Through my Eyes - Providing Personal Care

Connecting General Practitioners and Home Health

through Care Conferencing

Susan Lim, VCH IPCC Project Manager (susan.lim@vch.ca)Debra Sanderson, VCH Community Health Nurse (debra.sanderson@vch.ca)

JoAnne Douglas, VCH IPCC Integration Lead (joanne.douglas@vch.ca)

Quality Forum 2015February 19, 2015

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Disclosure

We have no involvement with commercial interests, no potential

conflict of interest and have nothing to disclose.

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Overview of Care Conferencing

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• Implemented throughout Home & Community Care

• Clients in the community have: Increasing complexity Unstable health status or acute medical

needs

• Effective collaboration & communication between Home Health & GPs is key

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• GPs + Home Health Clinicians• Pre-scheduled• 15-minute conference call or face-

to-face meeting• Exchange information• Collaborate on a plan of care for

shared clients

What is GP Care Conferencing?

How is care conferencing different from a phone call with a GP?

An in-depth discussion

Results in a new, change or revision to a care plan

Proactively facilitates best outcomes for the client

Providing information only (i.e. can be faxed)

Confirmation or receipt of orders

Quick question

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• Local Divisions of Family Practice• GP Reference Group• Practice Support Program (PSP)• GPs with large # of Home Health

clients

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How did we engage GPs?

GPCC Survey Highlights% Agreed or Strongly Agreed GPs HH

More aware of other issues affecting client health

89% 78%

Better able to exchange info with other providers in timely manner

86% 68%

Better supported in providing patient care 96% 75%

Enables a more proactive approach to patient care

93% 67%

Improves coordination of care 89% 69%

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1. Identify appropriate clients.2. Consult other team members.3. Schedule time with the GP.4. Prepare for the care conference.5. Conduct the care conference.6. Document the care conference.7. Fax summary to GP.

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Key Steps to Care Conferencing

• Educate GPs about Home Health • Learn about GP services• Provide proactive care• Develop a plan of care together

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What’s the value of care conferencing?

Patient Stories

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Care Conferencing in Action

• Prepare for the care conference• Collaborating is a culture shift • Builds relationships • Care conference champions are

needed

“It takes time but, in the end, saves time.”

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What have we learned?

• Simplify the care conference process

• Mentor new clinicians by: Providing hands-on support Developing scripts they can use Sharing success stories

• Establish protocols to care conference (e.g. every new palliative client)

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How will we spread the practice?

?Questions