Policy Guideline for Community Care Access Centre and Community Support Service Agency Collaborative Home and Community-Based Care Coordination, 2014

Transcription

1 Policy Guideline for Community Care Access Centre and Community Support Service Agency Collaborative Home and Community-Based Care Coordination, 2014 April, of 23

2 Policy Guideline for Community Care Access Centre and Community Support Service Agency Collaborative Home and Community-Based Care Coordination, 2014 Contents 1. Intent and Application of Policy Guideline Definitions Goals Target Population Legislative and Regulatory Requirements for Care Coordination for all Approved Agencies 6 6. Policy Standards for Home and Community-Based Care Coordination Home and Community-Based Care Coordination Model Lead Agency for Home and Community-Based Care Coordination Population Standards for Home and Community-Based Care Coordination Operational Standards: Service Quality Standards Implementation Guiding Principles Performance Metrics and Accountability Appendix 1: Leading Practice Synthesis I. Conceptual Model at the System Level II. Evidence-Based Care Coordination Standards III. Population-Based Home and Community-Based Care Coordination Practices IV. Evidence-Based Care Coordinator Functions V. Service Quality Standards Appendix 2: Examples of Collaborative Care Models in Early Development April, of 23

3 1. Intent and Application of Policy Guideline Aging and frail older adults are at a higher risk than other persons of increases in functional limitations and chronic illness that may lead to referral for placement to a Long-Term Care home. Ontario is committed to helping older adults stay healthy and live at home longer. Community Care Access Centres (CCACs) and Community Support Service (CSS) agencies will collaborate as one care sector to coordinate and optimize home and community care for older adults with frailty or long-term chronic conditions to support them in living safely and independently in the community. This Policy Guideline will enhance the capacity of CSS agencies to support older adults who are relatively independent and improve the ability of CCACs to focus on clients with complex and post-acute needs, thereby building on the strengths of the respective agencies. This Policy Guideline enables Local Health Integration Networks (LHINs) to implement the Policy Guideline Relating to the Delivery of Personal Support Services by Community Care Access Centres and Community Support Service Agencies, It also ensures that the coordination and delivery of home and community services is optimized to support broader health system goals. For CCACs, this Policy Guideline serves as a companion to the CCAC Client Services Policy Manual, specifically to Section 6.2.4, Service Co-ordination. 2. Definitions Approved Agency is an agency that is approved under the Home Care and Community Services Act, 1994 (HCCSA) to provide community services (professional services, personal support services, homemaking services or community support services). In this Policy Guideline, Approved Agency refers specifically to CCACs and CSS agencies. Care Plan sets out information about the overall set of services and activities being provided to meet the needs and goals of a client. It outlines how the different activities are organized and sequenced and identifies the specific roles and responsibilities of each formal and informal provider comprising the client s circle of care. For clients receiving home and community services from Approved Agencies, the Approved Agencies are responsible for developing the following components specific to home and community care as part of the client s Care Plan: i. Home and Community Care Coordination Plan is the personalized plan which details the client s health and social care needs and the full basket of home and community services to meet those needs. ii. Plan of Service is the plan developed or revised by each Approved Agency involved with the client that sets out the amount of services to be provided to a client pursuant to section 22 of the HCCSA. April, of 23

4 Home and Community-Based Care Coordination is a service that includes: The collaborative process of assessment, planning, facilitation and identification of options and services to meet a client's home and community care needs that is accomplished through appropriate communication across Approved Agencies and other relevant health care participants 1 ; and The deliberate organization of client care activities between two or more participants (including the client and their family) involved in a client s care to facilitate the appropriate delivery of home and community care services 2 and coordination of available resources to promote quality cost-effective outcomes. Home Care and Community Services Act, 1994 (HCCSA) is the legislation under which Approved Agencies provide home and community services. The use of the term home and community care in this Policy Guideline refers to the services provided by Approved Agencies. Restorative or Enabling Approach is an approach to care coordination, care and service planning and service delivery that focuses on what the client can do and wants to be able to do, not just on what they are unable to do at present. It offers clients the opportunity to be actively involved in identifying goals that are important and meaningful to them and to participate alongside their care coordinator to achieve their goals Goals All Ontarians who have an assessed need and are eligible will receive high quality home and community services and support including Home and Community-Based Care Coordination to optimize their health outcomes and quality of life. The delivery of Home and Community-Based Care Coordination will advance: person centered care; high impact practices across Approved Agencies and with other health sectors (e.g. primary care); and models of system-wide integrated care delivery (e.g. Health Links). Regardless of which Approved Agency provides Home and Community-Based Care Coordination, all clients will receive: Person- and family-centred care: Based on a philosophy of care, treatment and support that empowers clients to be active and knowledgeable partners in the health care process; holistic, collaborative, continuous, culturally sensitive and compassionate care that values 1 Case Management Society of America. (2012). Retrieved from 2 McDonald KM, Sundaram V, Bravata DM, et al. Closing the Quality Gap: A Critical Analysis of Quality Improvement Strategies, Volume 7 Care Coordination. Rockville, MD: Agency for Healthcare Research and Quality, U.S. Department of Health and Human Services; June NSW Australia (2010) Enabling approach in community care. April, of 23

5 client and family experience; considers the whole person - health, social, economic, mental and spiritual as well as their environment and family context. Equitable, accessible care: Ensuring all clients in all geographic regions will have timely, equitable and user-friendly access to coordinated home and community care based on their assessed level of need and unique individual, family and community circumstances. Consistent home and community practices: Standardized functions and consistent service levels reflecting client population need within and across Approved Agencies. Within these parameters, high flexibility to select and adapt local models to build on community strengths and effectively utilize established, readily available programs and services within a given region. High quality care and better value for money: Service delivery is based on evidence in order to improve quality and outcomes for clients. Service provider and population outcomes are transparent. Payment is based on evidence to reinforce quality and result in efficient use of resources. Quality measures and feedback are embedded to drive continuous quality improvement and accountability for outcomes. Integrated care: Coordinated home and community care that seamlessly supports and complements arrangements developed through local integration models and structures. Care coordinators exchange information appropriately with primary care and other approved coordination networks (e.g. Health Links) to ensure home and community care for the client and their family becomes less fragmented as well as better coordinated, monitored and evaluated. Home and Community-Based Care Coordination will improve Ontarians health outcomes and experiences with home and community-based care, mainly by improving the way care is delivered and received. It is expected that this will improve client, provider and system outcomes resulting in: Improved client and caregiver experience; Improved functional outcomes for clients and populations; and Improved system performance and sustainability. 4. Target Population The target population for this Policy Guideline is eligible older adults who are in need or are receiving one or more home and community services as a result of their frailty or long-term chronic conditions. Different approaches and standards will apply to three subgroups within this target population, categorized by level of need: April, of 23

6 TARGET POPULATION PROFILE: Older adults with frailty or long-term chronic conditions Health and/or Social Needs Description Lighter Care Needs Moderate Care Needs Complex Care Needs SEVERITY Mild-to-moderate Moderate-to-severe Moderate-to-severe STABILITY Stable Moderately stable Unstable SERVICE DURATION Short to long term Short to long term Long term-to-terminal URGENCY Routine or non-urgent Mostly routine Frequent, urgent SCOPE OF SERVICES Narrow-to-moderate Moderate-to-broad Broad SELF-DIRECTION ABILITY COMMUNITY NEEDS Strong self-direction/ informal network Some limitations requiring community support mostly without complicating factors Note: This is an initial profile description. Variable ability for self-direction Moderate medical, physical, cognitive and/or social conditions or complicating factors Weak or variable selfdirection/ informal network Complex medical, physical, cognitive and/or social conditions or complicating factors The use of the term client in this Policy Guideline means a client who fits within this target population description. 5. Legislative and Regulatory Requirements for Care Coordination for all Approved Agencies All Approved Agencies must comply with all legislated and regulatory requirements. These include: Assessing the client s requirements; Determining the client s eligibility for the services that the person requires (eligibility requirements are outlined in O. Reg. 386/99 under the HCCSA); For each person who is determined to be eligible, developing a Plan of Service that sets out the type and amount of each service to be provided to the client; Assisting the client in coordinating the services they are receiving if the client is receiving more than one community service provided or arranged by an Approved Agency, in accordance with the client s wishes (an ongoing activity); Providing services directly or indirectly; Waitlist management if services are not immediately available (placing the client on the waiting list and advising when services are available) (an ongoing activity); Reviewing requirements/ reassessment (an ongoing activity); and Revising the Plan of Service as necessary when the client s requirements change (an ongoing activity). April, of 23

7 The HCCSA also outlines requirements for: Client/ decision-maker participation in the Plan of Service (an ongoing activity); Inclusion of other assessments and information in the care planning process; Inclusion of the person s preferences (including preferences based on ethnic, spiritual, linguistic, familial and cultural factors); Ensuring that the services outlined in a person s Plan of Service are provided to the person within a time that is reasonable in the circumstances; Consent; Developing and implementing a plan for preventing, recognizing and addressing physical, mental and financial abuse ; and Developing and implementing a Quality Management system. 6. Policy Standards for Home and Community-Based Care Coordination The responsibility of an Approved Agency to assess and coordinate services is set out in the HCCSA (section 22(3)). These additional policy standards clarify the requirements for the broader coordination where the client requires home and community services that involve more than one Approved Agency. These practices are informed by an Ontario led synthesis of national and international leading practice in care coordination (see Appendix 1). 6.1 Home and Community-Based Care Coordination Model From first point of contact with an Approved Agency, clients will have access to a service that will enable them to receive information and help with referral and access to a broader range of services within their community. Home and Community-Based Care Coordination is an embedded service and set of functions, not a position. The ministry and LHINs recognize the value of this service for clients. The Home and Community Care Coordination model is based on a person and familycentred continuous client journey approach. The process and policy standards are based on assessed level of need which should take into account unique individual, family and community circumstances. The process is outlined as follows and further described through the descriptions of Coordinated Access and Intake, Standardized Assessment, Care Planning and Ongoing Coordination, Client and Family Engagement, Delivery of Home and Community Services, Supportive Transitions and System Integration : April, of 23

8 Home and Community Care Coordination Process: April, of 23

9 Coordinated Access and Intake: There is no wrong door to go through for clients to receive information or to access one or more home and community services. Individuals can be referred from a health care professional, institution such as a hospital or a Long-Term Care home, Health Link or may contact an Approved Agency directly or through a family member or friend. The home and community intake process will be transparent, timely and equitable for clients and their families. Within identified geographies, Approved Agencies will collaborate in a streamlined referral and coordinated intake process. As part of coordinated intake, a provincially agreed upon initial screening process must be in place in order to ensure clients will be matched to the most appropriate Approved Agency for a more comprehensive assessment and/or additional coordination support. This process will be necessary if the Approved Agency the client initially contacts cannot provide the comprehensive assessment, services or coordination support required based on the client s level and type of need. Standardized Assessment: The home and community service needs of each client will be determined through a provincially agreed upon coordinated, standardized assessment process that is transparent, seamless, timely and relieves clients and families from having to tell their story multiple times. The assessment will appropriately identify the client s clinical, functional and social care requirements and provide high quality evidence to support consistent and transparent decisions regarding the client s level of need (light, moderate or complex). The assessment process will be connected, modular and appropriately staged so that clients who require an in-depth comprehensive assessment will receive it. The client s assessment information will be used consistently for care planning across all Approved Agencies where required and in accordance with legislation and any expressed client consent. Approved Agencies will collaborate and share assessment information as appropriate and in accordance with legislation and any expressed client consent. Care Planning and On-going Coordination: Following the initial assessment of a client s requirements, the client will be offered help to organize the services required to live independently and safely in the community 4. Where the Approved Agency that completed the client s initial assessment cannot provide the level of coordination support required (see Section 6.3 for Population Standards for Home and Community-Based Care Coordination ), the client will be matched to the most appropriate Home and Community-Based Care Coordinator for on-going care coordination support consistent with this Policy Guideline 4 This may be in the form of a Home and Community Care Coordination Plan plus any applicable Plans of Service where the client requires home and community services that involve more than one Approved Agency; or a Plan of Service where the client requires one or more services that are delivered directly or indirectly by one Approved Agency. In accordance with the HCCSA, level of service will be identified in the Plan of Service developed by the Approved Agency that provides the service(s). April, of 23

10 (see Section 6.2 for Lead Agency for Home and Community-Based Care Coordination ). The client s care coordinator will: Consider all the assessments and information from other Approved Agencies and share information with others in accordance with legislation and any expressed client consent. Ensure the client and family knows who and when to call for on-going help. Work with the client and their family to set out the appropriate basket of home and community services in order to meet their goals. Work within their Approved Agency to provide timely access and manage waiting lists for any services delivered through their Approved Agency. Facilitate and coordinate access to other recommended services or arrange for alternate services where these are not available. Provide a restorative and enabling approach to care, utilizing strengths-based rather than deficit-based thinking, while ensuring continuity of care and family support. Ensure that interventions are organized and personnel/resources are marshaled to carry out the home and community care activities required to meet the needs of the client in a way that is harmonious and not fragmented, without duplication of time and resources. Provide on-going outcome-based monitoring and problem-solving. Work collaboratively to regularly reassess client needs, review requirements and revise the client s Plan of Service and/or Home and Community Care Coordination Plan as necessary. Comply with all applicable policy and service standards, in a manner that is consistent within and across Approved Agencies and regions, in accordance with evidence, professional norms and leading practice research (see Appendix 1 for a synthesis of evidence at the time of the drafting of this Policy Guideline). Client and Family Engagement: Subject to applicable legislation, clients and families have the right to: Be supported to be active and knowledgeable partners in the health care process. Be involved in assessment, service planning and care coordination to the extent they prefer in particular, client input as to their preferred care coordinator will be considered. Determine the extent of the involvement of their family or other supporters and put restrictions or set limits on the exchange of information or collaboration amongst the different Approved Agencies involved in their care. Decide the type and level of assessment and care coordination that they will accept (including no assessment or coordination) and should have an understanding of the impact of this on the nature or type of service that can be provided. Be provided with information as well as copies of their assessment, Plan of Service and Home and Community Care Coordination Plan according to their preferences and in a way they will understand. April, of 23

11 Delivery of Home and Community Services: Each Approved Agency providing a professional service, personal support service, homemaking service, or community support service must assess the client to determine eligibility, need and develop of a Plan of Service in accordance with section 22 of the HCCSA and O. Reg. 386/99. Approved Agencies delivering home and community services as part of the Home and Community Care Coordination Plan will consider the assessments and information from the care coordinator and other Approved Agencies as part of their process to develop a Plan of Service. All Approved Agencies should actively contribute to ongoing reassessments by communicating any significant change in need with the care coordinator accountable for the Home and Community Care Coordination Plan or other Approved Agencies, as appropriate and in accordance with legislation and any expressed client consent. Supportive Transitions: Any transition of assessment, care coordination or delivery responsibility between Approved Agencies will be organized so that it is seamless for the client and efficient (e.g. by eliminating any unnecessary duplicative steps and procedures and making appropriate use of shared technology). Client service and continuity of care considerations are paramount. Agency collaboration must also occur across LHIN boundaries. LHINs will ensure there are processes established to seamlessly transition care coordination responsibilities and services to ensure relative equity, smooth transitions and no gaps in care where the client moves to a different region. System Integration: Clients who are receiving coordinated home and community care may also require services from other health care providers (such as primary care, acute care, mental health, addictions services) or social services. In these cases, the Home and Community Care Coordination Plan is considered one component of the client s broader Care Plan. Home and Community-Based Care Coordination will be organized to complement and not duplicate other approved care coordination arrangements that exist across the health care continuum (such as Health Links) or that are provided through other sectors. Approved Agencies will collaborate and share information with other care coordinators and providers involved in the client s care as appropriate and in accordance with legislation and any expressed client consent. Where multiple sectors and care coordinators are involved, the overall point of access and interface with the client and family will be coordinated from the perspective of the client and their family, and delivered in a manner that is seamless and efficient. 6.2 Lead Agency for Home and Community-Based Care Coordination The following considerations apply in supporting clients to be matched to the most appropriate Approved Agency for providing Home and Community-Based Care Coordination. April, of 23

12 Local processes for Home and Community Care Coordination should evolve in accordance with the policy intention to strengthen CSS capacity to support older adults who are relatively independent, and improve the ability of CCACs to focus on clients with complex and post-acute needs, enabling: CCACs to lead Home and Community-Based Care Coordination for clients with complex care needs. CCACs to primarily lead Home and Community-Based Care Coordination for clients with moderate care needs in collaboration with CSS agencies within a shared care model where appropriate. o Notwithstanding CCACs primary leadership role for clients with moderate care needs, the coordinated intake and assessment process may result in an identified CSS agency leading Home and Community-Based Care Coordination for clients with moderate care needs who receive longer-term care and community support services primarily through CSS agencies (for example, clients in assisted living or day programs delivered by CSS agencies) and who present a known and manageable risk of complications or negative outcomes. CSS agencies to primarily lead Home and Community-Based Care Coordination for clients with lighter care needs. o Notwithstanding CSSs primary leadership role for clients with lighter care needs, CCACs may continue to lead Home and Community-Based Care Coordination for clients who receive services primarily through the CCAC and who have minimal interaction with CSS agencies. 6.3 Population Standards for Home and Community-Based Care Coordination Within different Approved Agencies, the nature of care coordination from basic to comprehensive as well as the level of intensity will vary according to the general nature of April, of 23

13 their programs and clients served while still taking into account the specific needs and specific circumstances of individual clients However, within each population subgroup (i.e. lighter care, moderate care and complex care needs), care coordination practices between and across Approved Agencies should be transparent and consistent as outlined below: TARGET POPULATION PROFILE: older adults with frailty or long-term chronic conditions Risk Profile Lighter Care Needs Moderate Care Needs Complex Care Needs MODEL OF CARE COORDINATION Linkage model which allows individuals with light to moderate health care needs to be cared for in systems that serve the whole population without requiring any special arrangements. Coordination model that operates through existing home and community structures and includes explicit processes to coordinate care across CCAC and CSS agencies as well as with primary care and other health care sectors. Full or system-wide integration model through entities such as Health Links, with resources from multiple systems that are pooled. Home and community care processes will be fully integrated with the processes delivered through local networks and primary care. Home and community care coordinators and providers should function seamlessly as part of a broader, integrated inter-professional team that crosses sectors. CARE COORDINATION INTENSITY FOCUS OF CARE COORDINATION Light-to-moderate intensity. Support client goals; support increased independence via effective pathways and system navigation; outcomes oriented monitoring. Moderate intensity. Support client goals; help client manage conditions and create support networks; manage risk with exacerbation of conditions to prevent or delay decline; outcomes oriented monitoring. High intensity. Support client goals; help client manage complex array of home care services and care requirements; manage risk of hospitalization, Alternate Levels of Care, or premature institutionalization; outcomes oriented monitoring. 7. Operational Standards: Service Quality Standards Service quality standards must be transparent to clients and consistent across Approved Agencies where appropriate (see Appendix 1 for an example of operational service quality standards under development within home and community care). April, of 23

14 8. Implementation Where appropriate, LHINs will engage Approved Agencies to clarify how Approved Agencies will work together to serve older adults with frailty or long-term chronic conditions in their regions consistent with the applicable legislative, regulatory, policy and service standards, including those outlined in this Policy Guideline. Where changes to existing practices and arrangements are required, LHINs will develop processes for collaboration across Approved Agencies that build on existing strengths to better address client needs. See Appendix 2 for examples of current collaborative care or regional models that are under development. Prior to implementation, the LHINs and the ministry will establish a province-wide collaborative process with Approved Agencies to develop service guidelines to assist with resource allocation decision-making. These service guidelines will categorize clients based on their characteristics (as determined using standardized assessment tools) with the purpose of ensuring consistent access to similar levels of service for similar clients. Service guidelines will provide parameters for care coordinators decisions about resource allocation, emphasizing the importance of clinical judgment while providing transparency about service level expectations for clients and families. As part of this process, LHINs and Approved Agencies will also work towards provincewide standardized measures and data processes. The ministry, LHINs, and Approved Agencies will ensure that Home and Community-Based Care Coordination processes and outcomes are evaluated in a manner that allows for timely, ongoing modifications to maximize the impact of this Policy Guideline and ensure any changes deliver value to clients and the overall health care system. This is will incorporate an audit and feedback approach to improving practice and integrated population outcomes Guiding Principles This Policy Guideline should be implemented in a manner that best advances the following principles: Future Oriented Position the home and community sector for greater capacity to prepare for the future through establishing an effective population- and needs-based continuum of home and community-based care in each region in the Province. The focus should be on the client experience A client s existing relationship with an Approved Agency is recognized and respected by other Approved Agencies. In implementing changes to current arrangements, facilitating a positive client and family experience and maintaining respect for existing relationships remains paramount. April, of 23

15 Service and care planning and delivery places an emphasis on minimizing or managing transitions between direct care providers, Approved Agencies and sectors that impact the client s experience. Respectful collaboration, communication and relationship building Each Approved Agency s services and core competencies are equally recognized, respected and leveraged; all Approved Agencies in the community provide vital services to the client. Informs and builds upon the process for seamless, consistent and client-focused communication across sectors and between providers involved in the client s broader system-wide care plan, as is being established through the development of Health Links. Strong partnership and team approach to streamlined intake, assessment and identification of the appropriate Approved Agency for the delivery of Home and Community-Based Care Coordination. Collaboration between direct care providers and care coordinators to identify risk to client and family and take appropriate steps to restore or maintain function and independence. Quality, Efficiency and Value Optimize existing assets. Leverage technology and other enablers. Promote adoption of standardized leading practices, while acknowledging appropriate regional differences. Performance measurement, electronic records, current remuneration systems and team-based incentives should be acknowledged and taken into consideration from early stages of model design and implementation. Appropriate funding/resource allocation based on evidence and population impact. Alignment with ministry and LHIN emerging policies and directions, in particular Health Links. Home and Community-Based Care Coordination will be aligned with regional intake and assessment practices to ensure timely and client-friendly access to the full basket of home and community services. LHINs are encouraged to develop collaborative processes to share facilities, equipment and personnel among Approved Agencies, leveraging existing services to reduce underused capacity and costs. Factors impacting variations should be understood. 9. Performance Metrics and Accountability Performance Metrics Performance measures, once finalized, should appropriately connect front-line, Approved Agency and team-based care to network (e.g. Health Link) and system outcomes. April, of 23

16 To achieve this, it is recommended that performance metrics take the form of an integrated scorecard approach made up of measures structured as an inter-related cascade of information. The final framework of indicators should enable the province, LHINs and Approved Agencies to monitor and evaluate the quality of care and allow for benchmarking across regions, sectors and providers. This will in turn support quality improvement and enable target setting to ensure continuous improvement. For example, rolled up to the provincial and LHIN level, results of indicators will provide an aggregated and summarized view of the impact of the implementation of the policy change. At the provider level, case-level information can be reviewed in order to help target care processes that might be reengineered to ensure that high-quality care is provided to clients. Provincial performance metrics should first be established to report on performance domains (policy goals). Team-based, provider and front-line indicators would then be established within the same domains as part of the implementation planning and continuous quality improvement process. The domains for performance measurement include: o Person- and family-centred o Equitable and accessible o Consistency in practice o High quality care and value for money o Integration of services and transitions of care Accountability Approved Agencies are funded by the LHINs and are held accountable through their multisector service accountability agreements (M-SAAs) with the LHINs. These agreements set out financial, operational and performance expectations for Health Service Providers (HSPs). LHINs will be responsible for reflecting any changes to operational expectations, such as identifying the appropriate Approved Agencies for Home and Community-Based Care Coordination, in their M-SAA with the HSP. These negotiated agreements follow a comprehensive planning process; each HSP must submit a Community Accountability Planning Submission (CAPS). The information contained within an individual CAPS may be reflected in the HSP s M-SAA with the LHIN. Any funding required to implement these changes will come from existing LHIN allocations. LHINs have the opportunity to reallocate funding based on local health system needs and priorities, within parameters set by the ministry. April, of 23

17 Appendix 1: Leading Practice Synthesis I. Conceptual Model at the System Level Especially for clients with complex care needs, care coordination functions will simultaneously and interactively occur through client/family self-directed activities and functions; home and community care provider activities and functions; and broader system or network activities and functions. Each of these complimentary processes needs to be understood and aligned to enhance client and family experience. This requires a high degree of communication, information exchange and coordination to ensure each process adds value to the client and is not duplicative. The following provides a conceptual model for simultaneous and complementary individual (i.e. self-management), sector (i.e. Home and Community Care Coordination) and system care coordination processes (e.g. Health Links) 5 : 5 Adapted from the Agency for Healthcare Research and Quality (2010) and supported by care standards identified by: Mery and Wodchis (2013); Wodchis (2012); Kodner (2011, 2010, 2009); Suter et al. (2009); Williams et al. (2009); and, MacAdam (2008). April, of 23

18 II. Evidence-Based Care Coordination Standards Home and Community-Based Care Coordination is most effective when it facilitates supportive care that optimizes wellness, improves abilities, addresses vulnerability and social complexity, manages exacerbations and aims to delay disease progression to the greatest extent possible. Home and Community-Based Care Coordination is a central component of integrative, shared care and, in particular, is essential to deliver the following components of standard care in partnership with clients and their families or caregivers 6 : 1. Initial assessment 2. Individualized care planning 3. Care plan implementation 4. Ongoing learning and education for clients and caregivers including support for selfmanagement 5. Care plan/goal monitoring 6. Formal, regular service evaluation 7. Transition support including continuity of care, transition management and information transfer Care coordination functions will organize systems around populations; enable providers to actively respect and respond to the individual s needs, preferences, values and unique circumstances in as seamless a manner as possible; and strengthen continuity in care providers. III. Population-Based Home and Community-Based Care Coordination Practices 7 Lighter Care Needs Enabling self-management: To be realized through enabling client, family and community-based self-management, including self-directed care coordination and leveraging strong informal networks. This is an enabling approach to support the individual to restore or maintain independence at home and in the community. It requires communication, education and information sharing to promote health, manage safety, optimize health and wellness and prevent or delay deterioration. 6 Phillips S.P., Kotecha J, and Martin M. (2013). Case Management and Care Coordination in Canada: Leading Evidence and Best Practices. 7 Mery G, and Wodchis, W. (2013). Management of Populations with Multiple Chronic Conditions in Ontario: Suggested Components of Standard Care and Performance Measurement for Shared Accountability; Phillips S.P., Kotecha J, and Martin M. (2013). Case Management and Care Coordination in Canada: Leading Evidence and Best Practices. April, of 23

19 Clients as partners: Clients are partners in the Home and Community-Based Care Coordination process in accordance with their own abilities and preferences. Each client s Home and Community-Based Care Coordination Plan will be adopted to be either fully self- or caregiver-directed, co-directed with their integrated team of Approved Agencies, or fully directed by a care coordinator. Risk management: Opportunities for prevention of further disability should be considered for this population to prevent avoidable escalation of care needs. The majority of the time, care coordinators will operate in a standby mode, acting as a safety net when the home situation becomes unstable and requires immediate intervention. Continuity: Supported self-management. Moderate Care Needs Enabling self-management: Same as Lighter Care Needs. Clients as partners: Same as Lighter Care Needs. Risk management: Early warning flags for predictable risks are routinely monitored to prevent avoidable escalation of care needs. Continuity: Same as Lighter Care Needs. Complex Care Needs Enabling self-management: Self-care approaches and caregiver education and support are employed to support and maintain long-term health outcomes, prevent and manage afflictions, promote independence and ultimately lead to a higher quality of life. Clients as partners: Same as Lighter Care Needs. Risk management: All identified risks are actively monitored and managed to prevent avoidable escalation of care needs. Continuity: Care coordinators will ensure a high degree of continuity exists in and across all settings, including informational, management and relational continuity. Informational continuity refers to disease or person-focused knowledge that is the common thread linking care from one provider to another, and includes clinical data as well as a client s values, preferences and needs. Management continuity refers to services being delivered in a complementary and timely manner, often coordinated across several different providers and facilitated through the use of a Home and Community-Based Care Coordination Plan, Care Plan or similar protocol, to provide a April, of 23

20 sense of predictability and security of future care for clients and providers. Relational continuity refers to establishing ongoing relationships between a client and consistent staff. IV. Evidence-Based Care Coordinator Functions The care coordination models developed within local communities and regions will take into account the standard roles, functions and activities of care coordinators based on national and international standards. National and International Standard Roles, Functions and Actions of Case Managers 8 Role/Function Location and Organization of Publication Canada United Kingdom Australia USA NCMN MOHLTC CMSUK UKDH CMSA NSWH CMSA ACMA NASW Initial Assessment Client identification Eligibility assessment Holistic assessment including Carer profiling Care Planning Client/carer collaboration Cultural, linguistic consideration Spiritual, psychosocial consideration Manage financial aspects for payer Care Plan Implementation Physical examinations* Treatment and prescriptions* Diagnosis* Provide clinical specialist services* 8 Phillips S.P., Kotecha J, and Martin M. (2013). Case Management and Care Coordination in Canada: Leading Evidence and Best Practices. April, of 23

21 Ongoing Learning and Education Client health education Carer and relative education Health care team education Community partner education Upgrade/refresh own skills and knowledge Mentor staff and students* Care Plan/Goal Monitoring Regular client /carer contact Regular care provider contact Regular medical professional contact Update client medical records* Formal, Regular Service Evaluation Care plan and goal changes Transition Support Reopen case if needed April, of 23

22 V. Service Quality Standards As an example, the following service quality standards are under development by CCACs. They reflect operational standards, not policy requirements, and can be changed outside of a formal policy process. Service Quality Standards Complex Chronic Community Independence Caseload size Small Medium Not applicable Initial contact <72 hours <72 hours <72 hours Initial assessment <7 days <10 days <14 days Wait time target for service initiation Move toward 5 day wait time for personal support and nursing (if required) Move toward 5 day wait time for nursing (if required) Move toward 5 day wait time for nursing (if required) Re-assessment Every 3-6 months Every 6 months Annually Follow-up (general) 7 days then weekly for 1 month 1 additional house visit/phone call in first month. Every 3 months after (house visit/phone call) Every 3 6 months (house visit/phone call) Follow-up post ED/Hospital <48 hours (contact) 7 days (home visit) <72 hours (contact) <7 days (home visit if required) <72 hours for stable at risk <7 days for supported independence Follow-up post- CCAC/CSS discharge <6 weeks <6 weeks <30 days (phone) April, of 23

23 Appendix 2: Examples of Collaborative Care Models in Early Development Toronto Central CCAC (TC CCAC) and CSS Collaborative Care Model Waterloo Wellington CCAC and CSS Partnership April, of 23