June 2014, OACCAC Annual Conference Integrated Community Assessment and Referral Team (ICART) A proactive approach to communitybased services for high-risk seniors Joanne Billing, South East CCAC Benedict Menachery, South East LHIN
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3 1 are we trying to solve? is it important? 2 was the solution developed? Agenda 3 5 4 does ICART look like? did we implement it? did we expect to achieve? 6 did we evaluate the model? 7 did we learn?
CC Image courtesy of Charlie Stinchcomb on Flickr 4 THE CHALLENGE
5 Community Perspectives The care received is excellent, but it is really difficult to navigate between providers. It is also difficult to know what care is available and how to access it -Recurring message from patients and residents Our communities told us that we needed to do more towards: Developing a well-coordinated local health system; Making it simpler to move from one part of the health system to another; Managing the healthcare needs of frequent users; Reducing duplication of interviews/assessments.
6 Feedback from HSPs and other stakeholders Need to enhance information sharing across organizations within the circle of care Individuals at high-risk are not uniformly known to care providers Inconsistent referral patterns Challenging fiscal environment
7 Alignment with Provincial and Regional Priorities Ontario's Action Plan for Healthcare Better integration of the healthcare system and across the continuum of care, including family health care, acute care and community care; Enhanced community based services; Seniors' Care Strategy Enhancing the Provision of Home and Community Care Services Addressing the Specialized Care Needs of Older Ontarians Caring for Caregivers Southeast LHIN Integrated Health Service Plan (IHSP3) Moving to a model in which high- risk clients are proactively identified and referred to appropriate services in their community Enhancing the ability of the health care system to respond to the care needs of our seniors Supporting and empowering caregivers
CC Image courtesy of Spushnik on Flickr 8 DEVELOPING A SOLUTION
9 Planning Process Planning team was constituted Team members included: CSS, CCAC, Hospital and LHIN staff Clinicians and managers Collaborative planning process to explore options and to identify an optimal model
10 Desired Future State A validated tool is consistently used across the healthcare system to proactively identify high-risk seniors High-risk seniors are offered additional support in both the community and hospital setting to enhance functional and cognitive status Standardized and equitable access to restorative programs across the South East region Regionally integrated healthcare system that supports transitions between providers
11 ICART Guiding Principles Face-to-face contact is the preferred mode of engaging with clients Client assessments and care plans will be shared between organizations in the circle of care Enhance coordination between CCAC and CSS Primary care will receive notification of clients being identified as high-risk Process will be streamlined with minimal handoffs Ensuring client confidentiality and privacy is critical Need to develop a scalable solution
12 THE INTEGRATED COMMUNITY ASSESSMENT AND REFERRAL TEAM (ICART) MODEL
13 Fundamental Elements Pro-actively identify high-risk seniors High-risk seniors who are admitted to hospital: Receive care that enhances functional and cognitive status Flagged for early CCAC engagement Streamline the provision of community-based services for identified clients
14 Identification of High-risk Seniors The interrai Preliminary Screener is used with the Assessment Urgency Algorithm (AUA) to identify high-risk seniors This is an Ontario derived approach that has been validated nationally and internationally Predicts risk of 30 day ER re-attendance, 90-day re-admission, increased LOS and Alternate-Levelof-Care (ALC) likelihood
15 Streamlining the Provision of Community-based Services The (ICART) Team is composed of cross-trained CCAC and CSS Care Coordinators This team receives a referral when a high-risk senior has been identified in the ER or at inpatient discharge Receipt of the referral triggers the following: Review of current CCAC and Community Support Services care plans In-person (re)assessments as appropriate Development/ modification of care plan Care plan is shared with Health Service Providers in the circle of care CCAC and/or local CSS organizations initiates/modifies services as identified in the care plan The client s primary care provider is notified
16 Client Trajectory Placeholder for simplified process map
17 What makes this model unique? High-risk clients are proactively identified and provided with appropriate services Minimizes client confusion Clients are not asked for the same information multiple times Emphasis on avoiding functional and cognitive decline in hospitalized individuals Hospital CCAC care coordinators are engaged earlier The integrated model (with co-located CCAC & CSS staff) streamlines the access to community services Provides an opportunity to collect data to drive health system planning
Used with the permission of Fran Oxford 18 IMPLEMENTATION
19 Implementation Teams Teams were created to implement the newly developed model The teams were composed of stakeholders including: CSS, CCAC, Hospital and LHIN staff Managers and frontline staff IT staff
20 Phased Implementation The project was implemented in a phased manner to manage resource constraints and other system priorities This resulted in a more nimble implementation that provided multiple opportunities to further refine the model It was valuable to apply the lessons learned from pilot sites during subsequent implementations
21 Current Status High-risk screening tool & ICART process established at two ER sites Brockville General Hospital Lennox & Addington County General Hospital ICART team in place Referral and service initiation processes formalized for community-based services
22 Current Status Planned Expansion Point of Identification ED (at triage) - BGH & LACGH ED (at triage) -QHC, PSFDH & KGH Primary care Self-referral Client Characteristics High-risk seniors (75+) CTAS 3-5 High-risk seniors (65+) Services Delivered CCAC Services IADL supports (MoW, ADS, transportation, etc.) from traditional (Community Home Support Services) and nontraditional providers Other Community Support Services (CHS, CNIB, etc.)
CC Image courtesy of JenGallardo on Flickr 23 ANTICIPATED BENEFITS
24 Anticipated Benefits: High-risk Seniors Improve quality of life for high-risk seniors Diminish client and family anxiety Prevent social isolation Early intervention- slowing decline (both physical and cognitive) Streamline access to community based services Enhance client experience with the health system Reduce delays in receiving services Reduction in avoidable decline in function within hospital Improved access to appropriate level and range of services Increased capacity for independent living within the community Stabilize and improve the health status of high-risk seniors
25 Anticipated Benefits: Health System Decrease unnecessary ER visits/ avoid the utilization of ERs for non-acute needs Delaying the need for admission to Long Term Care Home Reduce hospital readmissions and ALC days Increase utilization of community-based services Health system sustainability Foster system-wide communication regarding client needs and service provision
CC Image courtesy of StooMathiesen on Flickr 26 EVALUATION FRAMEWORK
27 Appraising the Model Typical PM indicators were used to monitor implementation E.g. completion of key milestones measures reflecting compliance with the new process Measuring performance E.g. # of individuals screened (> 400/month) % of Clients flagged as high-risk (~50%) % of flagged clients that were not known to CSS or CCAC (~90%) % of referred clients accepting service (~95%)
28 Determining Impact Challenging to quantify the outcomes of such initiatives on the health system and high-risk seniors Difficult to isolate the effects of this initiative However Potential to investigate effectiveness of initiative by reviewing data from a regional ED-CCAC notification initiative Long-term health system utilization trends may reveal some consequent outcomes
CC Image courtesy of drinksmachine on Flickr 29 LESSONS LEARNED
30 Key Enablers Health system partnership Leadership commitment across the continuum Regional CSS programs Seniors Managing Independent Living Easily (SMILE) Regional Care Coordinator Program Customized IT solutions
31 Looking back...looking ahead Ensuring that partners understand the value of an initiative is key to enhance uptake Initiatives must link directly to organizational priorities/strategy Stay focused on the shared problem and principles Don t wait for perfection start with something and make adjustments along the way Set timelines to maintain momentum, but recognize the need to be flexible Be mindful of competing organizational priorities or time commitments/demands Process maps Vs. Client Experience
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