Julie Kille, Operations LeaderBrynn Grierson, MSN, Clinical Nurse Leader

Dr. Sarah Stone, IDC PhysicianElizabeth Barrett, Administration Coordinator

Neil Fowler, Program Assistant

What we’ve been working on:

Case management (CM)

Patient Advisory Group

Addictions Group

CM restructuringRestructure of CM team with more defined roles

for each team memberComplexity score created

CM form and database changed to include complexity score

Indicators Unstable In transition Stable

Housing/Food/Income □ 0 □1 □ 2

Addictions & Mental

Health□ 0 □1 □ 2

Engagement &

Adherence□ 0 □1 □ 2

Medical Complexity □ 0 □1 □ 2

Score:_______________

CM Restructuring: Why?IDC team retreat

Evolving mandate of clinic to see patients with higher levels of medical and psychosocial complexity

Creation of complexity score gave us an idea of overall complexity of IDC patients

CM Restructuring: How?After the IDC retreat we realized we need more

than anecdotal/qualitative measures to evaluate CM and complexity of patients at the IDC

STOP evaluators shared with us the indicators used by the STOP outreach team.

THANKS!!

Modified these indicators to suit our needs

CM Restructuring: QIBeing able to quantify and measure CM. Not

just staff and patient reports

Helps determine patient care plan

Ensures appropriate team members are involved in patients care

Other changes/new initiativesRestructuring of Patient Advisory Group

New time and new location (at clinic)More frequent meetingsLess formal settingFood available

Changes made to increase patient engagement and patient voice

Creation of Addictions GroupDuring addiction clinic hoursLow barrier group (new members always

welcome)Support, education, and treatment options

provided by interdisciplinary teamFood available

Group created to increase engagement of our most marginalized addiction patients and to

offer alternative support and treatment options.

Other changes/new initiatives

Lessons LearnedBe creative when

developing evaluation measures

Importance of ongoing evaluation of own process (current process, groups etc). We now have the tools to do it!!

Importance of engagement and including patient perspective

We are not afraid of change!