VCH Home & Community Care Program (North Shore) October 15, 2014 Dine and Learn

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1 VCH Home & Community Care Program (North Shore) October 15, 2014 Dine and Learn

2 Home & Community Care on the NS Ministry of Health Policy Health Authorities shall deliver a publicly subsidized home health service Service Delivery Area within VCH: North & West Vancouver Covering geography from Lions Bay (including Bowen Island) across the North Shore to Deep Cove and up the Indian Arm

3 Home & Community Care on the NS (con t) Three Geographic Teams: South Team North/East Team West Team Based in three Community Health Centers: Parkgate CHC Bottom of Mt Seymour Central CHC Bottom of Lonsdale West CHC Bottom of 21 st St inside West Vanc Community Centre

4 Home & Community Care on the NS (con t) Teams comprised of: Registered Nurses Nurse Practitioner Physiotherapists Occupational Therapists Dieticians LTC Case Managers Home Support Supervisors LPN s Home Support Community Health Workers Administrative Support Staff Discharge Care Coordinators (LGH)

5 H&CC - Services Home Care Nursing Provided for Home Bound Clients Wound Care Home IV Therapy Continence Management Catheter Changes Medication Management Palliative Care On average visits / month

6 H&CC Services (con t) Occupational Therapy Assessments for: Safety Home Function Skin integrity Transfers Equipment

7 H&CC Service (con t) Physiotherapy Short term treatment for homebound clients only: Safety Assessments Mobility / Falls Risk Post Op Fractures Range of Motion Therapy

8 H&CC Services (con t) Dietician Short term treatment for home bound clients only: Swallowing Assessments Tube Feeds Nutritional Assessments Unintentional Weight Loss Assessments

9 H&CC Services (con t) Long Term Care Case Management Assessment for home support services Assessment for Assisted Living Assessment for LTC facility placement Admission to Adult Day Programming Financial Assessments/Rate Reduction Applications

10 H&CC Ambulatory Clinics Ambulatory Clinics 2 Locations West Vancouver West Van Community Center (main floor) 7 days per week North Vancouver Central Community Health Center (6 th floor) Monday to Friday Primary Setting for Community Nursing (default) Average 620 visits per month

11 NS Home Support Service is owned & operated by VCH on North Shore (Manager: Heidi Prinzing) 270 Community Health Workers (CHW s) Provide approximately 30,000 hours of care per month Focus is on promoting independence and allowing clients to remain in their own home Financial assessment conducted to determine cost for the service

12 NS Home Support (con t) Assessed for services by H&CC Team (mostly Case Managers) Supports offered: Personal care Continence management Respite care Medication management Nutritional support Safety & mobility support

13 Ready Response Team Pilot Project launched September 2013 Team of a Nurse Practitioner and 5 CHW s Response within hours Target Population At risk seniors experiencing short term illness Prevent an acute care admission and allow senior to remain at home Provide medical and home care on short notice in their own homes until stabilized or a maximum of 3 days

14 PARIS H&CC Electronic Health Record Primary Access Regional Information System

15 How do I access H&CC services?

16 Referral to H&CC H&CC Intake processes new referrals from Physician s and the community Contact us via phone / fax / Support available Mon Fri (08:00 17:00) Intake Clerk position added to the Intake Clinician Team last year to facilitate flow and communication

17 Intake - Phone One central number: Options to choose from: Option 1 returning a call Option 2 member of the public Option 3 physician s office or healthcare professional Option 3 is answered immediately by clerk (Vanessa) unless she is briefly away from her workstation or is engaged on the phone

18 Intake - Fax Fax number: Intake receives faxed referral Clerk date stamps received, creates a PARIS ID # and logs the referral Clerk faxes the referral back to the source, confirming receipt (outcome of a GP Focus Group)

19 Intake address: Referrals can be ed to this address Physicians/MOAs s clerk requesting an electronic version of referral form Physician completes the form and s form back to address above Intake Clerk will print off referral and replies via confirming receipt

20 Intake Referral Form

21 Intake Assessment/Eligibility Intake Clinician will complete an assessment of the client s needs to determine eligibility for H&CC supports The client s goals should be towards independence and self care where possible Family involvement is strongly encouraged Referrals are viewed through a philosophy of Home is Best

22 H&CC - Priority Guidelines Flowing from the the Clinician assessment, Priority Guidelines for Intervention based upon risk factors are attached to the referral: Priority 1A Priority 1B Priority 2 Priority 3 Priority 4 Priority 5 Within 12 hours (same day service) Within hours Within 48 hours Within 1 week Within 2 weeks Can occur after 2 weeks

23 Intake Service Confirmation

24 Intake Referral Assessment Outcome

25 Intake New Referrals (Jan Sept 2014) Faxed Referrals 821 Phone Referrals 374 ed Referrals 199 Total: 1394

26 H&CC Intake Referrals (Jan Sept 2014) 442, 32% 394, 28% LTC OT/PT 83, 6% RD HCN 475, 34%

27 Palliative Care Program on the NS

28 H&CC Palliative Care Program Spring 2014 Realignment of Palliative Care Program on the North Shore One programmatic structure under H&CC: 7 West (LGH) Hospice (14 th Street) Community (North & West Vancouver) Shift from acute care focus to community based focus Goal: manage and support palliative clients in the community rather than in the acute care system to increase # of supported good home deaths for clients

29 H&CC - Palliative Care Program Access to the Palliative Program: Would it surprise you if patient was no longer with us within one year? If yes make a referral to the Palliative Care Program Complete One Page Program Referral Form Fax to (Jane Jordan Program Assistant) Registered in Plexia Contact made by Coordinator, Palliative Care Navigation Patient opened and followed by Home & Community Care

30 H&CC Palliative Care Program

31 H&CC - Palliative Care Program Community: Community Team dedicated to supporting palliative clients to remain at home and to have a good home death (for those so desiring) Supported by GP s, PCOC s, Palliative Nurse Practitioner (coming late fall), RN s, Physiotherapists, Occupational Therapists & Dietitians, Home Support (CHW s) Average # of home deaths per month = 9

32 H&CC - Palliative Care Program Palliative Care Unit at LGH (7West): 12 beds (includes 1 community bed ) Short stay acute intervention for symptom & pain management Focus return patient to home/community with the appropriate supports established goals of care upon admission to unit RN / LPN staffing mix

33 H&CC - Palliative Care Program North Shore Hospice: Free standing - located at 319 East 14 th Opened November 2010 Built with capacity of 15 beds Currently 10 beds funded and operational End of life care within last 3 months RN/LPN/Care Aide staffing mix Average deaths / month = 15 Average Length of Stay = 11 days

34 Thank you.

35 VCH Regional Priorities Laurie Leith, Operations Director Coastal & Regional Director Home & Community Care

36 Regional HCC Program Executive Laura Case Chief Operating Officer Vancouver Community & Executive Sponsor Regional HCC Program Dr. Peter Edmunds Medical Director Regional HCC & Palliative Program Laurie Leith Regional Director HCC Program

37 VCH 14/15 Regional HCC Program Priorities Pay for Performance RAI homecare assessments. Goal 80% across VCH Home Health Redesign Community CST/PARIS upgrades Reduce Acute Care Demand*

38 VCH 14/15 Regional HCC Redesign Priorities GP Care Conferencing Telephonic Care Care Management Education Enhancements to our ambulatory care clinics

39 Ambulatory/Clinic Settings Telephonic Care VCH s HCC Redesign Goals GP Care Conferencing GP Office Home Visits Quality care is provided in the most appropriate setting. The client/family is educated, coached and supported to embrace self management at all levels of care. The clinician proactively connects with the client/family to ensure support for achieving the client s health goals and enabling independence. The clinician or the GP proactively schedules GP care conferences supporting an environment of collaboration. The HH team, Client/Family, GP and other health care agencies work in partnership with each other to deliver care. While balancing health, social & fiscal environments.

40 Three Key Strategies for Home Health Redesign GP Care Conferencing Telephonic Care Care Management education/training 40

41 North Shore GPCC Over 300 formal GPCCs have occurred since Oct North Shore was the first pilot site within VCH to trial GPCC. Currently in the sustainment phase of the initiative. Remember GPs can bill for this!

42 Telephonic Care What is it? A planned, proactive approach to support and monitor clients who have a stable chronic health condition over the telephone Driven by the client s goals of care Involves family/caregiver as defined by the client Involves coaching and educating of clients by phone Involves promoting client self-management Engages GPs & Home Health team to ensure inter-professional coordination Telephonic care is a competency not a role 44

43 Telephonic Care Populations of Focus Case managed (Maples 1 & 2) & stable wound clients who: have intact cognitive function can manage their chronic disease are not expected to deteriorate from their current health status have access to a telephone and able to use it have no barrier to communicate over the telephone (e.g. hearing, language, mobility) 45

44 North Shore Telephonic Care Began trialing telephonic care management in July The Home Health service stream of clients transferring over to telephonic are the Long Term Care case managed clients. In the process of including the palliative client stream, with PPS of over 60. Currently have one telephonic care nurse.

45 Questions for Discussion Do you believe there is an opportunity for GPs to notify HCC services of frail >80yrs clients appropriate for telephonic care? How else can we reduce acute care demand? Why do you think patients are coming to ED? What community services are we lacking?

46 Accessing Residential Care in Vancouver Coastal Health Deborah Lorimer, Director - Seniors October 15,

47 Access Process First appropriate bed Factors Urgency Individual care needs Preferred location Vacancies

48 Making the Transition Transitions into Residential Care come from many places. Priority Access is the referral center. Communit y Priority Access Receives Referral for RC Acute Other Community Emergencies: Highest priority Acute other Hospitals within VCH RC placement from Community within 1 month

49 Residential Transitions

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