Taking the bestPATH to Health System Integration Partnering to accelerate best care, best health, best value Des partenariats pour offrir de meilleurs soins, être en meilleure santé, optimiser les ressources
Agenda 1. Introductions 2. What is bestPATH? 3. Vision for the initiative 4. Key features and program design 1
1. INTRODUCTIONS 2
Our Panelists Today • Kim Baker, CEO, Central Local Health Integration Network – Moderator • Don Ford, CEO, Central East Community Care Access Centre • Steve Vanderherberg, Senior Manager of Community & Volunteer Engagement, WoodGreen Community Services • Don Harterre, Physician Lead, Primary Health Care Services of Peterborough • Kenneth Hook, Family Physician, STAR FHT, Tavistock • Patti Cochrane, VP Patient Services, Quality & Practice / Chief Nursing Executive, Trillium Site, The Credit Valley Hospital and Trillium Health Centre 3
2. WHAT IS bestPATH? 4
Overview • bestPATH is a broad, multi-year initiative aimed at improving quality of care for individuals with complex chronic illnesses • bestPATH is: • The consistent application of evidence-informed effective practices – putting into practice what we know works, all of the time • More coordinated care delivery, with planning and information sharing across health sectors • Person-centred care 5
Person-Centred, Continuous Care Long Term Care Person Community Hospitals Care Primary Care 6
3. VISION FOR THE INITIATIVE 7
Vision for bestPATH P erson-centred, A ppropriate, T imely H ealthcare Improve health outcomes, the experience of care, and system effectiveness through accessible and coordinated care for Ontarians with complex chronic illness 8
Aims best Care — Improve the care experience by making care more accessible, and provide a smooth journey through the system by ensuring clear communication and strong engagement, both among providers and between providers and care recipients best Health — Improve outcomes for persons with chronic conditions through the use of evidence-informed best practices best Value — Ensure care occurs in the most appropriate setting, reducing the rate of unnecessary hospitalizations and contributing to more appropriate resource utilization 9
bestPATH Partners • HQO’s vision for bestPATH is partnership -based • System partners from across many health care sectors are key to the successful design and implementation of bestPATH including: − Designing the key elements of bestPATH − Identifying opportunities to align bestPATH with existing initiatives − Developing and providing education − Demonstrating leadership and building support for bestPATH − Building capacity for change management 10
bestPATH Partners Health Quality Ontario has already engaged with system leaders from across the province in the development of bestPATH and will continue to do so as the initiative rolls out: • LHINs • Professional/Educational Membership Organizations • Clinical Specialty/Safety Organizations • System Innovators and Researchers • Ministry of Health and Long-Term Care 11
4. KEY FEATURES & PROGRAM DESIGN 12
Program Phases • Phase I – Focus on transitions of care – Self-directed stream (Q and Q+) • Future Phases – Broaden focus to include chronic disease management, independence and safety – More intensive level of support – Implementation later in 2013 13
Phase I - Self-Directed Stream Transitions of Care • Self- Directed “Q” (for Quality ) – Individual organizations from any sector register directly with HQO – Able to access change packages and step-by-step guides to improvement – Able to participate in all virtual learning activities – No obligation to report data, but encouraged to use the reporting system to help them track their progress 14
Phase I - Self-Directed Stream Transitions of Care • Self- Directed “Q+” (Quality Plus ) • Participating organizations benefit from all the materials offered to Q participants, plus direct HQO QI coaching and other supports. • Q+ organizations must: – Undergo a readiness assessment – Agree to become part of a QI team involving the local hospital, CCAC and its providers, primary care, community care, and long-term care – Agree to basic data collection and reporting 15
What Participants Receive Change Packages • Evidence informed and vetted by an expert panel and staff in the field • Endorsed by leaders in Canadian and Ontario health care standards HQO Quality Framework • Includes the best of IHI Model for Improvement, Lean and Six Sigma approaches to quality improvement Web Based Repository of Best Practices • Evidence-informed guides to best practices and implementation tips • Guides on quality improvement, measurement for improvement, change management Links to Innovative and Leading Edge Healthcare Practitioners • Partnerships with provincial, national and international leaders • Links to organizations who have successfully implemented best practices and addressed barriers to adoption 16
Targeted Focus for Maximum Impact • Focus improvement efforts on an identified population: – Analyze your population to determine local priority – Consider CHF, COPD, Diabetes, CAD & Stroke • Apply Evidence-Informed Interventions – Implement list of best practices identified by HQO through evidence reviews, success stories in literature 17
Model for Improvement for Phase I 1. What are we trying to Accomplish? i) Improvements in 7 & 30 day readmissions ii) Improvements in measures of patient experience for discharge transitions 2. How will we know that a change is an improvement? i) Changes in measures above ii) Process measures for adoption of best practices 3. What change can we make that will result in improvement? i) Best practices for transitions 18
Best Practices for Transitions Transitions • Assess for risk of readmission within 30 days of discharge; plan and schedule appropriate follow up as per readmission risk − For individuals deemed moderate to high risk for readmission (i.e., LACE score ≥ 10) treat discharge as a formal transfer of care − Timely follow-up appointments confirmed prior to discharge − “Warm handoffs” involving discharging and receiving clinician 19
Best Practices for Transitions Transitions • Medication reconciliation at key transition points • Conduct individualized care and discharge planning: − Health literacy assessment at admission − Use of “teach back” - ensure person understands care plan, treatments, how to manage symptoms, when/who to ask for help − Timely, written discharge documentation completed − Written discharge instructions to patients − Written discharge plans distributed to next care provider and primary care 20
Future Phases: Independence / Independence and Safety Safety • Enable the person to take a central role in their health and create a safe environment: − Assess health literacy and ensure person understands how to manage their health and care − Support the development of goals that are meaningful and important to the person • Enhance the person’s ability to live independently and safely : • Implement OHTAC “Aging in the Community’ recommendations: − Falls prevention − Targeted conditioning / exercise / rehabilitation − Caregiver support 21
Future Phases: Chronic Disease Management Chronic Disease Management • Structured visits: • Use chronic disease flow sheets and clinical practice guidelines (CPGs) to guide care planning and discussion during each visit with a patient with chronic illness • Leverage information systems: • Use alerts and/or electronic recall functions, flag patients who require specific interventions, plan specialist consultations • Coordinate care across disciplines including: • Specialists, nurse practitioners and allied health care professionals, creating a multidisciplinary team with shared accountability to provide care 22
What’s Next Visit www.hqontario.ca or email bestpath@hqontario.ca to learn more about participating 23
Experiences in the Community Presented by: Don Ford, Central East CCAC
Experiences in the Community What we hear: - “Don’t you people talk to each other?” - “How often do I need to tell my story?” - “Why won’t you listen to me?” - “Don’t you already have that lab/X - ray result?” - “Do you know who I should talk to if I need help?” - “How can you be sure I won’t get lost in the system?” What we surmise: The components work, the system doesn’t … so … We need to improve the experience, the transitions, the hand- offs … which … Should help to improve satisfaction 25
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