Champlain CCAC
ACHIEVE EXCELLENCE THROUGH ACCESS: Supporting Peritoneal Dialysis
Patients in the Community
OACCAC June 10, 2014Presented by:
Karen Lapierre Champlain CCACFiona Wall Champlain CCAC
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Champlain CCAC
Overview
• Background• Objectives• Results• Next steps
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Champlain CCAC
BackgroundGap Analysis 2010• Communication challenges between hospitals and
community partners• Lack of single point of contact for PD clients and
hospital partners• Continuity and consistency
• Lack of confidence and/or knowledge of skill sets available to provide in community
• Lack of access to a broader range of services e.g. Allied health and respites services
• Access to long term care
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Champlain CCAC
Background
• 2012 New Model of Care to Support Home Peritoneal Dialysis (PD) Patients in Champlain LHIN
• An innovative partnership between the Champlain CCAC, Ottawa Hospital and Renfrew Victoria Hospital
• Reorganizing of work processes • PD Nurse Care Coordinator role developed
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Champlain CCAC
Objectives
• Dedicated Regional CCAC Nephrology Care Coordinator – single point of contact
• Develop common standards of care• Standardize documentation and
communication tools• Standardize training/education for
service providers
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Champlain CCAC
PD Care Coordinator
• Spring 2012 dedicated regional Care Coordinator housed on site at TOH as single point of access
• System navigation• Liaison with service providers• RAI tools determine need of patient • Collaborates with Hospital team e.g. morning
rounds, family meetings, clarify treatment goals
• Home visits post hospital and ER visits; discharge to home dialysis
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Champlain CCAC
Common Standards
• Nursing process frame works• Contextualized PD community based
population• Guidance in specified review timing • Guide care plan development and
evaluation
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Champlain CCAC
Standard of CareStep of the Nursing Process• Assessment• Planning• Intervention• Evaluation
Categories• Physical status• Decision making related to plan
of care • Social supports• Equipment• Patient learning needs
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Champlain CCAC
Standardized Documentation and Communication Tools• Collaborative process spearheaded by partner
clinical experts• Championed by CCAC Care PD Care
Coordinator• Three principle documents
• Intra-agency communication tools• Helpful hints resource• Care
• Reviewed with service provider
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Champlain CCAC
CommunicationTool
• Service provider indicates issue
• Reviewed by HDU RN at TOH clinic visit
• Guides telephonesupport conversations
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Champlain CCAC
Helpful Hints
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Champlain CCAC
MonitoringRecord
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Champlain CCAC
Service Providers
• Expression of interest offered opportunity to service Champlain PD patients 2012
• Two successful providers across Champlain
• Agency PD champions identified• Standards of care expectations
• dissemination of documentation tools• provider education template
• CCAC PD Care Coordinator point of contact
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Champlain CCAC
Professional Services
• Nursing• In Home services
• Focus of interventions: assessment & symptoms management, cycler set up, monitoring of PD supplies, support, PD exit site dressing
• Goal: promote independence & teach patient/family
• Frequency: based on needs• Joint home visit by HDU case manager &
community nurse (day 1 & 6 wk post)
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Champlain CCAC
Professional Services
• Other Professional Health Services• Occupational therapy• Physiotherapy• Speech therapy• Social work• Nutrition
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Champlain CCAC
Support Services
• Personal support (ADLs)• Respite Care• convalescence• Assisted Living (IADLs)• Retirement Home• Dressing supplies• Equipment rental (commode, walker)
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Champlain CCAC
Results of Partnership• CCAC Care Coordinator 2012
• Single point of access to community based health• Improved access for dialysis patients
• PD case load numbers increase• Model of Care implemented –patient centered
• Service provider engagement• Better understanding of partner organization processes
• Improved communication hospital /community• Responsive ‘just in time’ and proactive problem solving
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Champlain CCAC
Results of Partnership
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Client Population74% Long stay
25 % Short stay
Champlain CCAC
Next Step?
• Continue with partnership• Continue to work closely with service
providers• Evaluate PD in LTC initiative• Streamline Intake of PD referrals
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Champlain CCAC
Questions
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