Patient Engagement: One Health Link s Perspective

Transcription

1 North East Toronto Health Link Patient Engagement: One Health Link s Perspective Presented by: Lisa Priest, Director, North East Toronto Health Link (NETHL) Stephanie Greco, Member, Patients Advisory Council, NETHL Bruno Geremia Co-chair, Patients Advisory Council, NETHL Walter Leahy, Liaison Care Coordinator, TC CCAC, NETHL Presented at: Longwoods Ways & Means Health Links Feb 26, 2015

2 North East Toronto Health Link

3 Levels of Engagement Direct Care Better Care System (Better Tracking and Triage for Equitable, Reliable Care) Governance Patients Advisory Council Policy Framework for Patient Engagement Continuum of Engagement Consultation Involvement Partnership and Shared Leadership Information Health Links patients Management System - identified in real-time Better Care - that Patients are enrolled develop the care plan identifies, tracks and and engaged with coordinators/ notifies Health Links simultaneously clinicians patients in real time Unmet needs of Health Links patients and their caregivers are brought to Patients Advisory Council Caregiver is co-chair of Patients Advisory Council and sits on NETHL Advisory Council Questions for program evaluation created by Patients Advisory Council; changes made based on results Conscience of Health Links talks Recommendations driven by patients Patient stories highlighting issues and system solutions Patient and caregiverdriven priorities Factors influencing engagement: Patient (beliefs about patient role, health literacy, education) Organization(policies and practices, culture) Society(social norms, regulations, policy) Adapted from: Carman, K., Dardess, P., Maurer, M., Sofaer, S., Adams, K., Bechtel, C., & Sweeney, J. (n.d.). Patient And Family Engagement: A Framework For Understanding The Elements And Developing Interventions And Policies. Health Affairs, 2013,

4 Direct Care: Health Link Better Care Program Initiation: Emergency Department BETTER (Better Tracking and Triage for Equitable Reliable) Care System 1) Identification & Reporting Identification by Classification Algorithm Display on System Report(s) 2) Notifications a) Initial Notification Notify NETHL Program/Care Coordinator c) Provider Notifications Notify Care Team (internal/external) PATIENT ENGAGEMENT & ENROLMENT PROCESS/OPERATIONS Patient is engaged in the ED by the TIP nurse or Sunnybrook staff or CCAC coordinator (if already in their care) that she/he qualifies for additional services as part of a Better Care system and that their primary care physician will be notified and they may opt of that service. We can then communicate risks to patients of opting out and request that family doctor be contacted about care planning without patient. Brochures will be mailed out to patient. NETHL Office is notified of Enrolment status. Should the Patient Opt Out, process ends, but will be revisited at future ED Visits. If patient not contacted while in ER ( time of day, weekend or staff not available) then patient will be contacted at home by one of the above to offer the program. Future Phases (Community Partners) Update Notification Settings 3) Administrative Functions If patient does not opt out, primary care physician is then notified by TIP nurse or NETHL office that the patient has been identified and that a Care Coordinator (where available) may be assigned or additional services may be available through NETHL partners. Assessment is scheduled through Care Coordinator/PCP. Assessment determines Care Team Requirements. Care Team augmented through referral request or consultation (via PCP/TC CCAC Care Coordinator). TC CCAC will contact patient in real-time NETHL is notified of additions to Care Team.

5 Better care patients Better Care System Frailty patients Better Care System - Identification of target population - Flagging - Notification ICCP patients ED Care Coordination

6 Quality Improvement: Health Quality Ontario

7 Patient Co-design NETHL s Patients Advisory Council Source: Smart Health Messaging

8 Health Links Program Evaluation Answers to questions developed by Patients Advisory Council Patient interviews, Feb. 20 th I thought [the Better Care] program was wonderful. They had asked me questions that hadn t been asked before My goal really is to get back on track- to have a normal day, I don t know what it is. It s been like that for the last 5, 3 months. It s a long time. There s somebody that needs the emergency service and it s not me

9 Stephanie Greco Member, Patients Advisory Council, North East Toronto Health Link Stephanie is a member of the Patients Advisory Council of the North East Toronto Health Link. She has been involved in co-designing a coordinated care plan, consulting on a patient workbook and helping guide questions for Health Links patients who are identified and provided care plans in real-time. Most recently, she created an All About Me patient card to help providers communicate better with patients. As someone who has interacted in the health care system since birth, she is expert in understanding the gaps that can occur. Through her work, she hopes to make the patient voice heard from the hospital to the community.

10 Life as a Patient with Complex Needs Patient since the day I was born Providers talking to family members, not me Asked the same question over Instead try: What should I know about you? What are your goals? How can I help?

11 All About Me

12 Bruno Geremia Co-chair, Patients Advisory Council North East Toronto Health Link Bruno is the co-chair of the Patients Advisory Council. In this capacity, he has led the group to co-design a care plan, enforced governance standards and insisted on transparency of information for patients and caregivers. He comes to this role with significant experience: as the father and a caregiver of a child now an adult - with complex medical issues, Bruno knows well the gaps that can occur from hospital to community and now, palliative care. Bruno has worked with community and hospital organizations to better integrate the family, patient and caregiver voice to the health care system. He has spent almost two decades in this role, working as a family leader at Holland Bloorview, cochairing the Family Advisory Committee from 2008 to 2012.

13 Walter Leahy Liaison Care Coordinator, TC CCAC, North East Toronto Health Link

14 Determinants of Health Social factors English is not first language Poor social supports Socially isolated Limited Mobility Patient Economic Factors Limited finances/ income Physical environment Lives in Toronto Supportive Housing

15 How We Worked Together with the Patient: Telemedicine IMPACT PLUS Nurse Women s SPRINT College ---- Supportive Hospital Virtual Ward Housing (Pain Clinic) Meals on Wheels Family Doctor TC CCAC Liaison Care Coordinator (most responsible provider) Core Care Team(approache s patient in Sunnybrook ED and initiates Care plan) Patient in the ED

16 Appreciation North East Toronto Health Link Patients Advisory Council Executive Lead: Malcolm Moffat, EVP Programs, Sunnybrook Medical Lead: Dr. Jocelyn Charles, Chief, Family & Community Medicine, Sunnybrook Administrative Lead: Lisa Priest, Director, NETHL (also leads patient engagement) NETHL Program Office: Linda Jones-Paul Kittie Pang Adwoa Rascanu Better Care Project Team Richard Mraz Navin Goocool Ashley Silver Ken Nwosu Anita Tang Mark Fu Kurt Rose, Director, Corporate Strategy & Information, Sunnybrook Jeff Curtis, Chief Privacy Officer, Sunnybrook Rebecca Morison, Legal Counsel, Sunnybrook Special thanks: Dr. Joshua Tepper NETHL Partners Anne Johnston Health Station Bellwoods Centres for Community Living Don Mills Family Health Team Flemingdon Health Centre Providence Healthcare Scarborough Academic Family Health Team Sunnybrook Academic Family Health Team Thorncliffe Neighbourhood Office Toronto Rehab Toronto Toronto Paramedic Services (EMS) TC-CCAC SPRINT Senior Care