Outcome‐Based Pathways to promote Quality and Value in Home Care
June 9, 2014
Janet MacLeod – MH CCAC
Susan Filax – Spectrum Health Care
Jacklyn Baljit ‐ OACCAC
Objectives
• To provide an overview of the design and proof‐of‐concept testing of Outcome‐Based Wound Care Pathways in the Ontario Home Care and Community sector
• To understand the impact of this initiative and how it promotes quality and value in home care
• To share lessons we are learning from OBP Proof‐of‐Concept Testing
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OBP Proof‐of‐Concept Sites
Of the 14 Community Care Access Centres (CCACs), there were 5 Proof‐
of‐Concept CCAC sites in collaboration with their Service Provider Organizations: • Central (#8 on LHIN map)
– November 26, 2012 •
North Simcoe Muskoka (#12)
– November 26, 2012 •
Mississauga Halton (#6)
– January 31, 2013 •
Champlain (#11)
– February 11, 2013 •
Erie St. Clair (#1)
– June 10, 2013 3
Current State: Wound Care
• Wound care represents an annual cost of $240 Million/year for CCACs
• Provide care to 33,000 patients with wounds annually
• Studies suggest that 40‐50% of home care wound costs can be reduced where best practice is adopted
Short Length of Stay Patients, 2011
Wound
28%
Non Wound 72%
Source: Wound Care best practices and outcomes: ICCP Literature Review, 2009
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Outcome‐Based Pathways
Outcome Based Pathways (OBPs) are evidence‐informed tools which, when used collaboratively by the CCAC and a SPO, map out a patient’s care journey. The OBP identifies expected outcomes that will be achieved at specific points in a patient’s journey when best practice care/treatment is delivered for a specific population’s needs (e.g. wound care or unilateral hip and knee replacement). These pathways have been created in an effort to ensure:
• Clinical best practices are applied in the provision of home care/services in order to achieve optimal patient outcomes. • Standardized reporting and outcome measurements based on the provincial application of best practices to evaluate home care sector performance in the provision of care/services. • The patient experiences a consistently high quality of service across the province
• Service Provider leadership and flexibility as the clinical expert in providing care or treatment.
• A mechanism exists for CCACs to more effectively monitor the progress of patients receiving services for a particular condition • To provide a framework for the CCAC Care Coordinator to proactively intervene/provide support when a patient’s care trajectory is not achieving the anticipated outcomes.
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Adherence to Best Practices
Wound Care OBPs were developed using published best practice guidelines from governing bodies such as: RNAO, CAWC etc. with a rigorous review process
OBPs include outcomes to identify key practices or milestones to be achieved and combines processes as well as clinical goals (e.g. referral initiated for compression or 20‐30% reduction in wound size) 6
Acknowledgements: OBP Proof‐of‐Concept Participants
Pilot Implementation Overview:
Wounds ‐ Volumes
• There have been 13,600 wound outcome‐based pathways ordered across 5 CCACs as of Sept. 5, 2013
Proportion of Wound OBPs across 5 Pilot sites
Traumatic Wound
21%
Venous Leg Ulcer
8%
Diabetic Foot Ulcer
8%
Pilonidal Sinus
7%
Surgical Wound
45%
Pressure Ulcer
11%
Diabetic Foot Ulcer
Pilonidal Sinus
Pressure Ulcer
Surgical Wound
Traumatic Wound
Venous Leg Ulcer
•
Pressure Surgical Traumatic
VLU
•
OBPs provide an opportunity to collect and understand previously unavailable provincial performance indicators. This enables a continuous quality improvement approach which will benefit our patients and improve quality and value in the home and community care sector. OBPs focus care delivery on outcomes that are driven by best practice. This table highlights some of the outcomes being reported including: confirmation of completion of a holistic patient and wound assessment; wound measurement (Length x Width x Depth); initiation of Compression Therapy; Pressure Relief Measures; etc.
Pilonidal •
DFU
Promotion of Quality and Value in Wound Care
Wound Measurement






Holistic Patient and Wound Assessment Completed






Discharge Planning Initiated for patient independence and prevention






Pressure Redistribution Measures Initiated

OBP Outcomes Derived from Best Practice Guidelines
0 to 7 Days


Compression Therapy Initiated
21 to 28 Days
20‐30% Reduction in Wound Size

Chronic Disease Self‐Management Plan Initiated






8
8
12

Final Interval (varies by wound type)
Wound is closed by __weeks
12 8
18
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Overall Lessons Learned
The journey has been a unique collaboration between CCACs and SPOs. It has:
• Provided standardization of wound care within the community home care sector, improving patient outcomes;
• Initiated new learning on the importance of utilizing data to guide care outcomes;
• Reinforced the importance of patient‐centred, evidence informed best practice;
• Provided the ability to involve Enterostomal therapists early in treatment;
• Increased the patient’s experience of team work and professionalism;
• Provided the ability for electronic communication which has enhanced the clarity of reporting.
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What We are Learning: Outcome-Based Care
Working Differently: CCAC Care Coordinators • Comprehensive assessment and care planning • Determination of eligibility and assign specific OBP • Accountable for tracking patient outcomes, through review of outcome reports and focus on expectations
• Measure patient progress according to defined expectations
• Strategize with providers on outlier (or unusual) patient situations • Provide more emphasis on care connecting, system navigation and stronger coordination role between service provider organizations, hospitals, primary care and community support services
Early Implementation Successes:
Mississauga Halton CCAC
Mississauga Halton CCAC ‐
Outcome‐Based Pathways
• Implemented February 1, 2013 in both Short Stay and Long Stay Caseloads
• OBPs adopted were:
•
•
•
•
•
•
•
•
•
Arterial Leg Ulcer
Diabetic Foot Ulcer
Pilonidal Sinus Ulcer
Pressure Ulcer
Venous Leg Ulcer
Surgical
Traumatic Wound Assessment (for unknown wound etiology)
Mississauga Halton CCAC
Surgical OBP – Interval Report Example
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Performance Findings‐ for all Wound OBPs
Period of Feb. 1st to November 21st (discharged only)
•
Mississauga Halton CCAC
Performance Findings‐ by Population
Period of Feb. 1st to November 21st (discharged only)
•
Mississauga Halton CCAC
Quality Improvement Approach
• Change management is the key • Project Structure to support the ongoing SPO and CCAC collaboration • Determination of shared Business practices and rules
• Education, job aids and ongoing knowledge translation
• Escalation processes for SPOs and care coordinators • Performance measures, monitoring and feedback
•
Mississauga Halton CCAC
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Quality Improvement Approach • Introduction of Chiropody services and orthotics • Addition of the Interprofessional Wound Care Team for rapid physician consultation for complex wounds when ET/WCA is requiring wound diagnosis, and treatment recommendations
• Testing of the version 1.0 Maintenance/Non‐Healing OBPs to inform further adoption
• Preparation for Outcome Based Reimbursement
•
Mississauga Halton CCAC
POC Evaluation Next Steps
• Piloting the Best Practice Readiness Tool to support new sites in implementing wound care outcome‐based pathways • Conducting a further clinical analysis on POC results to determine the variables that make the most difference in achieving clinical outcomes
• Further evolution of practice of wound care pathways and testing related to a model of outcome based reimbursement for wound care in 3 CCAC sites in collaboration with their SPOs
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Thank You!