The Transformational Role of Case Management in Community Health Care. Caroline Brereton, RN, MBA Chief Executive Officer Mississauga Halton CCAC

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1 The Transformational Role of Case Management in Community Health Care Caroline Brereton, RN, MBA Chief Executive Officer Mississauga Halton CCAC September 26-27, 2013

2 Agenda During this session we will: Describe the changing needs and increased demands in Mississauga Halton region and our CCAC Explain rationale for standardizing case management processes Current situation with our patient, Karl Provide overview of our approach to changing key case management processes Guiding principles Three core business processes to enable case managers to provide consistently excellent care to patients and their families Identify expected outcomes for system improvement and patient outcomes The ideal patient experience for our patient, Karl Next steps Questions 2

3 Mississauga Halton Region Demographics of Mississauga Halton region Region experienced Ontario s highest growth rate in population (12%) from 2006 to 2011 The population is expected to grow 46% over the next 15 years Second fastest aging population Over the next 20 years, the number of people over 65 years of age will increase at a rate that is the second greatest in Ontario The number of people aged 75 years and older will increase 143.4% by the year

4 Mississauga Halton Region Health conditions in Mississauga Halton region Six of all 10 deaths in region are caused by chronic conditions, including: Heart disease High blood pressure Diabetes Asthma Over past four years, emergency department visits in region s hospitals increased 13.4% compared to 6.4% for Ontario 4

5 Mississauga Halton CCAC Patient Demographics Mississauga Halton CCAC Supported 41,172 patients in 2012/13 Year-over-year increase of 5.3% 2,437,224 care service visits Year-over-year increase of 14% more services to meet 5.3% growth Increased services and more case management involvement required to keep patients safe at home Complexity of patients health care needs is changing Year-over-year growth in patients on Wait at Home to long-term care program increased 36% (high-need patients) Year-over-year growth in patients on Wait at Home Enhanced program increased 10.5% (high-need patients)

6 Core Business Redesign Why Core Business Redesign? Growing and changing needs of our patients Emerging technologies enabling improvements to our processes and systems Our evolving role in building a sustainable health system Our committed pursuit to continuously improving how we deliver our care to our patients and their families 6

7 Core Business Redesign Strategic Plan Priority Initiative Supports Client Care Model: Specific accountabilities and standards of care for case managers varies by patient population 1. Complex 2. Chronic 3. Recovery out of hospital (Short Stay) 4. Community independence Patient Populations are defined along the following dimensions: Health conditions Socioeconomic factors Degree of independence Acute episodes (risk, intensity, duration) Clinical judgment of intensity to optimize patient outcomes 7

8 Imperative for Change Situation: Karl in hospital recovering but will need rehabilitation and support to live independently Karl, 85, stroke patient in hospital Son Ben is his only relative in Canada Current state: Intake and assessment processes challenging for case manager Betty Betty was not involved in intake at admission Information was received too late and incomplete to facilitate smooth and safe transition Repeated steps Karl is confused Son Ben is frustrated 8

9 Core Business Redesign Think about the end before the beginning. Leonardo da Vinci We explored a vision of our patient's experiences Given this vision, what core business processes are required? Building on foundation of national case management standards and scope of practice, we: Completed a current state assessment that defines the core business, from patient referral to discharge from service Identified a detailed design for three priority business processes, including implementation plans and metrics 9

10 Guiding Principles Principle Metric Patient-centric Improved patient/family satisfaction scores (perceived improvement in care delivery, degree and utility of choice, ease of navigation, seamless transitions) Safe Reduced avoidable ED visits Reduced re-admission rates (overall and by discharge destination) Effective Reduced costs Timely Reduced wait times between assessment to initial setup and delivery of services Dynamic Improved ability to respond to changing conditions Efficient Reduced time from referral to initial home visit/ assessment/care planning (by discharge destination/ service type) Reduced internal transfers between case managers Equitable Improved access to services 10

11 Core Business Redesign Getting started: Comprehensive interviews with case managers, patients and family members, partners and stakeholders Leading practice review Data analysis CCAC best practice review Value-stream mapping sessions 11

12 Case Manager Voices My vision for the future is simplicity - reduced number of layers and manual processes. Use our technology more effectively to streamline and simplify. We have no formal processes to support patients to navigate complicated systems. A case manager can spend much time helping someone on the phone looking for a particular service, but the experience may be as good as the case manager s knowledge and experience, rather than a consistent approach. 12

13 Patient/Family Caregiver Voices Multiple assessment points with multiple case managers involved retelling storyfrustrating and confusing for patients and their families. One patient explained how she had five case managers in the past three months! Inconsistency of practice followed by CCAC case managers resulting in perceived inequity in services which can lead to complaints. Inconsistency between jurisdictions for example, MH CCAC may provide different service allocations than a sister CCAC. Perception from families about the type and quality of care depends on how loud you scream/advocacy of family member vs. what happens to isolated patients. 13

14 Core Business Redesign Selecting most impactful processes 1. Assessment at intake 2. Care planning and monitoring 3. System navigation at intake 14

15 Assessment at Intake Goal: Develop a highly efficient, patient centered intake process which sets up the right initial services the first time 15

16 Care Planning and Monitoring Goal: Improve consistency, timeliness and quality of information with service providers to better monitor patient health needs and allocation of services Establish a single work flow for monitoring patients health needs and allocating services 16

17 System Navigation at Intake Goal: Develop standard expectations and formalize Mississauga Halton CCAC s role in system navigation with the appropriate supporting processes 17

18 Ideal Patient Experience I am your Case Manager Access and transitions Acute Care integration and coordination Assessment and care planning Primary Care Long Term Care School/Other Transitions Well Short Stay Stay Community Independent Chronic Complex 18

19 Ideal Patient Experience Karl s ideal patient experience Access and transitions One assessment One case manager Patient directed Seamless transitions from hospital to home and care Assessment and care planning Set expectations Plan the right care at the right time Integrated and shared care/services plan Minimal wait times Patient directed Care integration and coordination Seamless transitions and integrated care Transitions Maintain Karl s quality of life Set expectations of discharge 19

20 Evolving Role of Case Management Role: Grounded in Canadian Standards of Practice for Case Management definition, we are evolving role of case managers to support the ideal patient experience Working definition of care coordination Access & Transitions Key functions: Patient-focused assessment and care planning Outcomes evaluation and management Care integration and coordination Central point of access to information for care team 20

21 Next Steps From planning to implementation: Develop comprehensive implementation plan for three business processes Collaborative and participatory, engaging the leaders who will be accountable for delivering and monitoring processes Collaborate with service providers and other partners Begin implementation November 2013 Evaluate and measure Share with other organizations Communicate with patients, stakeholders and partners 21

22 Questions? 22

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