Integrated Comprehensive Care Bundled Care

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1 Integrated Comprehensive Care Bundled Care Health Council of Canada National Symposium on Integrated Care Oct 10, 2012 C. Gosse, K. Ciavarella

2 St. Joseph s Health System SJHS is one of Canada s largest healthcare corporations, and one of Canada s longest running, having been founded in 1890 by the Sisters of St. Joseph of Hamilton. SJHS is composed of St. Joseph s Lifecare Centre (Brantford) St. Joseph s Villa (Dundas) St. Joseph s Healthcare Hamilton St. Joseph s Home Care (Hamilton) St. Joseph s Health Centre (Guelph) St. Mary s General Hospital (Kitchener) St. Joseph s International Outreach Program SJHS is focused on integration between the partner organizations to enhance continuum of care and to provide the best possible experience to those we serve.

3 Unique opportunity to demonstrate an alternate model of care The St. Joseph s Health System (SJHS) includes an Acute Teaching Hospital, Long Term Care Facilities and a Home Care provider in the same city Perfect setting to demonstrate and evaluate an alternate model of care. Better, Faster, Cheaper The SJHS has the governance, management and service delivery alignment to act as an early adopter of this approach. Local Health Integration Network (LHIN) support for this project

4 Current Model of Care in Ontario Challenges Hospital to community: Continuity of care for the patient is disrupted, increasing complications, readmissions, and costs. There are transfers of care that create communication risks and patient dissatisfaction. There are no fiscal incentives directly tied to outcomes, complications cations and readmissions. Duplication of information as patients transition between touch points.

5 Current state of care in the community Individual service providers don t have the opportunity to collaborate and leverage each other s expertise in caring for the patient The patient is asked to provide the same information multiple times There is no direct connection to the hospital team after discharge to the community All documentation of care provided in the home was kept in a paper chart, and in multiple locations

6 Alignment with Provincial Strategies Commission on the Reform of Ontario s Public Services 2012 Co ordination across a continuum of care Patient centered care System centered on patients, not institutions or providers Hospitals make discharge summaries available electronically to other care providers Improving access to care: remote communities Key Principles Simple for the patient Patient knows what will happen next Focus on what adds value to the patient Improve the patient experience

7 Project Objectives Demonstrate the benefits of integrated case management Opportunity to evolve the existing case management model into a patient centered model that follows the patient across the continuum of care Three patient groups with broad applicability in Ontario Total Joint Replacements (hip and knee) 500 patients/year Thoracic Surgery, Complex Pleural Space 320 patients/year Chronic Diseases (COPD, CHF) 120 patients/year Evaluate the impact Patient outcomes System concerns (quality, throughput, efficiency) Patient concerns (accessibility, continuity of care, satisfaction)

8 Integrated Care Coordinators Team of 4 Integrated Care Coordinators Variety of professional backgrounds Directly coordinate the care of the patient through both their acute care and community care pathway Expertly trigger interventions from both the hospital and community prevent readmissions complications Streamline the integrated continuum of care removing redundancies from the care of their patients improving the overall efficiency of case management and care delivery Navigate the Health System WITH the patient

9 Model: Total Joint Replacement Integrated Care Coordinator

10 Program Evaluation Methods Map existing model of care Independent evaluation by the Program for Assessment of Technology in Healthcare (PATH) Outcome measures Clinical outcomes: length of stay, readmissions, ER visits Continuity of care Economic model Benefits quantified in terms of costs Patient and stakeholder satisfaction

11 Patient Satisfaction Domains 1. education and knowledge 2. interactions and communications 3. coordination, advance care planning and timeliness of care 4. access to care (availability) and convenience 5. support for patient preferences and family involvement 6. overall satisfaction

12 Patient Satisfaction Questionnaires Pre hospital In hospital Homecare Referral Admission Discharge 60 days Questionnaire 1 Pre hospital & Inpatient Care Questionnaire 2 Transition Home & Homecare

13 Value Stream Mapping Critical to establishing the current state Front line staff participation is key, encourage transparent and objective discussion Identify change ideas which break down barriers One integrated care path for each patient group (hospital to home) Patient value statement always at the core of decisions PDSA cycles for change ideas

14 Patient Value Statement "Please help me fully understand my health challenges so that I can make informed choices about my care. I would like timely care when it is necessary, in the most suitable location. I want to be clear about what will happen next so I can prepare properly and try to worry less. Help support my recovery at home."

15 Project Successes More efficient home visits: Reduce time to complete a home visit by 50% Minimize duplicate documentation, re work Critical patient information available electronically before discharge Medication reconciliation Physician home care orders Patient s course in hospital Key clinical issues requiring follow up in the community Care providers have electronic real time access to documentation from all care providers in the home Real time access to the Integrated Care Coordinator when an issue is identified

16 Preliminary Results Elective Hip and Knee Replacemement SJHH Jan-Mar 2012 Ontario Jan-Mar 2012 SJHH April-May 2012 Acute LOS Rehab referral rate 12.2% 12% 8.5% Thoracic Surgery Apr-Dec 2011 Mar-July 2012 SJHH Average Length of Stay Hay Benchmark (Canadian Academic Hospitals) 7.6

17 Other project successes Central contact number for patients Integrated Carepaths (hospital to home) Standard templates for clinical documentation Cross training/knowledge transfer Team integration Total Joint Replacement: Physiotherapy with 24 hours of discharge High patient satisfaction

18 Strategies to support electronic health record We leveraged the St. Joseph s Home Care information system, Procura, as the platform to establish the electronic health record Devices used by the care providers in the home to support real time, secured access to view and document in the patient health record Tracking tool that communicates all patient information to the home care team from the day of hospital admission

19 Orders Intake Form Documentation Other Service Providers Hospital Scanned Nurse Home Care Physiotherapist

20 Patient Experience 65 year old man who was referred to the ICC project directly from our regional Lung Diagnostic Assessment Clinic (LDAP) New diagnosis of lung cancer Integrated Care Coordinator (ICC) met with Mr SB before he came to the hospital for surgery. Immediately indentified additional supports that would be required when discharged back to the community Social work and occupational therapist consult was initiated by the ICC as soon as the patient arrived in hospital Home care supports immediately put in place prior to discharge: Home physiotherapy within 24 hours of discharge Occupational therapy home assessment Life Line initiated

21 The ICC Team

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