All of these measures rely directly or indirectly on the completion and
submission of the Communication Tool
Bold text indicates new measures developed since the IDEAS team work
Looking Forward: Resources to Support
Teams in Coordinated Care Planning
•
Coordinated Care Plan package of documents:
• Hard copy package of documents
• Electronic copy
http://www.southwesthealthline.ca/libraryContent.aspx?id=21470
•
Lunch and Learn In-services:
[email protected]
•
Health Link Quality Coaches:
[email protected]
[email protected]
•
Huron Perth Health Link healthline.ca Micro Site:
http://www.southwesthealthline.ca/libraryContent.aspx?id=21470
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WELCOME TO HURON-PERTH HEALTH LINK
What is aHealthLink? Watch the video to learn more!
TRANSFORMING OUR HEALTHCARE SYSTEM
Heatthlinks will transform how we provide Heanhcareinour communities. This new
model of heanh servicesis about partnering bothtraditional and non-traditional
services inaway that wraps carearound those complexand vulnerablepatientsto
keep them safe and functioning.
HEALTHLINKS WILL:
• Improve access to rami~ carefor seniors andpatients withcomplex
conditions
• Reduce avoidable emergency room visits
• Reduce unnecessary re-admissions to hospitals
• Reduce time for referral from primary careto specialists
• Improve the patient'sexperienceduring their journeythroughthe heatthcare
system
ThiS resourct was aeated 11 partne-rsh~ wrth the 1-klron Pttth farrij" health teams, oorrtrKJnty suppott sei'VJC.is, hospitals, CCAC. mental heath and addictions
agtnc.u . long term carefacllles, pubic htakh unl s, emergency medea!stMcts. soCJBIHMCts, and the South West LHIN.
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HEALTH CARE PROFESSIONAL RESOURCES
Huron Perth Health Link Coordinated Care Plan Package of Documents
The following documents are tools for teams to use to plan and implement a Health LinK Coordinated Care Conference:
• care Conference ChecK List
Care Conference Communication Tool
• Coordinated Care Plan: User Guide
• Coordinated Care Plan
• Coordinated care Plan Process Key Points
• Coordinated Care Plan Process Map
• Complex Needs Screening Tool
• Consent Form: PersonaVHealth lnformation
Chart: My Plan for Future Situations
• Patient Identification - 5 Point Criteria
• What is a Hea~hlink?
Chronic Obstructive Pulmonary Disease (COPD) Links
• Canadian Thoracic Society (CTS) . Provides a comprehensive list of online tools and resources for the professional to access to better
manage patients with COPD. including slide decks and care plans as mentioned previously in the worKing group documents.
• College of Family Physicians of Canada - List of Canadian associations and organizations that provide full-text clinical practice guidelines on
their websites.
• Family Physician Airways Group of Canada (FPAGCJ- Resource library and tools that providing best-practice guidelines available to
physicians in management of COPD
• Respiratory Guidelines for Professionals - The COPD Action Plan is a tool to facilitate communication between the COPD patient and hislher
healthcare professional team. Professionals can fill out form with patient specific information and save data typed into the form.
RNAO Best Practice Guidelines for COPD Management - This guideline will address the nursing assessment and management of stable.
unstable and acute dyspnea associated with COPD.
Congestive Heart Failure (CHF) Links
• Canadian Cardiovascular Society_- Provides guidelines for dyslipidemias, heart failure, atrial fibrilliation, and more.
• Canadian Heart Failure Network . Learn more about heart failure in Canada and now to more effectively treat patients.
Frail/Elderly Links
• Arthritis Society_- Getting a Grip on Arthritis: Best Practice Guidelines
This resource was created in partnership with the Huron Perth famt( health teams. community support seMces, hospitals. CCAC. mental health and addictions
ag@ncin , king ttrm cart f!leki@s, public hu lth units, t mtrgtncy mtdical strviots. sociiI strvioes. and the So-uth West LHIN.
£?ontario
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Coordinated Care Planning: Meet
Florence
Coordinated Care Planning Meeting held August, 2014
Background
•
Florence is an 88 year old woman
•
Coordinated Care Planning Conference included the
following team members:
• Primary Care Physician
• Nurse Practitioner
• Registered Nurse
• CCAC Care Coordinator
• Community Support Services Care Planner
• Florence’s daughter-in-law
Florence’s Goal
To be with and help friends
“They are nice. Everybody is so friendly and make you feel
welcome. I’ve never asked for anything that I didn’t get lots of help.”
“I’ve grown quite fond of her [neighbour across the hallway]…
she’s game to do most things with me.”
“She knew I liked to cut hair…anyway, I fixed her hair.”
What helps Florence?
•
Occupational Therapy, Seniors Apartment, Housekeeping
• Bathlift, walker, large calendar, weighted pens, laundry
“It’s [the apartment] all on one floor…there’s no steps so I don’t
have to worry about falling”
“I think it’s just having people around” – Florence’s daughter, Wendy
“I have a girl that comes in every Monday morning and cleans.”
•
Positive outlook
“I can do anything I want to do”
•
•
Sharing past achievements with others/pride
Social activity
• Music and dining, playing piano
“I sat down at the piano yesterday and played a few pieces.”
What’s Important to Florence?
•
Getting out and doing things with friends
“Three weeks, I wasn’t ever out of this place.” [describing
when she was ill]
“This is what I say; Pretty nearly everybody has fun in a
different way”
•
The people that help her
“She has a nice, low voice.”
“She was really good.”
“They are nice. Everybody is so friendly and make you feel
welcome. I’ve never asked for anything that I didn’t get lots of
help.”
“The Meeting” from Florence’s
Perspective
“Each one got up and gave their view of if they
could add to what they’ve already got.”
The Evolution of Florence’s Exercise
Program
•
The CSS Care Planner arranged a 1:1 home support
exercise program tailored to meet Florence’s needs
•
Over time this has evolved; friends of Florence that live in
her building expressed interest and have now joined her to
form a group exercise program right in the building
•
This has opened Florence up socially and she now also
participates in a community dining program and has started
a walking group with other women that reside in her facility
•
She has even started supporting one of her neighbours with
visual impairments
The Coordinated Care Planning Goals
Created by Florence and her Team
•
The goals that were created looked at increasing
Florence’s ability to socialize in her new home.
•
Occupational Therapy was recommended and CCAC
provided this assessment.
•
Community Support Services worked to create an
exercise program.
•
The Primary Care Team has continued to monitor
medical conditions that affect Florence’s activities.
•
Reviewing medications and providing education on how
to use those medications properly
•
Follow up testing to monitor her condition
Some Potential Considerations from
Kimberly:
Engaging the individual in the process is important…
1. Ensure care plan is shared with individual and the care
team
2. Making the goals person-centred (e.g. Increased ability
to get groceries is related to her mobility and breathing)
3. Follow up care plan updates can create a very large
document when they are added to the original care
plan document. Is there a possibility to have an update
form?
4. Look at doing a follow up care plan meeting after a
while to see if goals have been obtained or new ones
to work on together.
Thank you !
Shift in Healthcare
Before 1850….
• Longevity=35-40 years
• Leading causes of death= infectious diseases
Canada today….
• 89% deaths due to chronic diseases (WHO Atlas 2012)
• Almost everyone over 65 years has at least 1
chronic disease
• More than 30% have 2 or more
Population needs in the “near” future
Modern Day Healthcare
“Does amazing things to patients.
Does wonderful things for patients.
Does very little with patients.”
What is Chronic Disease Self-Management?
Self-Management:
Is a person’s active participation in
reaching his or her best health &
wellness. It involves the ability to
manage everyday tasks and having the
confidence to do so.
Important to know!
• Clinicians are present for only a fraction of the
patient’s life.
• Nearly all outcomes are mediated through the
patient’s behaviour.
• Motivation is not enough. People also need selfconfidence, and certain skills that can be modeled
and taught in group sessions or via one-on-one
interactions.
The Disconnect…..
Barlow, J. Interdisciplinary Research Centre in Health, School of
Health
and Social Sciences, Coventry University, May 2003.
Effective Self Management
• Targets the person with the chronic disease, as well as
their caregivers, and clinicians /other healthcare
professionals.
• Programs that include support for behavior change for both
the person with the chronic condition(s) and for the health
care professionals supporting them.
Chronic Disease Self Management Program
Stanford University Licensed Program
Principles of Modeling, Goal Setting & Problem Solving
•
•
•
•
•
•
•
•
Developed through 25 years of applied research at Stanford
Adapted for implementation in Canada
Leading practice (Health Council of Canada 2012)
Group sessions of 6 to 15 participants
Free 6 week workshop 2½ hours per week
Co-led by Peer Leaders with chronic health conditions/HSP
No need for a Doctors referral
Not meant to replace or duplicate disease specific education &
supports
• General program offered in English, French & Spanish; also
have license for Diabetes and Chronic Pain
Chronic Disease Self-Management Programs are
Effective!
Demonstrated improvements at 6 months in people
who participated in a Self Management Program
(Compared to those who did not)
 Increase in weekly exercise
Better overall understanding of symptom management
 Better communication with physicians
 Increased self-reported health
 Decrease in health distress
 Decrease in fatigue, disability, and social activity limitations
“Living a Healthy Life Workshop”
Action Planning
Action Planning
1.Something YOU want to do
2.Achievable (something you can do this week)
3.Action-specific (Losing weight is not action specific. Avoiding
snacks between meals is)
4.Answer the questions ▪ What ▪ How ▪ When ▪ How often
5.Confidence level of 7 or more
Decision Making Tool
“Should I start this new medication?”
“Fors”
Score 1- “Againsts”
5
Score
1-5
It might make me
feel better.
5
There may be side
effects I don’t like.
3
It could help
prevent
complications.
4
Another pill I have
to remember to
take.
1
I might be able to
do more
5
I may not be able
to afford the cost.
3
It may not work.
3
“Againsts” Total=
10
“Fors” Total=
14
Ruth Anne’s experience
Don’t take our word for it!
• “I am so glad that my husband and I signed up. We are now up and
moving more than we ever could before. The interaction with this
friendly group of folks was great. Would recommend this to anyone.”
-D.R (Participant)
• “It was great to meet others with the same condition. We were able
to vent our feelings freely and offered each other encouragement
and support. Everyone learned that we are not alone.”
- L.G. (Participant)
• “After attending the workshop I feel that I have a better
understanding of the disease and more coping strategies to help me
in my day to day life to help me manage my diabetes.”
- P.D. (Participant)
“Getting the Most from your Healthcare Appointment”
• Free 1.5 hour workshop for small group of people.
• Discuss what to do before, during and after their
appointment/visit.
• What questions to ask and how to make sure they
understand everything before the end of the visit.
• Setting an action plan and follow up are key.
• Participants provided with free resources and tools
that they can use.
Diabetes, Footcare and Self Management
A few stats….
• Neuropathy will develop within 10 years of onset of
diabetes in 40% to 50% of people with type 1 or
type 2 diabetes. (CDA 2013)
• People with type 2 diabetes may have neuropathy
at the time of diagnosis. (CDA 2013)
• Canadian Association of Wound Care, the Canadian
Diabetes Association (2013), and Registered
Nurses Association of Ontario (2013) state 49% to
85% of amputations are preventable.
“PEP Talk: Diabetes, Healthy Feet and You”
• 2 leaders facilitate this FREE 2.5 hour workshop for 6-15
people. (1 professional and one layperson)
•Help empower participants to self-manage preventative foot
care via:
-Foot/Shoe Tracing
-Foot Self Exam
-Case Study discussion
-Commitment to change (action plan)
-Foot Screen conducted by professional
• Link participants to services focused on preventing diabetic
foot ulcers and foot screening services.
More patient supports!
• Quarterly newsletter patient/consumer newsletter
“Back to Basics”
• Developed “Living Healthy with Exercise”intergenerational community exercise program
• Resource section on website
• Social Media –Facebook and Twitter
What can health care providers do?
“Healthy change occurs through
connection…. not power.”
Self Management Support
• Empower and prepare people to manage their
health
• Emphasize their central role
• Use effective self-management support strategiesassessment, goal-setting, action-planning,
problem-solving and follow up
• Organize internal and community resources to
provide on going support to people (Robert Wood Johnson
Foundation)
Free Health Service Provider Training
Choices and Changes- Clinician Influence, Patient
Action
• Provides clinicians with an opportunity to explore their
own beliefs about the change process
• Provides the clinician with specific strategies that can be
utilized within the highly time limited constraint of the
typical visit.
• Case studies, videos, role playing
• (Up to 6 Mainpro- M1 credits)
Only in the Southwest!
Treating Patients with C.A.R.E
(Connect, Appreciate, Respond, Empower)
• Provides a model and specific techniques that guide
all staff members (literally anyone who comes in
contact with patients) – to communicate in ways
that will enhance satisfaction and encourage
patient partnership.
• Case studies, videos and role playing
And one more….Health Literacy Workshop
Did you know that:
• 60% of Canadians and 88% of seniors have low
health literacy?
• 1 in 9 ER visits were due to drug adverse events
and that 68% of these visits were preventable?
• 1 out of 3 patients do not understand the answer
to their questions at discharge?
• it’s estimated that 3-5% of total healthcare costs
are due to effects of limited health literacy in
Canada?
Make it Simple!
• Cardiovascular
• Monitor
• Assessment
• Consult
• Diet
• Modify
• Elevate
• Discontinue
• Confidential
• Dressing
Assess understanding
Stop asking, “Do you understand?” to assess
comprehension.
Awareness
Effective Workshops in Design and Practice
program
Challenges faced by health care providers in their
teaching, planning and facilitation include:
• Feeling the need to cover the content
• Ability to engage learners
• Work with diverse groups
• Personalize learning
• Low patient interest
• Teaching relevant content in short sessions
• Time management
• Pressure to use PowerPoint
Clinician Coaching
W.E- Stroke RN
“I have had a few successes (yay!) with using some of the
strategies we discussed, and perhaps more importantly I
am learning to re-frame my thinking about how to be truly
helpful in my interactions with clients. I'm still working
through this weird resistance that keeps me from the next
steps. I've started journaling a little bit about it - using
some of the choices and changes principles on myself!! :)”
“I'm also very gradually, becoming more comfortable &
confident in accepting that it's not up to ME to decide what
clients need. I remind myself that "I'm just a small part of
a large, ongoing process."
Clinician Coaching
M.D- Physiotherapist in a FHT
“I have actively reduced the volume of
materials/advice I am giving. That is a really good
change.”
“I have still been working on some of my choice of
questions, checking with the client (reviewing) and
have asked one person what their confidence level
was. Actually, this has been very interesting. I like
the changes I have made so far, clients seem to
respond well.”
More Provider Supports!
• Webinars
• “The Change Exchange” -Monthly e-newsletter-tools, articles, videos, websites
• Self Management Toolkit online and print
• Brief Action Planning- coming soon!
• Resource section on website
• Social media
Important Takeaways
• It takes practice, feedback and reflection…for both
the patient and the provider.
• Information only becomes useful knowledge when
it is placed in the context of a client’s world.
• All members of the health care team affect health
outcomes.
Contact us
www.swselfmanagement.ca
or call 1-855-463-5692
Question and
Answer
South West Health Links
Improving Outcomes of
Patients with COPD
Robin McFadden, MD
COPD Management: What’s New?
Acute Exacerbations of COPD:
• what is the optimal strategy for managing AECOPD ?
• PREVENT THEM !!!
AECOPD: Prevention Strategies
Vaccinations
Long-acting Anticholinergic:
Exacerbations
TORCH: ICS/LABA Reduced
Exacerbation Tate Over 3 Years
OPTIONAL Study: Hospitalizations for
AECOPD
Optimal Pharmacotherapy
AECOPD: Definition
AECOPD: Corticosteroids
AECOPD: Antibiotics
Antibiotic Treatment of Purulent
AECOPD
Antibiotic Treatment of Purulent
AECOPD
Question and
Answer
GBHS JOURNEY
Phase 1: 2012 COPD Readmission Avoidance
Phase 2: 2013-14 Triple Aim COPD REACH project
Phase 3: 2014-15 INSPIRED project
Disclosure of Commercial Support
GBHS INSPIRED team has received financial support through the CFHI
collaborative in the form of an educational grant.
Potential for conflict(s) of interest:
GBHS INSPIRED team: Jane Wheildon, Val Fleming, Angela Schmidt,
Shaundra Anderson
Management of Potential Bias
• The presentations will manage potential bias by
ensuring that data and recommendations are
presented in a fair and balanced way.
• The presenters will speak to a full range of
products that can be used in this therapeutic
area.
COPD Readmission Avoidance Project
Aim
Decrease hospital readmissions and ED visits related to COPD using a systems approach
to show evidence of success.
Accomplishments
•
Appointment with a Health Care Provider (HCP) within 1 week of discharge
•
Discharge summary dictated, transcribed and sent to HCP within 48 hours
•
Use of COPD order set & pathway
•
Self-management education prior to discharge
•
Assessment by CCAC Nurse Practitioner
•
Follow up phone call
•
Robust data collection
TRIPLE AIM
• Canadian Foundation for HealthCare Improvement working in
partnership with IHI – Institute for HealthCare Improvement to bring
the Triple Aim to Canada
• Triple Aim: An approach to optimizing health system performance.
Through the simultaneous pursuit of three dimensions, called the
“Triple Aim”:
 Improving the patient
experience of care
(including quality and
satisfaction)
 Improving the health
of populations
 Reducing the per capita
cost of health care.
THE ROAD TO UNDERSTANDING
THE PATIENT’S JOURNEY
COPD IN-PATIENT PROCESS CHALLE NGES
& O PPORTUN ITIES
Patient Admittt-d Throu,h
ER
Pathwoy Initioted In ER
• Otasion to Admrt
Howatt all
'COPO
patttrtts
...... od in
diiJIOOstd
ER
PabtnU not
Confusoon
bttwMn
Potllwov
not olwlov>
bone
propor1y
ordtr set
ond
pathway
diocnoso
'"-~')
strnm l •~t
Clrt to
patttnt
Strtamfinll"'c tht
COPD Pothwoy
A.Jcn toQBP
( usinc the pathway~
ltarninc frx nurse &
patient t •ptaat•on(s)
~an of cart clu y
BluoCOPO
folder pen to
~lnER
Not always
gtvtn to
pantots'"
ER
Staff do not
know about
b<ut fo dtr
MtdRt<IBPMHI
To butilrtod on ER
Not consistent
• Phlrmxy ttch
completes 8.-4
G.ip wM nU'llnC
00
Sicn'
BPMH
Pattents not cltar on
their mtd1Cat1on hst
Patient admit t o ln~tient
Unit
@J
Phys.•cran contrau;ty
(pog"'l olgonthm}
lnt.01sp.
P an of Cnt nttds
to be m rttd .soontr
· not a ways current
Admission Hx
Complex 0/C
-screenine tool
completed
Referral to CCAC
Rapid Response
Nurse/NP
Contu.s.on u to plan
Mid Roc
of cart rf ~t.-nt
admmH to ott unit,
fiYiiWtd 1(111
dr~
B
Huflfn& noc
lmprovt \
f eduut~
to
staff and
folder
('""• of doyl
KMdunotup-
....
comp~t•nc
COST
tCHSatt
"-":;:j
Follow kty
documentatton
Aerts
header on
whrttboard
@"'~
an of care to
tors toQIP
? Expected
LOS
Patltnt Iabe ltd as
fr.qutnt flytr
Focus of cart tht
KUte eRCerbat~
(non·com~ tant
Pt onxitty 1'
l
Smolt•nc cessation &
USI of NRT
l;clt of coordination rt:
communication
Plan of cJ rt
. amonc
providers
-betwMn
provHttrs
· and to pJht nt
(knowlodce dtficot}
Define care plan
to the O;y of D•scharge
- with c earlydefintd
proctsses
C=:V
J
terminants of hea
MH
S/EstaM
Fam•ly support
Obesity- Nutrruon
S.afety in home
Ready for 0/C
Otff.cu t to dtttrmi'l•
rtldonHS for D/C
EDD
Patttnthomt
tf'IV.ronmtnt uns.aft
Ud< of fomdy ' " - '
Bul t t Rounds
{
pahents rt blue
\
Nurs• s not
rud•ty waa.ab4
lnconsisttnt
pattent eduatJOn
i:S t o tlwll' plill of
conststtntfy
nee re portanc)
(
Bullet Rounds
~
BPMH
NotiCC'Uf'tllt
COPO Pathway
o_.unoyfor)
Improve TOA
proctss
Nurs.mort
It now tdct~bfe of
pat•ent rep an of
cart
Cornplt• D/C nHds
borrlor to D/C homo
Physician rtluctanct
to D/C- dutto 1'
lnctdtnct of
rtadmls.uon
~opcommunotyof
ort frx th1s croup
lCOPD}
c:·m·:~
ommrnHrt
competency
G. .
,~
atum&w«lt
wrthpt
KcountabJt
~:n;~
Tum {bund t
rty rtsourcts
Nun.e NIVtCitOr
~~···®
h.O: procnm
rm • n~h ous.t)
I
l
~~put
~?)
rovtmtnu
COPD REACH PROJECT TRIPLE AIM MEASURES
Population
Health
____.,
::-PO admissL.
rate
-tl
r--f--
~
---+
Referriil rates to
Smoking
Cessation
.J
"
snJOkersre~rces
~
RT (Nic:atine Replace mer
~rapy) Referral rate.
l
orta ity ra1 t:
Order Set
rder Set Utilization lt.tes
s.,okinc cessation lntervem.ions
rrnproved
Experience
r--r----Patient
Triple Aim
.::::;
'\....)!
5atisfaction
COP D
...,.
Pathway
Meds c:hedl: on admission &
disdlarge
Patient
HOBIC measures
Educ~tion
r-----.
Call rates
Compliana riltes
Follow-up
Contact
Therapeutic
SeH-Care
NRC Pidter Survey
Medlcal Outcomes Study
[SF q11estiorm.ire)
Follow-u-p
appointment
" ient Interview Analys•~
cost of care
____.,
ERvisits
r-' r---
Admissions
LOS
.
...
""""Jl'
i
· 1\:lmission/Readmission ates
Medic~tion
L)l
Discharge
Redesign
...
Recondliation
r
.._j
"
Rapid response
~
ER Visits
Med re< compliance
~"lectronic
delivery to do~
)
TRIPLE AIM COPD REACH PROJECT
• Ongoing review from various data sources to monitor our COPD
patients
• Ongoing identification of our top 10 patients (DAD, NACRS, FHT
identified high users, CCAC clients, ER and Medicine Inpatient Staff)
with analysis.
• Detailed chart reviews including both the LACE tool and the NICE
tool. These chart reviews identified many opportunities for
improvement!
• Completed Home Visits of the Friendly Faces and analyzed the
information that the patients provided.
INSPIRED JOURNEY
 August 2014- GBHS selected as one of 19 teams across Canada
to partner with CFHI
 Sept/Oct- establishing team
 Followed INSPIRED model- Respiratory Therapist/Spiritual Care
core team membership
 Oct/November –inpatient evaluation for INSPIRED
 12 patients have been reviewed- of those we currently have 7
active patients ( 3 passed away, 1 declined, 1 placement)
New Patient and Caregiver Journey
Admitted to
Hospital
Contacted by
INSPIRED
coordinator
early
Clinical f/u from
INSPIRED (home
visits/ calls)
Discharged
(if possible a LOS)
early postdischarge f/u
Existing
primary care
services and
programs
(coordinate)
Carol
An INSPIRED Patient Story
Angela Schmidt, MA, DMin
Spiritual/Emotional Team Member,
GBHS Inspired Program,
March 2015
Our First INSPIRED Patient
• Carol , 77 years of age, female
• Role of the Spiritual/Emotional Provider on team
– experience of illness
– personhood
– hopes
– faith
– support system
– present needs
– advanced care planning
“Everything has Changed”
• Carol had worked at a local golf and country club for many years.
She enjoyed being with people.
• Family
• Interests
• “The biggest challenge has been not being able to go outside, and
feeling bored.”
Hopes
• “Being with my family makes life
worth living.”
• “I hope for time. Being as well as I
can be.”
• “I hope to see my husband again.
I want to go heaven to be with
him.”
Strength
Not Denial of Illness
Building the Relationship
• Met with Carol twice at home (alone, family at work)
• Met in the hospital three times
• Advanced Care Planning
• Importance of setting up the ACP conversation with the
patient and with the family
Maintaining the Relationship
• Continuity of connection
• Patient request for spiritual care
• Saying goodbye
• Our learnings – taking time; continuity of relationship;
connection; ask about faith; hidden needs; opening the
conversation about dying
Challenges
 Sharing information between sectors – continue to problem solve as issues arise
 GBHS – Owen Sound has just recently implemented the electronic patient chart on
some units. Manual review of charts will still be required and is time consuming.
 Quick access to pertinent COPD specific data is stored in different locations i.e.
PowerChart, Paper record, INSPIRED SharePoint etc.
 Finding hand held fans in the winter is not easy!!
 Establishing measures for INSPIRED versus overall COPD population
 Time consuming, mentally taxing and the staff need to acquire specific skills
related to home visit interviewing techniques and the development of a
therapeutic working relationship.
 Understanding the effectiveness of various current COPD programs in isolation
and as part of chronic illness management across the continuum of care
Considerations
The INSPIRED framework can be translated for most chronic disease
management not just COPD.
Understand your data, where it comes from and what it means.
Listen, understand and appreciate the patient’s perspective and ask
“What Matters to You”?
Incorporate the patients’ goals in the care plan.
The addition of spiritual care team member is proving to be integral
part of Chronic illness management.
Seamless bridging of services even though may fall outside
traditional boundaries.
GBHS Owen Sound Measures
COPD Average Length of Stay (ALOS)
excludes ALC days
10
9
8
7
6
5
4
3
2
1
0
6.503
5.814
Fiscal 12_13
Fiscal 13_14
Dec-14
Oct-14
Nov-14
Sep-14
Jul-14
Aug-14
Jun-14
Apr-14
May-14
Mar-14
Jan-14
Feb-14
Dec-13
Oct-13
Nov-13
Sep-13
Jul-13
Aug-13
Jun-13
Apr-13
May-13
Feb-13
Mar-13
Jan-13
Dec-12
Oct-12
Nov-12
Sep-12
Jul-12
Aug-12
Jun-12
(excludes ALC days)
Apr-12
10.0
8.0
6.0
4.0
2.0
0.0
COPD as Most Responsible Diagnosis
Acute Average Length of Stay
May-12
Average Length of Stay (Days)
Cost of Care
Avg Provincial Length of Stay (PLOS)
190
Number of Visits
Apr-12
160
140
120
100
80
60
40
20
0
Dec-14
Nov-14
Oct-14
Sep-14
Aug-14
Jul-14
Jun-14
May-14
Apr-14
Mar-14
Feb-14
Jan-14
Dec-13
Nov-13
Oct-13
Sep-13
Aug-13
Jul-13
Jun-13
May-13
Apr-13
Mar-13
Feb-13
Jan-13
Dec-12
Nov-12
Oct-12
Sep-12
Aug-12
Jul-12
Jun-12
May-12
Cost of Care
COPD as Main Diagnosis ER Visits Volumes
191
Applying a Quality
Improvement Approach to
COPD Programs
London Family Health Team
-
Dr. Cathy Faulds MD, CCFP, FCFP, ABHM
Miranda Ross RRT
Emily Stoll BSc
Presenter Disclosure
• Presenters: Dr. Cathy Faulds, Miranda Ross, Emily Stoll
• Relationships with commercial interests:
– Grants/Research Support: none, none, none
– Speakers Bureau/Honoraria: none, none, none
– Consulting Fees: none, none, ~$500 from Pfizer to Emily for educating
primary care providers on EMR use
– Other: none, none, none
Disclosure of Commercial
Support
• This program has received no financial support.
• This program has received no in-kind support.
• Potential for conflict(s) of interest:
– No potential conflicts of interest.
Mitigating Potential Bias
• This program is not funded by any outside sources.
• No particular pharmaceuticals will be discussed in this
presentation.
Key Messages
• Why did we need a COPD program?
1. System data indicated that COPD patients were going to the ER
instead of being managed in primary care
•
Seen in Primary Care Physician/Group Practice Report1
2. Physician rosters were low for roster size
•
We didn’t know our COPD patients
• How did we build a COPD program?
1. Case Finding through use of Thoracic Screen2
2. Use of EMR tools and ongoing data review
3. Team approach to building a chronic disease program around best
practices and guidelines
Objective of our COPD Program
• Design a proactive preventative program for patients with COPD
− prevent patients with COPD from becoming top 5%
• Introduce principles of QI in the care of patients with COPD
• Identify COPD population
• Adhere to and measure best practices in COPD care
• Follow the ‘COPD patient’ through the entire system and measure this
journey
• Follow the ‘COPD patient’ from case finding to end of life and
standardize aspects of this journey
Benefits
PATIENT
• Improved quality of life through earlier diagnosis (shown through
improved MRC score)
• Streamlined care through additional management at the primary care
level
PHYSICIAN
• Comprehensive care that allows for delivery within team
• Results in increased efficiency, decreased time investment, and
increase in the physician’s supply
SYSTEM
• Decreased ER usage and hospital admissions
• Decreased referrals to specialists
Rate of Hospital Admissions for
Patients with COPD
Spread of
COPD
program
numbers from HQO Primary Care Practice Report1
This is a workshop on how to build a chronic disease
program that provides both a proactive approach to
COPD prevention and early stage management,
and avenues for reactive treatment in hospitalized
and later diagnosed patients with COPD.
Timeline
pilot completed with one physician’s resources
(MD and RN)
initial pilot
program
developed
first round of
case finding
completed
2009
2010
pilot
launched in
one
physician’s
practice
2011
pilot
complete;
program
shows great
potential
2012
2013
2014
Upon joining the LFHT we had additional
resources, such as an RRT, pharmacist, program
planners, etc… to help the spread of the program.
Timeline
pilot completed with one physician’s resources
(MD and RN)
initial pilot
program
developed
first round of
case finding
completed
2009
2010
pilot
launched in
one
physician’s
practice
pilot spread
to LFHT
2011
pilot
complete;
program
shows great
potential
2012
2013
2014
case finding
for entire
LFHT takes
place
program implemented with LFHT resources
(MDs, RRT, pharmacist, etc…)
COPD Process Map
Assessment
may be done
with Social
History Reports
to determine
Smokers and
Ex-Smokers
within the
Team.
1
Start
At appropriate visit,
patients are
assessed for
screening based on
current or previous
smoking status.
Physician may
message RT in
NOD to book
follow-up
appointment.
The Thoracic
Screen may be
performed via
call.
Thoracic Screen is
performed on
patients when
warranted and
documented in the
Procedure section
of the CPP
2
Physician may be
called in to review
medications if
previously
prescribed.
3
No – Rescreen in
three years (record
spirometry in CPP
and indicate result
in comments;
program recall).
Program Planners
track these patients.
RT loads Spirometry
template.
RT completes
routine visit using
the Spirometry
template. Thoracic
Screen may be
repeated. Physician
reviews, diagnoses
and signs off the
encounter.
No – Rescreen in
three years
(recorded in
comments and
program recall).
Program Planners
track these patients.
RT greets patient
and completes
height, weight and
BP.
4
Is the Spirometry positive?
RT greets patient
and completes
height, weight, O2
saturation, chest
auscultation and BP.
Is the Thoracic Screen
positive?
Patients who
are current
smokers will
also be referred
to smoking
cessation.
Yes – RT books a
COPD Management
Visit. Positive
spirometry is
recorded in the CPP
with comments.
Yes – Patient
booked for
spirometry
appointment with
RT.
RT loads COPD
Management
template.
RT completes
routine COPD
Management visit
and completes
template.
Physician reviews
medications and
Physician and/or RT
gives all necessary
documents (scripts,
reqs, referrals etc.)
to patient to be
completed before
next visit. Chest xray ordered as
needed.
Physician and/or RT
decide on
appropriate f/u
interval and rebooks
patient.
Appropriate care
provider completes
all necessary
documentation in
NOD.
Follow-up
intervals may
be 3,6 or 12
months.
5
POINTS OF ENTRY: 1. no Thoracic Screen 2. Thoracic Screen 3. Spirometry 4. diagnosed (physician,
hospitalization, specialist) 5. management begun (physician, hospitalization, specialist)
Case Finding
• needed to identify entire roster – numbers low for roster size
numbers from HQO Primary Care Practice Report1
Case Finding
• Standardized EMR coding and documentation important
in harnessing patients – 305 code OR social history
documentation was used to identify smokers
• Patients identified and screened with a two-part process
1. Thoracic Screen2
2. Spirometry
Case finding was carried out on all patients age
40+ who were current or ex-smokers.
Thoracic Screening
Do you cough regularly?
YES
If the answer is yes to one or
moreNO
of these questions, the
patient is booked for
spirometry.
Do you cough up phlegm regularly?
YES
NO
Do even simple chores make you short of breath?
YES
NO
Do you wheeze when you exert yourself (exercise, going up stairs)?
YES
NO
Do you get many colds, and do your colds usually last longer than your friends’ colds?
YES
NO
Identification of Patients
current and ex-smokers were documented in EMR (305 code or social history)
reports pulled to capture this population
current smokers were called by
LFHT pharmacist to administer
thoracic screen
ex-smokers were called by LFHT
RT to administer thoracic screen
thoracic screen administered
negative thoracic screen –
results were recorded in EMR
and patients were flagged for
recall in 3 years
positive thoracic screen – results
were recorded in EMR and
patients were booked with RT
for spirometry appointment
*NOTE: No literature to support 3 year recall. Based on resources.
DUE TO IN
HOUSE
SPIROMETRY
MACHINE
98%
OF
SPIROMETRY IS
NOW DONE IN
OFFICE
Coding Diagnoses
• Patients with a negative spirometry had their results recorded
in the EMR and were flagged for recall in 3 years
• Patients with a positive spirometry were diagnosed with COPD
• Standardized EMR coding and documentation important once
patients are diagnosed – 491 code used to identify patients with
COPD
• Using this code allowed for us to pull rosters of COPD patients
Case Finding Results
38% increase in roster size
during pilot program by sole physician
Case Finding Results
percent (%) of patients with COPD
Percent of patients with COPD at each stage at the point of diagnosis.
Building a Chronic Disease Program
• Wagner’s Model of Chronic Disease Implementation3
• Not disease specific
• Remains part of comprehensive care
• Based on guidelines4 and evidence-based medicine
• Determined appropriate methods of treatment, timelines for
screening and management, and evidence based measures
to focus on
• Built clinical EMR and data tracking tools
COPD Logic Model
COPD Specific EMR Tools
• COPD Screening Template
• Used for initial screening
• COPD Management Template
• Used for standard COPD visit
• COPD Mini Template
• Used by physician before or between visits with the RT
• COPD Flowsheet
• Collects summarized measures over multiple visits
the LFHT uses Nightingale EMR
EMR Tools – Sample Template
COPD Screening – Thoracic Screening
EMR Tools – Sample Template
COPD Management
COPD Management Visit
THIS VISIT INCLUDES…
•
•
•
•
•
•
•
•
•
•
•
•
•
•
assessment of lung history – smoking status
exacerbation frequency and management
physical assessment
review of labs and tests (i.e. Hb and x-ray)
MRC score
COPD stage
medication review and changes
puffer education (technique and use)
immunizations (given if needed)
self-management goals
action plan setting and review
referrals (if necessary… see next slide)
end of life discussion (if necessary) – may be referred for ACP
re-booking for follow-up
LFHT Roles & Referrals
Pharmacist
smoking cessation, medication management
Registered
Dietitian
at / after
appointment
with RRT
Nurse
Practitioner
Social Work
Chronic
Disease
Nurse
nutrition counselling
co-morbidities, frail / elderly, house calls
mental health counselling
co-morbidities, multiple chronic diseases
EMR Tools – Sample Template
COPD Mini
EMR Tools – Sample Flowsheet
COPD Management
1
10-Sep-13
0
0
10-Dec-13
0
1
2-Sep-14
1
1
22-Jul-14
1
1
9-Sep-14
1
1
05-Sep-14
1
1
8-Jan-14
0
1
3-Sep-14
1
1
20-May-14
0
1
4-Feb-14
0
1
17-Jun-14
1
1
20-Nov-12
0
0
30-Sep-14
1
1
6-May-14
0
1
1
0
0
1
0
1
1
1
1
1
0
0
1
0
PHQ2 in Past Year
Self Management in Past Year
In past year
Given in Past Year
Offered In Past Year
Pneumovax Series Complete
O2 Therapy
O2 Saturation
Chest X-ray in Past Year
Hemoglobin in Past Year
On Spiriva
1
Hemoglobin Date
10
0
0
0
37.1
12-Mar-14
1
68
96
3
126
11-Aug-14
1
08-Apr-14
1
1
1
0
96%
30-Mar-09
1
18-Dec-13
1
1
0
15-Aug-14
0
15-Aug-14
1
10
0
0
0
29.7
10-Sep-14
1
82
80
2
151
11-Nov-11
0
04-Jan-14
1
1
1
0
95%
31-Oct-08
1
09-Oct-14
1
1
0
10-Sep-13
1 walking
12-Aug-14
1
10
0
0
0
19.7
20-Nov-12
0
50
78
1
145
01-Apr-14
1
13-Dec-14
1
1
1
0
94%
12-Apr-11
1
14-Oct-14
1
1
0
10-Dec-13
0
28-Jul-14
1
01
0
0
0
19.7
02-Sep-14
1
86
93
2
143
23-Aug-14
1
23-Aug-13
0
1
0
0
97%
14-Apr-09
1
15-Oct-14
1
1 Burns, Malcom
0
2-Sep-14
1 biaxin, walking
12-Feb-14
1
10
0
01-Jun-14
1
2
33.8
22-Jul-14
1
94
118
2
145
20-Mar-14
1
15-Aug-14
1
1
1
0
97%
19-Jun-09
1
22-Oct-14
1
1 Timkin 2010
0
22-Jul-14
1 walks
23-Apr-14
1
00
1
35
23-Jul-12
0
01-Jun-14
1
2
21.0
09-Sep-14
1
75
68
1
147
19-Sep-14
1
12-Jul-13
0
1
1
0
97%
0
1
0
9-Sep-14
1 quit smoking
12-Nov-13
0
01
0
100
12-Aug-14
1
0
0
27.4
12-Aug-14
1
68
80
1
139
29-Aug-14
1
26-Jun-14
1
1
1
0
98%
14-Mar-08
1
07-Dec-07
0
1
0
05-Sep-14
1 walks dog
05-Sep-14
1
01
12cig/
0 daily
08-Jan-14
1
1
1
26.3
30-May-13
0
71
98
2
140
16-Jun-12
0
16-Dec-13
1
1
1
0
95%
01-Aug-08
1
13-Nov-14
1
1
0
8-Jan-14
1 diet
16-Jul-14
1
00
1
0
0
23.9
03-Sep-14
1
87
92
2
138
11-Jun-14
1
27-May-14
1
1
1
0
95%
06-Oct-09
1
01-Nov-13
0
1 Dr. Sardar, 2008
0
3-Sep-14
1 walking
05-Jun-14
1
1
20-May-14
1 quit smoking
06-Sep-13
0
Date of Last
Exacerbation
BMI
Date of
Spirometry
q 1 Year
Pack
Years
None=0;
1= 1;
>2=2
FEV1/
FEV1 FVC
(%) (%)
1
15-Aug-14
MRC Grade Level
Spirometry
Hemoglobin (Value)
Exacerbations in Past 6 Months
Referal in Past Year
Ex-Smokers
Non-Smokers
Smokers
Date of
Referral to
Smoking
Cessation
On Steriod
COPD Patients
Co-morbidities
Action Plan Review q 6 Months
Action Plan Reviewed q 12 Months
Last seen
(Action Plan
Reviewed)
(1 = yes, 0 = no)
Patient Measures
90
02-Sep-14
1
01-Jun-14
45
Chest X-ray
Date
Pneumovax
Date
Annual
Influenza
Referrals
Date of Last
Referral
Date of Last Self
Management
Goal
Self
Management
Description
Date of PHQ2
0
06-Sep-13
0
01-Jun-14
1
1
24.1
09-Apr-13
0
79
2
147
10-Apr-14
1
03-Aug-14
1
1
1
0
97%
16-Nov-10
1
31-Jan-14
1
Respiratory
1 Medicine
50
04-Feb-14
1
01-Jun-14
1
1
28.7
04-Feb-14
1 88.9 94.8
1
126
23-Jan-14
1
07-Sep-12
0
1
1
0
94%
08-Nov-10
1
02-Jul-05
0
1
0
4-Feb-14
couselled to
1 stop smoking
06-Aug-14
1
1
49
14-May-13
0
01-Jun-14
1
2
40.1
17-Jun-14
1
86
98
2
108
12-May-14
1
28-May-14
1
1
1
0
95%
25-Jul-08
1
06-Nov-14
1
1 LT Patrick 2008
0
17-Jun-14
1 quit smoking
23-Sep-14
1
01
0
25
20-Nov-12
0
0
0
26.5
29-Oct-12
0
74
90
1
159
20-Aug-14
1
29-Aug-14
1
1
0
0
97%
29-Aug-12
1
0
1
0
20-Nov-12
1 inhalers
21-Aug-12
0
01
0
45
30-Sep-14
1
1
1
24.0
30-Sep-14
1
61
59
2
153
25-Jun-10
0
04-Jun-14
1
1
1
0
97%
03-Apr-09
1
25-Feb-14
1
1 Rob -smoking
1
30-Sep-14
walking and
1 antibiotic
19-Jun-12
0
00
1
23
0
0
42.5
06-May-14
1
59
95
2
170
15-Apr-14
1
25-Jun-13
0
1
1
0
93%
17-Jul-09
1
05-Nov-13
0
1
0
6-May-14
1
06-May-14
1
10
0 1ppd
01
0
00
01-Jun-14
82
01-Jun-14
01-Jun-14
Process, Outcome & Balance Measures
number of smokers in the practice
Smoking Cessation Data
Decreased Exacerbations
Percentage of Patients with Exacerbations
100.00
90.00
80.00
70.00
no exacerbations
60.00
50.00
one exacerbation
40.00
multiple exacerbations
30.00
20.00
10.00
0.00
20…
2010
2011
2012
2013
2014
Decreased Hospitalizations and ER Use
percent (%) of patients with COPD
Percent of COPD patients who report a COPD related visit to the emergency
department or hospital admission in past 6 months.
25
Faulds
QIIP
20
15
10
5
0
2009
2010
* data from provincial program – PILOT
2011
2014
Hospitalizations and ER Use
percent (%) of patients with COPD
Percent of COPD patients with none, one, or multiple COPD related visit to the
emergency department or hospital admission in past year
Hospitalizations and ER Use Data
• Registered to receive local hospital data
− LENS reports for London hospitals
• Provided daily, weekly and monthly data through portal
• Data reviewed daily by physicians
− Patients in for COPD-related problem are contacted
− Follow-up by physician or RRT
• Data reviewed monthly by Program Planners
− Tracking and data purposes
• No specific program for this in our area
− Developed own internal process
Plan-Do-Study-Act (PDSAs)
• Data is reviewed monthly by individual physicians
• Implement practice-specific PDSAs
• Monitor status of individual patient data and practice data
• Data is reviewed monthly by Lung Health Sub-Committee
• Implement LFHT-specific PDSAs
• Monitor status of overall team data
Other EMR Tools
• House Call Visit with Chronic Disease Template
• Used for house call visit in which patient has a chronic disease
• Advanced Care Planning Screening Template
• Used for initial screening
• Advanced Care Planning Visit 1 Template
• Used for standard ACP visit
• Advanced Care Planning Visit 2 Template
• Used for standard ACP visit
• Advanced Care Planning Follow-Up Template
• Used for subsequent ACP-related visits once plan in place
Advanced Care Planning Background
• Fewer than half of Canadians have discussed health care
treatments with a family member or friend to express what they
would want if they were ill and unable to communicate
• Only 9% have ever spoken to a health care provider about their
wishes for care
• Over 80% of Canadians do not have a written plan5
Advanced Care Planning Pilot
• We felt that this conversation was best addressed in Primary
Care
• Developed Advanced Care Planning Pilot with COPD program
• Created templates that allow use to capture the planning
process into an Advanced Care Directive
• Templates also prompt and allow for multiple members of the
team to use them
Advanced Care Planning Template
Advanced Care Planning Template
Advanced Care Planning Template
Advanced Care Planning Template
Advanced Care Planning Template
Benefits
PATIENT
• Improved quality of life through earlier diagnosis (shown through
improved MRC score)
• Streamlined care through additional management at the primary care
level
PHYSICIAN
• Comprehensive care that allows for delivery within team
• Results in increased efficiency, decreased time investment, and
increase in the physician’s supply
SYSTEM
• Decreased ER usage and hospital admissions
• Decreased referrals to specialists
Working with a respiratory therapist in the family health team has
“proved
to be much more helpful than I could possibly have realized.
Not only does the RT help optimize treatment strategies for my
asthmatics and COPD patients, she also trouble-shoots a variety of
other respiratory complaints and conditions. Having access to
someone who can objectively assess lung function and triage patients
accordingly has been immensely helpful. Patients are better informed
about their condition and leave the office armed with a guidelinesupported management plan that they are able to easily follow
themselves. This improves both patient compliance and quality of
care. Although not convinced before, I can’t imagine practising
without our respiratory therapist as a team member now.
-Dr. Ouellet LFHT physician (initially a skeptic)
”
Summary
• Able to identify patients with COPD through Case Finding
• Thoracic Screen
• Spirometry
• Building of EMR Tools allowed for AHP involvement and data
analysis
• Team based approach improves care for patient and
decreases burden on physician and system
– reducing the likelihood that these patients will make it to the top 5%
References
1. (2011). Primary Care Practice Report. Health Quality Ontario.
2. (2013). Canadian Lung Health Test. Canadian Thoracic Society.
3. (2006). Wagner’s Chronic Care Model for Chronic Disease Management.
Improving Chronic Illness Care.
4. (2010). Canadian Respiratory Guidelines – Chronic Obstructive Pulmonary
Disease. Canadian Thoracic Society.
5. (2014). Cancer and Advance Care Planning. Speak Up/
Question Period
Thank you for your time.
COPD Pilot Project at SGH
Prepared for :
Health Links Learning Collaborative –
Learning Session #1
Arden Park, Stratford Ontario
March 31, 2015
Objectives of the Presentation
1. Overview of the SGH COPD Pilot Project
2. Discussion of the findings and “take-aways” generated
from the pilot project
3. “Next steps” for management of COPD patients
Why?
Average Length of Stay (ALOS)
Conservable Days
Alternate Level of Care days (ALC)
Why?
 Shift from “global funding” to Quality Based Procedures (QBP’s)
 “New” Health Based Allocation Methodology
(HBAM) funding formula introduced to the Alliance
 Identify efficiencies for E1-500 (Medicine/Palliative Care Unit) and
E2-600 (Telemetry)
 One of the strategies identified was to reduce the ALOS for the
Medicine Program’s highest volume Case Mix Group (CMG):
“COPD, With/Without Pneumonia”
Who Was Involved in the Project Team?
 CCAC
 Perth District Health Unit
 Stratford Family Health Team
 STAR Family Health Team
 Horizon ProResp
 SGH Staff (Nursing, RRT, Leaders, Administrative Support)
 Huron Perth Healthcare Alliance Project Management Office (PMO)
Who Was Included in the Pilot?
• Two units at the SGH site were originally identified to be
included in the pilot project:
E1-500 (Medicine/Palliative Unit)
E2-600 (Telemetry Unit)
• Patients admitted to either of those units with a primary
diagnosis of:
“COPD, with or without pneumonia”
What Were the Key Factors to Getting
Started?
 The development and implementation of the (revised) COPD
Admission Order Set
 Roll-out of the Smoking Cessation Program to the staff of E1500 (Medicine/Palliative Care Unit)
 RRT assessment, education and completion of “Self-Efficacy for
Managing Chronic Disease Scale” (in-hospital and postdischarge) to assess patient confidence with self-management
What Were the Other Components of
the Pilot Project?
• Discharge planning meeting 24-48 hours prior to
discharge including patient/family
•
•
•
•
•
Community Involvement – Post-Discharge
Rapid Response Nurse visit
RRT visits (provided by Horizon ProResp)
Nursing and NP visits
Family Health Team follow-up
Smokers’ Helpline follow-up
What Metrics Were Included in the
Pilot Project?
• # of patients admitted to the pilot with COPD (with or without
pneumonia)
• # of patients with COPD discharged with CCAC/supports
• Length of stay for CMG ‘COPD (with and without pneumonia)’
• # of readmits – specific with CCAC support
• Patient confidence with self-management measured on admission
and on f/u (at 6 weeks or when they are discharged from CCAC
services)
• COPD Admission order sets on chart (random 10% audit)
COPD ORDER SET
GOALS OF RRT CONSULT ON UNIT,
POTENTIAL POINTS OF DISCUSSION
EDUCATION - Enable patient to have a better
understanding of COPD and the management of COPD
Ranges from 20 min to 50 min
 Smoking
 Pathophysiology (basic overview)
 Causes, symptoms, triggers
 Medication review
 Action Plan – speak to physician
 Pulmonary Rehab – speak to physician
Smoking Cessation Consult form
This is the form that is used to
complete the BCI. The 5 A’s are
embedded in the form to ensure the
process is carried out. The form is
faxed to Smokers’ Helpline upon
discharge if the patient agrees to the
support.
COPD Program at HPHA
HOSPITAL TO COMMUNITY
What is the transition from Hospital
to Community?
• CCAC Care Coordinator arranges discharge meeting
• Participants : CCAC, MRP, RRT - hospital and community, Rapid
Response RN, Nursing agency, COPD pilot lead, Patient and
caregivers
• CCAC provides an NP if patient is not member of STAR or Stratford
Family Health Team; otherwise CCAC to notify FHT staff of patient
discharge
• May also include LTCH staff
COPD Program at HPHA
COMMUNITY
INVOLVEMENT:
•Stratford Family Health Team
•STAR Family Health Team
What happened once the patient was discharged?
 The Process Map included FHT being notified by CCAC (fax) that a
patient our FHT was being discharged from hospital
Stratford Family Health Team
• 10 patients belonged to physicians of SFHT
• 6 patients were assessed in SFHT Respiratory Clinic
• 1 patient required home visits only
• 3 patients overwhelmed, turned down office visit
What happened once the patient was discharged?
Stratford Family Health Team
Patients were seen by family physician within one week
Patient was contacted by phone by RN, CRE from SFHT
Respiratory Clinic – in-office appointment offered
If did not wish in office appointment, reviewed resources
available
Stratford Family Health Team – Respiratory Clinic
Maintained by Maria Savelle, RN, CRE
 Spirometry testing (to confirm COPD if not done in hospital )
*one patient treated for COPD x 10+ yrs, does not have COPD
 Review pharmacological treatment, ensure optimized according to
Canadian Respiratory Guidelines
 Continue education re: self-management of COPD including COPD
Action Plan
 Offer Pulmonary Rehab if appropriate (SFHT Program available)
 TEACH trained – Smoking Cessation Counseling offered
 Arrange availability of follow-up contact, assessment as required
 *Challenge: communication piece missing from CCAC to FHT
**an established program/resource for managing patients with COPD
is available for SFHT patients, but receiving communication that the
patient was in hospital is the challenge!
Refer, as required, to other SFHT Allied
Professionals/ Programs:
 Occupational Therapist (Falls Prevention, mobility, medical
equipment)
 Dietitian
 Pharmacist
 Hypertension Clinic
 Healthy Hearts / Hypertension Clinic
 Chiropodist
 Stress Management Group
 Chronic Pain Group
 Memory Clinic
COPD Program at HPHA
FINDINGS
What Were the Pilot Project Findings?
 28 patients enrolled in the pilot
 38 patients discharged from SGH with a
diagnosis of COPD (i.e. 33 patients from E1-500
and 5 patients from E2-600)
What Were the Pilot Project Findings?
• 19/28 (68%) had COPD Admission Order Sets
on chart
What Were the Pilot Project Findings?
• 18/28 patients were discharged with CCAC
supports
• 10 patients had formal discharge meetings with
multiple team members present
What Were the Pilot Project Findings:
• 3/28 identified as (current) smokers
• 1/3 documented as being given the “Ready to Quit
Package” with Smoking Cessation Consult Form being
completed
• 7 patients (documented) as being on Home O2 program
upon discharge – all patients in the study were eligible to
be seen by RRT at home as part of the pilot project
whether receiving O2 or not
What Were the Pilot Project Findings?
• 2 patients were readmitted during the 3 month pilot
project
• “Self-Efficacy for Managing Chronic Disease” completed
by:
 15 patients while in hospital
 12 patients @ 6 weeks post-discharge
What Were the Project Findings?
Average Length of Stay for the 3 month pilot:
E1-500 6.79 days
As compared to: 2011/12 (7.7 days) and 2012/13 (7.1 days)
Average Expected Length of Stay for the 3 month pilot:
E1-500 6.85 days
As compared to: 2011/2012 (7.3days) and 2012/13 (6.7 days)
What Were the Pilot Project Findings?
Average Length of Stay for the 3 month pilot:
E2-600 7 days
As compared to: 2011/12 (5.8 days) and 2012/13 (5.5 days)
Average Expected Length of Stay for the 3 month pilot:
E2-600 7.2 days
As compared to: 2011/2012 (6.7 days) and 2012/13 (7.3 days)
What Did We Learn?
• Important to identify champions related to initiation of the COPD
Admission Order Set
• All staff involved in the process need to be included in education
regardless of the amount of involvement they are likely to have
• COMMUNICATE, COMMUNICATE, COMMUNICATE…
• ‘Early-in-the-hospital-stay’ education by the RRT’s is important
• It is helpful for physicians to participate in the discussion related to
identifying the Expected Date of Discharge (EDD)
What Were the Challenges We Encountered?
• 14 week “Patient Flow and Process Optimization Project” was
rolled out on E1-500 during the pilot project:
▫ Multiple pilot projects running simultaneously
▫ ‘Change fatigue’ experienced by E1-500 staff
▫ ‘Communication overload’
• Multiple Leadership changes, vacancies, restructuring during this 3
month period…
Next Steps
• Continue to provide coordinated COPD care at
SGH with a view to expand to all sites of HPHA
• Provide ongoing education to staff at HPHA,
FHT’s and community agencies related to
management of the COPD patient population
Video with Dr. Narayan
Post Pilot Project
 Order Sets no longer being used consistently
 Referral to CCAC and RRT not sent
 Readmission rate 13/14
▫ 26% COPD ER visits were seen more than twice in the year
(3.8 visit/person average)
▫ 12% of Admitted COPD patients re-admitted within 30
days
 Length of stay
▫ Average Length Of Stay 6.4 days
▫ 1.7 days above Expected Length of Stay
WHY?
ROOT CAUSE
WHY?
Patients not receiving COPD education
WHY?
Patients do not have in home support post discharge
WHY?
Referral did not go to Horizon Pro Resp
WHY?
RRT did not get COPD treatment order (also means in house
WHY?
Order set was not used and no written order to refer
WHY?
Physicians unable to find order set
education was not done)
Moving Forward
Educate, Communicate & Support
Education:
• Physician education re printing order sets
• Clerk/nurse education re printing order sets
• Quick reference sheets created and posted
with printing order set instructions
• COPD specific Care Plan
• COPD Clinical and Patient pathways
• Smoking Cessation
• Booking Follow up appointments
• Patient education packages
• Staff COPD e-learning
• Outcome driven documentation supporting
Clinical Pathway
Communication
• Pathway reviewed and approved by all
Stakeholders
• COPD QPB awareness wall in all Medical
units
• Medical Care Team Meetings
• Staff meetings
• Collaborative Care Team meetings
• E-mail
• In-services
• Standard work
Support
• Team Leads all educated and will support
• Manager awareness and access to all
material
• Senior Manager support and awareness
• RRT support to be arranged for Seaforth,
Clinton and St Marys Patients- 41% COPD
admissions
Sustainability Plan
Communicate, Educate, Support
▫
▫
▫
▫
▫
Audit process to measure COPD admissions using order sets.
Team Leads will offer continuous education and support
All COPD material available on forms online
COPD e-learning
Expected outcome built into electronic documentation with
timelines
▫ Monitor metrics – Improvement Opportunities – PDCA
▫ Standard work
▫ Education packages available on all units
Creating a culture focused on Outcomes &
Performances
Do not let BEST get in the way of BETTER
Question and
Answer
Closing Remarks