Improving Integration in the Continuum of Care: Valuable ... Presentations/TA03... · 13 Evidence:...

Improving Integration in the

Continuum of Care: Valuable

Lessons from Two CCACs

Achieving Excellent Value

OACCAC

June 7 , 2016

COMMON GOALS Patient at the centre of care

Enhanced communication and increased trust

among partners

Different sectors working together in

collaboration with a focus on the patient

Focus on quality highlighting HQO quality

improvement tools

www.ideasontario.ca

IDEAS Applied Learning Project

Jennifer Houston- Manager, Client Services

North Simcoe Muskoka CCAC

Carla Beaton- RPh, CGP, FASCP

www.ideasontario.ca 4

Learning Objectives

1. Describe how this collaborative increases value to patients and caregivers by strengthening the model of MedRecduring transitions to help delay and avoid hospitalizations.

2. Explain how specific quality improvement methods can be used to achieve system efficiencies, improve integration and excellent inter-professional communication.

3. Recognize the impact of BOOMR on balancing patient/ family/ staff needs and experiences with complex system expectations, funding and regulatory requirements during the transition experience.


BOOMR Project Overview

Better COordinated CrOss-Sectoral Medication Reconciliation

Recognition: Ideas Alumni Achievement Award 2015

Honour Role, Minister’s Medal Award


OUR BOOMR PROJECT

Why? To reduce preventable hospital readmissions due to

medication related problems/complications from transitions of

care

Why does it matter? Hospital visits:

Cause distress to resident and family

Result in complications

delirium, falls, infection, polypharmacy

Are costly to the system


How much does a hospital visit cost?

a) $ 650

b) $ 1000

c) $ 5000

d) $ 7000


The average hospital stay in Canada costs nearly $7,000 per

patient, and even more for patients who have an underlying health

condition, according to a new report by the Canadian Institute for

Health Information. Mar 19, 2008


How much does a hospital visit cost due to

COPD?

a) $ 1000

b) $ 5000

c) $ 10,000

d) $ 30,000


Up to 79 per cent of Canadians with COPD

avoid everyday activities2.

Hospital admissions for COPD lung attacks in

Canada averaged a 10-day length of stay at a

cost of $10,000 per stay. The total cost of

COPD hospitalizations is estimated to be at

$1.5 billion a year3.

Reference: Definitive Healthcare


Evidence:Patients vulnerable to harmful medication

errors during transitions from hospital to LTC ISMP 2013 Long Term Care Advise-ERR

Mary

Fall / ankle fracture , 2 week wait for surgery

27 medications on file, 2 week stay in hospital

90 day stay in convalescent care

Discharge on 27 medications

Something is wrong here

We could do something about this

And here’s how…


Evidence:Patients vulnerable to harmful medication

errors during transitions from hospital to LTC ISMP 2013 Long Term Care Advise-ERR

LTC homes and Pharmacies are finding that late-day

admissions have become the norm rather than the

exception. He cites an unpublished study that found

80% of admissions occur between 12 noon and 8

pm.

Frank Grosso , CEO, American Society Consultant PharmacistsTHE CONSULTANT PHARMACIST DECEMBER 2015 VOL. 30, NO. 12, 692


Evidence: errors during

transitions from hospital to LTC

TESS

99 y.o. CHF & BP ~ 90/50 since transfer 2

months ago

Admitted on Amlodipine 20mg daily instead of

hospital discharge order of "Amlodipine 5 mg po

once daily" ( transcription error)

After med review, dose corrected to 5 mg daily

and blood pressure returned to normal. Resident feeling less dizziness and no nausea.

Prevented potential hospitalization or fall due to hypotension


Evidence: multiple sources of medication

history will reveal important discrepancies

Helen

Multiple transfers

Many ER visits

Incomplete records/sources:

COPD diagnosis not consistent on all sources and no medication for COPD

Glaucoma missed as a medical condition and no eye drops in 2 years


Evidence: interview with patient

or family is essential

William

Clarified his bag of white powder is Splenda because he has diabetes

Discovered he had Tamiflu in hospital – not on any documents

Hospital inventory stocked short acting version of his long acting drug – dose discrepancy later discovered when pharmacist viewed vial from home- dose “lost in translation” during transfer


Evidence: information in the right

place at the right time is essential

Glenn

No medications prior to hospital hip surgery

Admission medications included Fragminpost op and pain medication prn

After MedRec completed with inter-professional discussion “trio call”, hospital Rx for ASA discovered on another floor of LTC home for Glenn and the process had to be redone


Step 1: Coordinating a

Cross Sectoral Team

Obtain support from executive sponsors

Align the stakeholders with the common goal

“Kick off “ the BOOMR method holding a face to

face meeting with all stakeholders to deliver

“model of improvement” and begin positive

relationships

i.e. patients, family, physicians, discharge

planners, CCAC case managers,

pharmacists, nurses, care coordinators, LHIN

representatives


BOOMR

“Model of Improvement”

1. What did we try to accomplish?

Avoid drug related problems to reduce hospital

admissions and improve resident experience

2. Show evidence of the problem with a story

Mary’s Story of 27 medications

3. What will change, how will you measure

improvements?

Workflow efficiencies, communication, quality of

RAI-HC assessments, patient satisfaction

Measure with a modified ISMP quality audit,

satisfaction surveys, time studies


Step 2: Change the Medication

Reconciliation Process

Innovation Start MedRec process on bed acceptance day (48 hours ahead of

admission)

Highly adoptable improvements for BPMH Hospital staff utilize discharge checklist to ensure nurse receives

all essential information

CCAC added previous pharmacy to RAI-HC section Q

Pharmacist interviews patient / family remotely

Increase Value in communications CCAC included reason drug was used if possible

Trio Call = Collaboration of professionals (physician/nurse/

pharmacist) with one phone call – stops wasting everyone’s

valueabe time


Step 3: State your AIM and

Measure your results

Pilot Aim: by June 2015, improve quality of

MedRec by 50%, avoid hospital visits due to

medication and improve the patient

experience during transition of care into the

LTC home


Changes Ideas into action

PDSA (Plan, Do, Study, Act) Change Ideas

PDSA#1 Initiate MedRec on bed acceptance

day (48 hrs) before admission

PDSA#2 Change quantity and quality of

communicated parts of RAI-HC to LTC

pharmacy

PDSA#3 Initiate remote pharmacist/resident

interview

PDSA#4 Implement inter professional

communications “Trio Call”


Family of Measures:

Outcome, Process, Balancing

Outcome measures - resident testimonials

Percentage of resident/family satisfaction with

medication increased from 57% to 83%

“The families/residents seem more relaxed on admission day, knowing

that they have already had a conversation with the pharmacist and if

they had any concerns they have had their questions

answered……fantastic collaborative process with one thing in

mind…..the Resident ”

Lori A. DOC


Family of Measures:


Resident/Family satisfaction

• Patient quote: “ I was pleasantly surprised…..the pharmacist

already knew about my medications…. everything was already

there”.

• Family quote “Impressed to see the interest in mom’s

medications before we moved in so everything is ready when we

get there”.


Family of Measures:


Clinician/Staff satisfaction

Staff quote: “ saved me time when the admission is so organized

ahead of time”.

LTC Pharmacist quote: “This method saves time waiting for

information. We are not rushed, avoid mistakes and are able to

discuss our clinical concerns directly with the nurse and

physician… much better”.

Physician quote: “It works so well, why did we not do it this way

before?”.


Results/Impact

Process Measure

0

1

2

3

4

5

6

7

8

9

10

01

/12

/20

14

07

/12

/20

14

13

/12

/20

14

19

/12

/20

14

25

/12

/20

14

31

/12

/20

14

06

/01

/20

15

12

/01

/20

15

18

/01

/20

15

24

/01

/20

15

30

/01

/20

15

05

/02

/20

15

11

/02

/20

15

17

/02

/20

15

23

/02

/20

15

01

/03

/20

15

07

/03

/20

15

13

/03

/20

15

19

/03

/20

15

25

/03

/20

15

31

/03

/20

15

06

/04

/20

15

12

/04

/20

15

18

/04

/20

15

24

/04

/20

15

30

/04

/20

15

06

/05

/20

15

12

/05

/20

15

18

/05

/20

15

24

/05

/20

15

30

/05

/20

15

05

/06

/20

15

11

/06

/20

15

17

/06

/20

15

23

/06

/20

15

29

/06

/20

15

05

/07

/20

15

11

/07

/20

15

17

/07

/20

15

23

/07

/20

15

29

/07

/20

15

04

/08

/20

15

10

/08

/20

15

Mo

dif

ied

Qu

alit

y sc

ore

Modified Quality Score of Joint Med Rec Process

Modified Quality Score Median Target (Perfect Score)

Kick off

HTE team building workshop

3 way call & resident dialogue

Review of Process map

Meeting with CCAC

Reduced waste of documents sourced from CCAC


Discrepancies and Clinical Concerns

0

2

4

6

8

10

12

Discrepancies and Clinical Concerns Identified ThroughJoint Med Rec Process

# discrepancies # clinical concerns

Pre-BOOMR: ‘You don’t know what you don’t know’ BOOMR intervention: More discrepancies are being detected and clinical concerns are being resolved to avoid drug related problems leading to potential hospital visits


Results/Impact

Clinical Outcomes

No hospital visits (ER or Admissions)

Reduction in polypharmacy - reduction in potential falls

Patient Experience

More satisfied with knowledge about medication (57% to 83%)

More satisfied with the admission experience

Efficiency, Productivity, Effectiveness

5 - types of LEAN waste reduced - workflow more efficient and staff

more productive (saved 1 hour of nursing, 30 min of MD time)

Effectiveness improved staff relationships

Economic Analysis or Cost Effectiveness

Polypharmacy reduction with pharmacist intervention resulted in

drug cost savings of $1000 per patient

Hospital admission charges avoided


Learnings from BOOMRFive types of waste reduced

Type of Waste Brief Description BOOMR waste reduction

defects time spent doing something incorrectly –time to list mediation for transfer that is not useful for next health professional

HPG and hospital discharge sent directly to pharmacist –trio call to discuss

overproduction Doing more than what is needed by the patient – more than one BPMH interview

Med history collected before dialogue with patient

waiting Waiting for the next event to occur –waiting for resident information or a call to complete MedRec and process orders

Start med history collection 48 hrs ahead, consistent info communicated

over processing Work not valued by patient or aligned with their needs – time spent on health profession calls back and forth and/or med incident analysis and reporting

time spent triaging medication at front end ELIMINATED MED ERRORS in project- NO HOSPITAL VISITS

human potential

Waste and loss due to not engaging patients/ residents or staff, listening to their concerns/ideas

Face to face meetings –engaged resident/staff toproduce better discharge plan


CCAC Experience


Pivotal Moments for CCAC

Quality Improvement Tools

Fishbone Diagram – shows cause and effect

Identifies to the team what the issues are and

how it is effecting the success of the project

Awareness that CCAC assessments affect the

next sector’s work and ultimately the patient

Process Map –complete current process, add

change ideas and then consider the

resident/patient centered process map


Pivotal Moments for CCAC

Quality Improvement Tools

Adaptive Leadership

Know when to turn up or down the pressure of

change

Do not dwell on the fact that not all stakeholders are

engaged – they will engage when the time is right for

them

Team Effectiveness

Have clear vision of the goal

Working together and listening to each other’s needs

leads to decreasing waste in the system


Potential Barriers at CCAC

Not the right time for the organization to change

assessment or MedRec process

Not a priority to focus on medications or MedRec

Staff not included at the beginning

Coordinating priorities for success


Lessons Learned in CCAC

Be mindful of who is receiving your assessment

and how it will be used- your reputation is at

stake

Next sector needs completeness and accuracy

of RAI-HC to make the best decisions for the

patient’s safety – reasons for changes in drugs,

health status, functioning status

Have the will to discard traditional roles - Stay

focused on the patient and not our disciplines


Lessons Learned at CCAC

Involve everyone in the early planning of change

and continue with follow up communications

Coordinating dates and times for system

efficiencies

Collaboration will help get the right information at

the right time (i.e. “previous pharmacy” info

added by CCAC to the RAI-HC section Q)


Lessons Learned at CCAC

Improved relationships and respect resulted from

listening to needs and lending a hand - saying

“yes” instead of “no”

Improved Trust

Will drive improved experience


Long Term Care Experience


Background LTC Experience

Previous Thinking:

MedRec to be started after resident is admitted to

LTC/ Residential home

Lack of trust in information from other sources

Resident and family had passive role in MedRec

Late admissions. Everyone in a crunch to get

MedRec done


Lessons Learned in LTC Community

Aligned with CCAC goals to unclog the system

Improved communication and ultimately

improved trust with CCAC

Start the MedRec transition process on bed

acceptance day

Critical thinking and alignment allowed BOOMR

method to become an everyday process and not

a task


LTC Community Pharmacy Experience


Background of MedRec in LTC

Pharmacy

Original Med list sources not available

Reasons for discontinuation or change of a drug

not always explained

Currently complete MedRec in paper version

No access to CCAC Health Partner Gateway

website

No access to Drug Profile Viewer like acute care


Pivotal Moments in LTC Pharmacy

Before admission day, the pharmacist given the history of patient

and medication information

Pharmacist interviews the patient or family about the medication

history

Pharmacist has opportunity to focus on the resident directly and

discover clinical concerns

Trio call provides the pharmacist the opportunity to discuss

medication concerns with nurse and physician


Overall Learning

BOOMR method drives better clinical outcomes

and resident satisfaction – “not just a drug list”

Achieving this system-wide change requires

sectors and organizations to simultaneously

prioritize Medication Reconciliation for quality

improvement


We need listen to each other and the

patient/resident to realize improvement

QI tools ( i.e. PDSA, Fishbone diagram and

Process Map) useful for momentum and clarity

Crossing Sectors needs face to face interaction

and teamwork (relationships are key!)

The project needs a leader/“owner” to be the

catalyst however the credit belongs to the team

Overall Learning

www.ideasontario.ca

Kimberley Floyd, Director, Patient Care Services

Vijeetha Raviraj, Rehabilitation Services Lead

Melanie Seeds, Rehabilitation Services Coordinator

A Continuum of Integrated Care for Seniors –

Model of Success for Sustainable Care within

Physiotherapy Reform

CW CCAC

Context

• The Ministry of Health and Long-Term Care launched an initiative to

reform PT services

• As of August 1, 2013, CCACs are the single points of access for all

publicly funded in-home physiotherapy services

• In the Central West CCAC, the expansion of in-home physiotherapy is

one part of a broader strategy, that includes exercise and falls

prevention classes as the lead provider for all 149 classes across the

LHIN

Overall Vision:

To Develop a Sustainable Model of Physiotherapy

and Exercise & Falls Prevention Program

in the Central West Region

Execution of PT Reform in

Central West CCAC

Allowing for continuity of care

between in-home physiotherapy and

exercise and falls prevention with

CCAC implementing and

overseeing both streams

Developing a flexible, streamlined

and innovative delivery model that

blends exercise and falls prevention

classes to optimize available

resources and maximize outreach to

seniors.

Benefits of Program

• Seniors are navigated to appropriate

health services by leveraging existing

system structure of CCAC

• Utilize centralized function to

implementation and navigation that

ensures efficiencies and better quality

in providing services and monitoring

of service providers

• One stop source of information for

program options for seniors and other

stakeholders

Central West CCAC

Video with our Seniors

PT Continuum of Care:

https://www.youtube.com/watch?v=wflcBuMNLP4

https://www.youtube.com/watch?v=wflcBuMNLP4

A Continuum of Integrated

Care for Seniors

• Safe and effective transition between PT Streams; and more broadly,

between 1:1 therapy and group exercise

• Timely access to service along the care continuum

• Opportunity to identify and address system gaps

• Continuum of care that supports integrative practice and early identification

of senior care needs

• Care offered close to home in neighbourhood locations

In-Home Physiotherapy Services

• All CCACs received funding to offer increased 1:1

PT services

• Eligibility Criteria

• PT/PTA model of care

• PT Streams & Goals

– Stream 1: Improve and Rehabilitate to Independent

Function

– Stream 2: Assess and Restore to Optimal Function

– Stream 3: Maintain and Prevent Decline in Function

• Equitable access to 1:1 PT services across CW

LHIN

Exercise and Falls

Prevention Classes

• The Central West CCAC coordinates

publically-funded exercise and falls

prevention classes to support seniors

• Eligibility Criteria

• Program Goals

• Equitable access - All classes are

replicated in congregate and community

settings including specialized classes

sensitive to community needs

Full Continuum of Care

Exercise and Falls

Prevention

System Navigation

1:1 Physiotherapy

High Intensity

Specialized COPD & Stroke

Small Group Therapy

Intermediate IntensityMAINTENANCE to Prevent Decline: Stream 3

RESTORE to Optimal: Stream 2

IMPROVE to Independence: Stream 1

Other Community LinkingOHIP-funded Clinics

Sit Fit / Low Intensity

Current State

• Fully implemented – 149 classes across

CW CCAC

– Increased accessibility to senior’s wellness

programming

• Utilization of PTs and PTAs in service

delivery

– Opportunities to support best practices

– Maximize scope of practice

• Fostering new and existing partnerships

• Patient experience focus on specialized

programming

North Etobicoke-West

Woodbridge-Malton

Neighbourhood

Bolton-Caledon and

Dufferin Neighbourhoods

Brampton and Bramalea

Neighbourhoods

Concept of Specialized

Classes

• COPD Quality Based Procedures

– Transitions priority with our acute care partners

– Focus on leveraging evidence based practice for COPD

care

– Creating a link between hospital and community to

maintain functioning and prevent readmissions

• Needs of the Stroke Survivor

– Partner with the West GTA Stroke Network

– Collaborative development and ongoing education

incorporating stroke best practice experts

– Targeting the commonly house-bound stroke

population

Multiple PDSA Cycle “Ramps”

Develop

routine

practices/

standardize

Design

systems

to avoid

mistakes

Improve work

design

Change Concepts

Engage the healthcare

provider/ resident/family

Multiple PDSA Cycle to

Implement Specialized Classes

Develop

routine

practices/

standardize

Design

systems

to avoid

mistakes

Improve work

design

Engage the

healthcare

provider/

resident/family

Patient Engagement Form PT Assessment Form

Stroke COPD

Specialized Programs

Our Values

• Patient at the centre of care

• Enhanced communication and increased trust among partners

• Different sectors working together in collaboration with a focus on the

patient

• Focus on quality highlighting HQO quality improvement tools

• Designated one-stop system navigation and patient interaction through

dedicated physiotherapy hotline

– Offers a direct link to physiotherapy and exercise/falls prevention (ExFP) options

available to seniors

– Enhanced system navigation

– Seamless transitions

– Ease of referral from outpatient, primary care and patient/family

Patient-Centered Care

Patient communication material to bring awareness to program

options:


• Information & Registration Sessions

– Organized by CW neighbourhood

– Individualized, includes PT ax and CC connection/navigation

– Outcome measures to revaluate patients

– Demonstration of improvement

• Program Design to Support Local Neighbourhoods

– Health Equity Lens

– Co-design specialized programs with patient and caregiver input and

ongoing feedback


• Consistent service provider fosters trusting Patient-Provider relationships

– Overseeing PT assesses patient before the program

– Monitoring of participants to ensure appropriate PT intervention

• Dedicated team wrapped within congregate settings to support efficient

process

– Mini screening assessments

– Falls prevention committees

– Communication binder

Enhanced Communication

• Integrated Care Planning

– Platform to work closely with RH/AL staff

– Problem solving together

– Concurrent with Falls Prevention Committee

– All care providers involved in discussion

– Community Partner Referral Form

• Role of the Rehabilitation Services Coordinator

– Link between seniors, SPOs, community partners and internal CCAC staff

– System navigation and I&R

Enhanced Communication

Community Partners

Referral Form

• Community Partnerships

– Unique partnership with Parks & Recreational Departments, Health and

Transportation

– Bringing isolated seniors into recreational facilities

• Regional Partnerships

– Adult Day Services (ADS)

– Supportive Housing in Peel (SHIP)

– Assisted Living (AL) building (e.g. Dufferin County Supportive Housing, Canes

Community Care, Peel Senior Link)

Cross-Sectoral

Collaboration

• Health Partnerships

– West GTA Stroke Network

– WOHS Pulmonary Rehab Program

– Telehomecare

– Family Health Teams

– Community Health Centres

– Alzheimer Society

– Self-Management Program

– Acute Care

– In- and Out-Patient Rehab

Cross-Sectoral Collaboration

Just Some of Our

Partners…

• Co-designing specialized programs with physiotherapy clinical practice

leads

• Patient experience embedded in program design

– Patient engagement survey for specialized programs

– Patient card and hand-outs

– Participation of Team Lead, Care Coordinator and Rapid Response Nurse during

intake and assessment

• Risk reporting system to track trends and mitigate future risks

• Consistent reporting to CCAC by SPOs

Focus on Quality

• Low Attrition Rates

>90% retention rate

<10% patient drop-out

• Designated Physiotherapy Hotline

1000+ inbound and outbound calls monthly

200% increase since implementation of this point of contact in 2013

• Patient Satisfaction Surveys

Putting results into practice

Focus on Quality

Patient Experience Survey

Most Significant Improvements Reported

Client-Reported Goals of Exercise/Falls

Prevention Program

0%

10%

20%

30%

40%

50%

60%

70%

80% 73%68%

60%

45%

36%

27%

0% 20% 40% 60% 80% 100%

Increase stength andendurance

Prevent falls

Improve balance

Maintain independence

Meet other seniors or socialize

95%

91%

86%

55%

50%

What Worked Well

• Strong Communication

• Fostering Relationships

• Truly Collaborative Planning / Early Engagement

• Commitment to Patient Engagement & Satisfaction

• Build Flexibility within Model for Organic Growth

• True System Navigation

• Proactive Model: Risk Mitigation from the Beginning

• Investment in Upstream, Health Promotion Approaches

• Demonstrating Value of Program using Common Metrics

• Having a Consistent Project Working Group with Consistent

Patient and Caregiver Representation

• Strengthening Resourcing and Team Capacity

• Team-based, Inter-professional Care Planning (Health Links)

• Build Ongoing Education Opportunities to Internal Staff

Keys to Success

Questions

-19 -

Director Patient Care Services:

Kimberley Floyd ([email protected])

Rehab Services Lead:

Vijeetha Raviraj ([email protected])

Rehab Services Co-ordinator:

Melanie Seeds ([email protected])

mailto:[email protected]



Overarching themes: Patient at the centre of care

Enhanced communication and increased trust among

partners

Different sectors working together in collaboration with

a focus on the patient

Focus on quality highlighting HQO quality improvement

tools

Date post:	14-Jun-2019
Category:	Documents
Upload:	lelien
View:	215 times
Download:	0 times

Improving Integration in the Continuum of Care: Valuable ... Presentations/TA03... · 13 Evidence:...

Documents