Integrated Comprehensive Care – Bundled Care Better, Faster, Cheaper February 27, 2013 | Dr. K. Smith
S T . J OSEPH ’ S H EALTH S YSTEM (SJHS) SJHS IS ONE OF THE LARGEST CORPORATIONS IN C ANADA DEVOTED TO HEALTH CARE . O UR MEMBER ORGANIZATIONS PROVIDE EXCELLENT , COMPASSIONATE CARE ACROSS THE CONTINUUM . S T . J OSEPH ’ S L IFECARE S T . J OSEPH ’ S H EALTH S T . J OSEPH ’ S H EALTHCARE , S T . M ARY ’ S G ENERAL S T . J OSEPH ’ S H OME C ARE S T . J OSEPH ’ S V ILLA - C ENTRE , B RANTFORD C ENTRE G UELPH H AMILTON H OSPITAL , K ITCHENER D UNDAS SJHC provides a multitude C HARLTON C AMPUS is a of services that respond to SJLC is a multigenerational SJV has built a new vision St. Joseph’s Health Centre, tertiary care teaching SMGH provides adult, community needs. place of care, hope and of long term care; one that Guelph has been serving centre, which includes the acute care to people in Mandate is to help people education. The new understands that “there’s the Guelph and regional kidney transplant Waterloo Region and including the frail, elderly, concept of health care no place like home”. SJV Wellington community centre, oncologic surgery beyond. As home to the and combines long term care staff embrace the mission; since it first opened as a and a large acute care Regional Cardiac Care disabled, lead more with Brant County’s first providing compassionate refuge for the sick, hospital. Centre SMGH provides a hospice as well as a centre care with dignity and injured, frail and the independent lives. This is full range of cardiac care K ING S TREET C AMPUS done through nursing, for research and respect. Over $70 million indigent in 1861. Today it including surgery, provides personal and home academics. The SJLC in new buildings is Guelph's leading, fully angioplasty, and S tate-of-the-art, stand- support, and volunteer commitment to the transformed the Villa and accredited, non-for-profit pacemaker insertions. alone facility including a services, as well as our Mission and philosophy of Estates into a modern provider of resident long SMGH continues to Surgery and Satellite providing compassionate home able to meet the term care, complex Constant Care, Palliative meet the needs of the Dialysis Centre. Care, Healing Touch, With care will never change. needs of seniors and their continuing care, community, recently W EST 5 TH C AMPUS provides Seniors in Mind, and families. and rehabilitation opening a 100,000 sq. specialized tertiary mental Corporate Health services. ft. addition. health services for Programs. residents of Central South No. of beds : 205 No. of beds : 452 Region in Ontario. No. of beds : n/a No. of beds : 235 No. of beds : 760 No. of Staff : 165 No. of Staff : 306 No. of beds : 160 No. of Staff : 164 No. of Staff : 340 No. of Staff : 4,432 Annual budget : $11 M Annual budget : $22 M No. of Staff : 921 Annual budget : $30 M Annual budget : $10 M Annual budget : $500 M Established : 1955 Established : 1879 Annual budget : $120 Established : 1921 Established : 1861 M Established : 1890 www.sjlc.ca www.sjv.on.ca Established : www.stjoes.ca www.sjhh.guelph.on.ca www.stjosephshomecare. 1924 ca www.smgh.ca I NTERNATIONAL O UTREACH P ROGRAM International Outreach has been bringing good intentions to life around the world since 1986. From Haiti to Uganda to Sudan, IOP partners with developing countries to provide training in current medical and nursing techniques, transport basic medical supplies, and make donated equipment operational. International Outreach is funded by the Sisters of St. Joseph of Hamilton, Canada and supported by member organizations and friends of St. Joseph's Health System. Projects are aimed at building capacity for sustainable programs; teams include physicians, nurses, biomedical engineers, and other healthcare personnel. SJHS T OTALS BEDS = 1,800 BUDGET = $683M
Demonstrate the value of an integrated model of care Patient centered model Follows the patient across the continuum of care • Acute care in hospital • Home Care in the community Three client groups with broad applicability in Ontario (1,200 clients) • Hip and Knee Replacement • Lung Cancer Surgery • Chronic Diseases (chronic lung disease and heart failure) Evaluation • Conducted by Program for the Assessment of Technology in Health (PATH)
Integrated Care Coordinators Team of 4 Integrated Care Coordinators • Directly coordinate the care of the patient acute care to community care • Expertly trigger interventions from both the hospital and community • Prevent readmissions • Prevent complications • Streamline the integrated continuum of care • Navigate the Health System WITH the patient
Hip/Knee Replacement Surgery Home Care Team Integrated Care Coordinator
Client Value Statement "Please help me fully understand my health challenges so that I can make informed choices about my care.” “I would like timely care when it is necessary, in the most suitable location.” “I want to be clear about what will happen next so I can prepare properly and try to worry less.” “Help support my recovery at home."
Key Components of ICC • Integrated Care Coordinators • Partnership with a single service provider in the community • Central contact number: access to the team (24/7) • Very engaged and committed team
Key Components of ICC • Shared electronic health record • Flexibility in communication: • Skype, phone calls • Timely access to medical care
Transforming the Way We Deliver Care (Video)
Edward 68 years old, Lives at home with his wife, in Brantford ON Diagnosed with Lung Cancer through the Lung Diagnostic Program at St. Joseph’s Healthcare Hamilton In August 2012 underwent Lung Cancer surgery at St. Joseph’s Healthcare Hamilton
Edward BEFORE NOW After 7 days in hospital, he is After 5 days in hospital, he is discharged home on Thursday discharged home on Thursday Saturday: Saturday: His chest tube site is bleeding quite a His chest tube site is bleeding quite a bit, and he and his wife decide to go bit, and he and his wife call the ICC the Brantford General Emergency central contact number; They speak Room; they are sent home after a with the Integrated Care change in dressing. The CCAC Coordinator… Thursday evening: He is suffering from shortness of breath and right shoulder pain; His wife bring s him to the Brantford General Hospital ER for assessment He waits a few hours for an assessment and tests and is sent home ; The CCAC and home care providers are not aware of the visit
Edward's Home Care Record
Edward BEFORE NOW After 7 days in hospital, he is After 5 days in hospital, he is discharged home on Thursday discharged home on Thursday Saturday: Saturday: His chest tube site is bleeding quite a His chest tube site is bleeding quite a bit, and he and his wife call the ICC bit, and he and his wife decide to go central contact number; They speak the Brantford General Emergency with the Integrated Care Room; they are sent home after a change in dressing. The CCAC and Coordinator… home care providers are not aware The ICC sends the nurse in to assess the bleeding. A picture is sent to of the visit surgeon for review. The patient stays at home, with a follow up in the Thursday evening: clinic in 2 days. All events are He is suffering from shortness of breath documented in the electronic record and right shoulder pain; His wife bring s him to the Brantford General Hospital ER Thursday evening: for assessment He is suffering from shortness of breath and right shoulder pain; The Integrated Care Coordinator sends a respiratory therapist in the home for assessment, He waits a few hours for an assessment using an oximeter. and tests and is sent home ; The CCAC and A direct visit with the thoracic surgeon is scheduled home care providers are not aware of the immediately, with all his information provided to the visit physician.
The Team’s Perspective (Video)
Results Hip and Knee Replacements • Decreased length of stay and referrals to rehab • Decreased ER visits Lung Cancer Surgery • Decreased length of stay: significant savings ($1,500+ per patient/client) • Decreased ER visits (9% versus 13%) • Reduction in hospital costs represents a 15%-23% savings per patient Chronic Disease • Fewer ER visits after discharge • Fewer readmissions 30 days after discharge Patient/client satisfaction is very high
SJHH length of stay
Average Cost Per Case F2011/2012 $16,000 Average estimated direct costs Q1 F2012/2013 $14,000 $12,000 $10,000 $8,000 $6,000 $4,000 $2,000 $0 CMG 112 CMG 114 CMG 320 CMG 321 Open Lung Endoscopic Total Hip Total Knee Resection Lung Resection Replacement Replacement
A Client’s Experience www.skype.ca
Alignment With Other Initiatives • Quality Based Procedures/ HSFC • Apply learnings to the development of Health Links models • Seniors Strategy for Ontario: “Living Longer, Living Well” • HNHB LHIN Discharge Transition Bundle Project
Potential Alignment with CCAC • Integrated care plan (hospital/home): patient specific outcomes • Integrated home care team delivering care • Entire bundle could be contracted to hospital/home care collaborative • Accountability for all cost: home care, readmits, ER visits CCAC Contract Integrated Care Coordinator Home Care Team Client in Hospita l Client at Home 21
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