The Importance of Care Coordination: The Partnerships

Transcription

1 The Importance of Care Coordination: The Partnerships Partnerships for Health for Health Experience A Chronic Disease Prevention and Management Demonstration Project Mike Hindmarsh: Project Leadership Team

2 Background Funded by Ministry of Finance Strengthening Our Partnerships program In partnership with MOHLTC Sponsored by the South West LHIN

3 The Goal Integrate t the component parts of the health care system by sharing information across the continuum of care, advancing primary care partnerships and linkages to tertiary care, engaging the patient in selfcare and enabling improved information management

4 In other words. Building teams family physicians, home care, community health providers, specialists within primary care and across organizations to take an integrated approach to the prevention and management of chronic disease High need Moderate need Keeping people at the base of the pyramid! Low need

5 Why Bother? Patient populations are aging and becoming more complex Transitions in care are discontinuous and leading to more and more mistakes Patients are tired of repeating their stories and feeling like they have to manage OUR broken system Providers are increasingly frustrated by poor communication processes across care settings Patient outcomes are bad, but we can do better!

6 Project Participants Twelve primary care practices + ~100 + South West CCAC Diabetes Educators Mental Health teams Community providers Physician specialists Thames Valley Family Practice Research Unit South West LHIN Team composition varies according to patient t need, patient load, organizational constraints, resources, clinical setting, and professional skills.

7 A Recipe for Improving Outcomes Evidence-based Clinical Change Concepts and Care Coordination Ideas Model for Improvement What are we trying to accomplish? How will we know that a change is an improvement? What change can we make that will result in improvement? Act Study Plan Do QI strategy Ontario CDPM Framework System change strategy 1. Learning Collaboratives 2. Knowledge Transfer Days 3. Web-based Tutorials 4. Self-directed (all receive Practice Coaching) Learning Modalities

8 Ontario s Chronic Disease Prevention and Management Framework INDIVIDUALS AND FAMILIES Supportive Environments Healthy Public Policy Personal Skills & Self- Management Support HEALTH CARE ORGANIZATIONS Information Systems Community Action Delivery System Design Provider Decision Support Productive interactions and relationships Activated communities & prepared, proactive community partners Informed, activated individuals & families Prepared, proactive practice teams Improved clinical, functional and population health outcomes

9 Model for Improvement Three Questions Model for Improvement What are we trying to accomplish? What are we trying to accomplish? How will we know that a change is an improvement? How will we know that a change is an improvement? What changes can we make that will result in improvement? What change can we make that will result in improvement? Act Plan Study Do

10 Four Learning Modalities 1. Spread Collaborative 3. Web-based Learning 2. Knowledge Transfer 4. Coaching only Outcomes Congress

11 Progress to Date Improvements in care processes increased foot, eye and renal screening increases in patients setting self care goals A1C and lipid testing. Improvements in business processes Flow mapped Changes tested and implemented Moving toward right work by right team member

12 % of Patients with Documented Foot Exam in last 12 months Oct-08 Nov-08 Dec-08 Jan-09 Feb-09 Mar-09 Apr-09 May-09 Jun-09 Jul-09 Aug-09 Sep-09 Oct-09 Note: Default goal line is depicted

13 % of patients screened for microalb in last 12 months Oct- Nov- Dec- Jan- Feb- Mar- Apr- May- Jun- Jul- Aug Sep- Oct Note: Default goal line is depicted

14 % of patients with 1 HbA1c in last six months Oct-08 Nov-08 Dec-08 Jan-09 Feb-09 Mar-09 Apr-09 May-09 Jun-09 Jul-09 Aug-09 Sep-09 Oct-09 Note: Default goal line is depicted

15 % with Depression Screen in last 12 months Oct-08 Nov-08 Dec-08 Jan-09 Feb-09 Mar-09 Apr-09 May-09 Jun-09 Jul-09 Aug-09 Sep-09 Oct-09 Note: Default goal line is depicted

16 Care Coordination Progress to Date DEC RNs reviewing patients in common with their primary care partners Targeting education to patient needs Handling o-morbidities CCAC case managers are case conferencing with primary care Conducting home visits with at-risk patients On-site consultations Mental health social workers are treating depression in conjunction with primary care

17 Anticipated i t Long Term Outcomes Patients will experience highly coordinated care Less chaotic practice Role satisfaction physician can delegate with confidence Partnership sustainable Improved clinical outcomes / quality of life Improved patient tself-management Appropriate system utilization

18 What Current Participants Are Saying The best part.. is using the experience of many partners to improve outcomes. The initiative focuses on how to improve communication and teamwork We re not letting people fall through the cracks and in fact we are helping them manage better.

19 What Participants are Learning Organizing team Choose an area of practice for improvement (diabetes!) Obtain guidelines for care and determine measures to monitor improvement Collect baseline data identify gaps and opportunities Conduct planned care Experiment with self-management support Test changes small and fast and observe what happens! Move to other components of the CDPM

20 Learning (cont d) Start one patient at a time until processes are stable and efficient Create follow-up processes Monitor measures regularly Test changes small and fast and observe what happens! Move to other components of the CDPM

21 What does it take? Commitment tto improvement, make it a priority, it be prepared dto give up old activities Committed community partners wiling to work outside of siloes Patient centredness is hard, needs a lot of focus External facilitation support is helpful Strong physician leadership, and nurturing of all leaders is a must Step wise approach to chronic disease management concrete resources give each team member a role to support clinical care

22 Want more information? h Learn Collaborate Improve Care