cfhi-fcass.ca
Improving Patient-centred Chronic Care through Collaboration
in Atlantic Canada
April 9, 2014
Jenn Verma, Sr. Director, Collaboration for Innovation & Improvement, CFHI (for Vickie Kaminski, President & CEO, Eastern Health, NL)
IHI-BMJ Forum
Atlantic Healthcare Collaboration for Innovation and Improvement in Chronic Disease
Charter signed by all health regions in Atlantic Canada
CFHI is a not-for-profit organization funded by the Government of Canada
No conflicts of interest to report 2
How can we close the gap, to make best practice, the common practice?
MIND THE GAP
>Healthcare
improvement
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• Healthcare spending: PacMan of provincial budgets (40% of public spending)
• New mantra: cost containment, waste reduction, efficiency gains, value for money
• Hospital care: dependency is high; difficult to enter & exit!
Multi-morbidityDiabetesMental HealthCOPD
*Self-managementSystem designDecision supportCommunity action
Newfoundland & Labrador
17 health regions + CFHI
4 provinces
10 Improvement projects
*Based on the Expanded Chronic Care Model5
*Halifax6
*Saint John
How can we reach young adults with mental illness and help them to thrive?
1.2 million Canadian youth have a mental illness
< 20% receive the care they need
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PEER 126 (Peers Engaged in Education & Recovery)
Age- & culturally appropriate programming
Upstream investment
Working at the edges of the system healthcare, social services, mental health & addictions
7Horizon Health team lead, Sue Haley-Lajoie
*Halifax8
*Gander/Grand Falls
How can we prioritize dignified, proactive chronic care and reduce reliance on hospital care?
12% of Ontarians with
COPD account for 1 in 4 ER and hospital visits
16 million (1 in 2)
Canadians have a chronic disease
49% of adults 65-79 years
of age and 59% of adults 80 years and older report having at least two chronic diseases
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>60% fewer ER visits, hospital admissions and days in hospital
$900,000 in indirect ‘cost-savings’
Patients at end-of-life had lower LOS & were more prepared (advance care plans)
INSPIRED COPD model of care
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Patient with Capital Health INSPIRED Medical Director, Dr. G. Rocker
INSPIRED-like COPD model of care
• Community outreach pilot with 3 patients complete
• 9-month adult ambulatory respiratory care pathway developed
60% of care maps/standard patient order sets developed
April 1st set to implement standard care maps & accept ambulatory referrals
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Central Health team lead,Valerie Pritchett (3rd from left)
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How can we deliver care that’s truly centred around the person and their family, not their disease(s)?
• Interdisciplinary care for people with diabetes & overlapping conditions
• Program for advanced COPD patients
• Free community-based program for wellness & risk factor management
• Interdisciplinary care for people with complex, medically unexplained & multiple conditions
Integrated Chronic
Care ServiceCommunity Health Teams
Diabetes Management
CentreINSPIRED COPD
Outreach
Capital Health team leads, Tara Sampalli and Lynn Edwards
Prince Edward Island
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1 in 7 has a high-impact, high-prevalence chronic illness
Self-management support provided by a trained health professional can ↓ healthcare use and ↑ health status
How can we deliver care that’s truly centred around the person and their family, not their disease(s)?
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Supporting Realistic Behaviour Change
• 10 community providers developing new skills to help patients
• 14 facilitators teaching providers these skills
• 4.8, 3.99, 4.76 scores (out of 5) for provider changes in attitude, use of new skills and training• Increased confidence in delivering
new skills (14-point improvement)
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Health PEI team lead,Donna MacAusland (3rd from left)
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“meeting with our academic mentor and improvement coach has proven invaluable. The
amount of knowledge transfer, on the spot decision-making and the ability to get things
done…has given us great ability to move things.”16
cfhi-fcass.ca
June 9-10, 2014St. John’s, NL
Workshop on the Rock
Contact:Jennifer Verma, Senior Director, Collaboration for Innovation and Improvement, CFHI T: 613-728-2238 (x.348) C: [email protected]
@CFHI_FCASS 17
