Client Care Model Board Meeting April 25, 2012 Outstanding care – every person, every day
The Client Care Model The Client Care Model is a framework that standardizes how we define, work with, and are accountable for five client populations. Each receive specific case management intensity, care planning and service that align with their care needs. 2
W hy this? W hy now ? April 2 0 0 9 May 2 0 0 9 Impact from Regulations MOHLTC announces ALC / ER removing PSW caps: higher Governm ent Wait Times priorities (i.e. utilization & programs like Hospital Flow) Home First May 2 0 0 9 Novem ber 2 0 0 9 CCAC Provincial Client Client Care Model concept Services Committee Analysis CCACs Provincial (population-based model for of Improved Care & System delivering care) Sustainability Septem ber 2 0 1 0 May 2 0 1 1 6 Proof of Concept sites test CCM implementation begins various populations and Local CCACs at each CCAC according to report evidence-based local needs and capacity findings 3
Our Place in the System Clients w ere “our” clients Clients are “system ” clients 4
W hat is the value of CCM? • Better outcomes Clients • Better experiences • Smoother transitions • Better care for clients • CM more knowledgeable about specific population needs Em ployees • More clearly defined roles & accountability • Sustainability to address population aging and chronic CCAC & disease management • Accountability and performance management System • Enhanced integration with community services and primary care 5
Outcom es from other CCAC’s Satisfaction Outcom es Costs •Costs for contracted •Higher likelihood of •Clients and caregivers services remained client dying in preferred described feeling neutral place (Complex clients) supported, especially during transitions •Slight reduction in costs •Decreased Length of as per best practices Stay for Community •CCAC staff benefit from (Short Stay) Independence clients focused approach to Case Management •Positive change in pain control and reduced •Improved provider- social isolation for Case manager Complex clients relationship (Complex) 6
Com plex Case Population Anticipated Standards of Care Managem ent Definition Outcom es I ntensity Caseload Size • 1 or more health • Maintain clients at • High intensity Case conditions home Management • Unstable & • Support clients & • Significant role in I nitial Contact < 72 hours unpredictable families to achieve system navigation • Little or no support degree of stability in I nitial < 7 days network preferred care Assessm ent • High risks in more destination Re-Assessm ent RAI-HC every than one area 3-6 months • RAI score 17+ Follow -up • 7 days post- ( General) initial visit Sub-populations: • weekly 1st • Adult month • Senior Follow -up post • < 48 hours • Palliative ED/ Hospital (contact) • 7 days (Home Example Visit) Client with CP , Follow -up post- < 6 weeks Arthritis, Diabetes, CCAC discharge Depression, falls 7
Chronic Case Population Anticipated Standards of Care Managem ent Definition Outcom es I ntensity Caseload Size • 1 or more health • Maintain clients at • Moderate Case conditions home Management • Direct-care needs • Support clients & intensity focused on I nitial Contact < 72 hours are stable & families to achieve helping client predictable degree of stability in manage health I nitial < 10 days Assessm ent • Client is self-reliant preferred care condition(s) & with support destination preventing further Re-Assessm ent RAI-HC every network • Provide a support decline 6 months • RAI score 11-16 structure that Follow -up • 1 follow up in promotes self- 1 st month ( General) Sub-populations: reliance (e.g. ADL • q 3 months • Adult assistance to keep Follow -up post • < 72 hours • Senior clients in their ED/ Hospital (contact) • Palliative home) • > 7 days (Home Visit) Example Follow -up < 6 weeks Client with Alzheimer’s post-CCAC Disease and no discharge behavioural problems 8
Com m unity I ndependence Case Population Anticipated Standards of Care Managem ent Definition Outcom es I ntensity Caseload Size • May have 1 or more • Support clients to • Moderate-to-low health conditions maintain their health Case Management • Capable of & well-being intensity I nitial Contact < 72 hours independent living • Foster a self- • Focus towards • Stable support management increased I nitial < 14 days network and/ or can approach & linkages Assessm ent independence via be self-reliant to community-based effective pathways & Re-Assessm ent RAI-HC • RAI score 1-10 resources. system navigation annually Follow -up Every 3-6 Sub-populations: ( General) months • Stable At Risk • Supported Follow -up post • < 7 days for Independence ED/ Hospital Supported Ind. • < 72 hours for Example Stable at Risk Elderly client with Follow -up post- < 30 days difficulty bathing CCAC discharge independently 9
Short Stay Case Population Anticipated Standards of Care Managem ent Definition Outcom es I ntensity Caseload Size • Require short-term • Support clients with • Low Case education, care or acute/ rehabilitation Management support needs to transition intensity I nitial Contact < 72 hours • High potential to to self-care return to I nitial By exception independence Assessm ent only • Stable & predictable Re-Assessm ent n/ a care trajectory • < 1 month Sub-populations: Follow -up post admission • Acute ( General) • on-going • Oncology monthly as • Rehab needed • Wound Follow -up post ED/ Hospital < 7 days Example Follow -up Clinic client – wound post-CCAC < 7 days care discharge 10
W W CCAC Tim elines March Sept – June – April 2 0 1 2 May March Aug 2 4 th Aug 2 4 th 2 0 1 2 2 0 1 2 2 0 1 3 Client Caseload Go- Live Date Categor- Develop Expression of Reassignm ent Phase Tw o: ization I nterest & Education CCM Team Monitoring, For on Standards Process Structure Evaluation & Existing of Care Revisions Clients 11
Project Team Structure 12
Com pleted Tasks for Aug 2 4 th CCM Go-Live date Creation of CCM Project Team Structure & breakdown of project task responsibilities Client categorization for existing clients Interim process for categorization of new clients prior to Aug 24 th : Community Case Managers to categorize at initial assessment Resource Case Managers to categorize once new chart received Focus groups to help inform decisions around the new caseloads & team structure • Team Coverage model • Primary Care / Family Health Team linkage model • Rural Case Management factors • Retirement Home relationships • Rostering • IALP clients 13
Next steps for Aug 2 4 th CCM Go-Live date • Expression of Interest process & development of new caseload/ team structure • Determine process for categorization of new clients from point of Intake for Aug 24 th Go-Live date • Education on Standards of Care and Roles & Responsibilities for CM’s and TA’s specific to each population • Identification & revision of local business processes • Communication with clients & stakeholders • Caseload reassignment 14
CHANGE MANAGEMENT The overall goal of the Change Management Framework is that it acts as a vehicle to cement a WWCCAC organizational culture that is: Change resilient • Supports a learning environment • Committed to Continuous Quality Improvement • 15
CCM … From a process view point CHANGE: a movement, development, or evolution from one form, stage, or style to another ( Merriam Webster) Something old Something new stops begins 16
People are different…. Something old Something new stops begins 17
Kotter’s 8-Step Model for Leading Change 1. Create a Sense of Urgency 2. Create a Guiding Coalition 3. Create a Vision for Change 4. Communicate the Vision 5. Empower People and Remove Barriers 6. Generate Short-Term Wins 7. Build on Gains 8. Anchor New Approaches in the Culture 18
People need tim e to “digest” change Adoption / evolution comfort / complacency excitement / acceptance shock / denial curiosity / Perform ance desire to know fear / anger negotiation depression / reality check Tim e 19
The Trapeze 20
Outstanding care – every person, every day
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