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Integrating partners to improve care for complex patients
BC Health Leaders ConferenceOctober 23, 2014
North York Central
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Session Objectives
Understand the complex care challenges of the highest users of the acute care system
Understand the challenges in transition from one care setting/provider to another and the strategies aimed to improve coordination of care between acute and primary care
Discuss practical strategies to apply a learning organization model to enable an effective collaborative care model between acute and primary care for this population of patients
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Audience Polling
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Poll Everywhere Test
• For today’s session, we will be using Poll Everywhere to
complement our discussions
• Instructions will be demonstrated on-screen
• Polling Test
• Who would win the Stanley Cup if the Canucks play the Leafs in the finals this year?
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Audience Poll: Demographics
• To help get to know your peers today, please select the option that best describes your sector in the health system:• Primary Care• Emergency Medical Services• Acute Care• Rehab and Complex Care• Long-Term Care• Home Care• Community Support Services• Community Mental Health• Regional Role• Provincial Role• Other
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Applying a Learning
Organization Model to Care
Coordination
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A coordinated partnership is needed to address
the needs of our most complex patients
• Studies show that 1%-5% of patients utilize 2/3 of Ontario’s health
expenditures
• These patients tend to be:• >65 years of age• Multi-morbid: COPD, CHF, Diabetes, Cancer, UTI, Mental
Health and other conditions• Multiple admissions and/or ED visits• Multiple care providers, multiple medications
• The Ontario Ministry of Health announced Health Links in Dec. 2012
• The intent of Health Links is to improve care coordination, to reduce ED and hospital use, and improve the patient experience
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Five Health Links were defined within the
Central LHIN
• Central LHIN has ~ 1.8 million residents
• The LHIN has 13.2% of Ontario’s
population; largest among the LHINs, and one of the fastest growing
• Currently 12.5% of people in Central LHIN are over age 65; by 2021, seniors will account for 16.1% of the population
• The North York Central Health Link was established in the southern area of the LHIN, serving a catchment of ~400,000
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North York Central Health Link is a partnership
across many sectors
• Organizations and care providers have come together to improve care to individuals with complex care needs living in our community
• Partners include NYGH, North York Family Health Team, Central CCAC, Toronto EMS, Community Support, and Mental Health and Addiction agencies
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NYCHL delivers intensive care coordination
supporting an enhanced medical home model
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• NYCHL is designed to better support patients and providers across the continuum of care to:
• Improve the patient experience• Reduce avoidable ED visits• Reduce avoidable admissions• Enhance linkages and transitions
of care
• The partners quickly established a vision aligned with the Ministry’s
focus on care coordination, and recognizing the importance of the Medical Home
• Initial success has been achieved because of strong hospital, primary care and CCAC leadership and front-line provider engagement
As a learning organization, NYGH integrated the
five domains into our Health Link leadership
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Team Learning
• Co-creation and a safe learning environment enable innovation through rapid PDSA cycles
Shared Vision
• Aligned leadership is critical
• A Medical Home model is at the core of our Health Link
Systems Thinking
• Faster is not always better
• Governance supports whole-system design
• Focus on sustainability
Mental Models
• Working across traditional lines
• Keeping the Patient and Family at the centre of all we do
Personal
Mastery
Personal Mastery and Team Learning are at the
heart of collaboration, yet can vary significantly
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North
York
Central
Health
Link
• People with a high level of personal mastery are able to consistently realize the results that matter most to them
• They do that by becoming committed to their own lifelong learning
• When the energy of a team is aligned, members work more effectively together
• Organizations need to facilitate discussions that focus on the collective dialogue
• Each leader and care provider is at a different stage of personal mastery
• All partners are at a different stage of evolution as a learning organization
Personal Mastery Team Learning
A co-creation model valued individual
contribution through a team learning approach
• Health Link leaders focused on co-creating to bring staff together across different organizations, sectors and roles
• Keeping discussions focused on Shared Vision enabled the teams to work effectively together to accelerate improvements to patient care
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NYCHL Steering
Committee
Identification, & Intake
Mental Health&
End of Life
Physician Engagement
Central LHIN System Planning
Committee
Performance Measurement
Patient & Caregiver
Advisory Group
Patient Management
Project Support Team
Team-based learning and modeling have facilitated collaborative design
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• NYGH –
Med & ED
• CCAC
• PCP
• Community Agency
• EMS
• CCDC
• NYGH – Pharm
• CCAC
• PCP
• Community Agency
• Caregiver advisor
• NYGH –Psych & ED
• CCAC
• Mental Health Agencies
• Hospice/ Palliative
• Patients & caregivers
• Health Link and complex care needs
• FHT & FHO physicians (advisory)
• NYGH
• CCAC
• NYFHT
Patients and caregivers are integral to co-
creation within NYCHL
• A Patient and Family Advisory Group was established in July 2013, comprised of includes patients and caregivers (Health Links and non-Health Link patients)
• The Advisory Group meets monthly, and provides input into a number of Health Links initiatives
• Coordinated Care Plan• IT solution• Patient Surveys• End of Life engagement• Patient communication binder (new suggestion)
• In addition, Patient and Family Advisors are members of the NYCHL Steering Committee and working groups
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Audience Poll: Co-Creation with Primary Care• How far advanced are your collaborations with Primary
Care?• Telling• Selling• Testing• Consulting• Co-Creating
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ConsultingCreating
Audience Poll: Co-Creation with Patients• How far advanced are your collaborations with Patients
and Caregivers?• Telling• Selling• Testing• Consulting• Co-Creating
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ConsultingCreating
Building a Shared Vision and
Changing Mental Models
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Building a shared vision rallied leadership
across partner organizationsBuilding a shared vision together establishes guiding principles that foster
learning and excellence. By unearthing shared pictures of the future you
gain alignment, motivation and commitment.
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• Partners of the Health Link came together to decide on the goals and key principles through an initial business case and then visioning workshop in April 2013
• Executive leadership from each of NYCHL’s founding partners consistently
uphold this vision, prioritize Health Link in their organizations, and actively break-down traditional barriers for patients receiving care across multiple providers
Family Physician and Specialist engagement
are critical to success for our patients
• A high level of engagement between Primary Care and Hospital leaders through key champions is critical to success
• NYCHL benefits from strong Primary Care engagement and integration with the hospital:• NYGH Department of Family and Community Medicine (300 MDs)• Ability to leverage Central LHIN Primary Care Lead network• Participating in departmental, FHT, MSA and OMA meetings• Hosting lunch & learns in physician offices• Developed on-line web-calculator to use the PRA and EMR templates for
the referral form• Exploring research opportunities through shared HIS-EMR databases• Collaborating on End-of-Life pilot projects to enhance care
• We are also well-supported by NYGH Clinical Chiefs, to enable enhanced specialist access for Health Link care coordination
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• NYGH’s Strategic Plan 2012-2015 established a focus on Connecting Care to enhance hospital-physician communications and engagement
• Key initiatives from this strategy provide a foundation to the communications critical to Health Links care coordination:• Established fax notifications for Family Physicians and HL Care
Coordinators when a patient visits ED, is admitted and/or discharged• Collected and share cell phone numbers for family physicians with
hospital specialists to facilitate warm hand-offs• Access to select Family Physician ‘back-line’ numbers to facilitate
appointments within 7 days of discharge• Developing a physician directory to enhance PCP-Specialist contact• Participating in OTN/OMD e-Consult pilot to improve specialist access• Supporting a shared hospital-FHT database for research and analysis
NYGH’s Connecting Care Strategy provides a
foundation to primary care integration
Traditional mental models had to be overcome to
create a sustainable patient-centred Health Link
Mental models are preconceived notions of how the world works.
Organizations have to increase their ability to identify and analyze mental
models.
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Organization Structure and Boundaries
Primary Care Provider Perception and Engagement
Specialist Provider Perception and Engagement
Patient and Caregiver Perception and Engagement
Patient Identification Care Coordination
Governance and Leadership
Rapid Cycle
PDSAs to
Test and
Implement
New Models
The Central CCAC provides intensive care
coordination as critical supports to our patients
• NYCHL is founded on two dedicated Health Links Care Coordinators from the Central CCAC
• Care Coordinators are funded through existing CCAC operational dollars, and provide intensive care coordination for Health Links patients
• Patients are supported through active use of the Coordinated Care Plan, and a high-touch approach to care coordination:
• Case conference at the start of interventions to bring the full team together• Increase in face-to-face interactions between patient and care coordinator• Regular touch points until the patient is more stable (e.g. initially weekly)• Creative solutions that focus providers on meeting patient/caregiver goals• Incorporated Personal Computer Video Conferencing (PCVC) and expect to
increase the use of OTN to support patients and caregivers• Actively use the Coordinated Care Plan to guide the patient’s care
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The NYCHL model engages the patient and care team to collaborate at key changes
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Inpatient
ED
PCP
Community Services
Engage Patient
Engage Physician
Hold Case Conference Complete CCP Follow up on
actions
Two HL Care Coordinators
(CCAC employees)
Patient Identified
Patient situation changes
EMSMental Model Changes
Audience Poll: Whiteboard Session
• Consider examples of where you have changed a Mental Model
• Describe the success in achieving that change in a few words
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Evolving our Systems
Thinking
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Systems Thinking
The ability to look at what generates patterns of behaviour and the
underlying causes of that behaviour. Systems thinking is the about
restructuring ideas to uncover the causes of core problems.
• Several factors have encouraged a systems-thinking approach within our Health Link:
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Shared Vision and
Common Language
Multi-Organization
Steering Committee
Committed Partners
Flexible Leadership
Incremental Growth
Goals and
Outcomes Oriented
Patient and Family
Centred
Change
Management
Focused on
Sustainability
4 7 820
3237
4454
6883
96113
131
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Faster is not always better: NYCHL is slowly accelerating enrollment with new intake sources
Jul Oct Nov
2013 2014
Aug Sep Dec Jan Apr MayFeb Mar Jun Jul Aug
Cumulative # of patients
Launched Health Link
(Retrospective)
Real-time inpatient
referrals (LACE)
Piloted ED patients
Real-time PCP referrals
(PRA)
Real-time CCAC referrals
(DIVERT)
Community Support & EMS
referrals
• Started small, focused on key comorbiditiesbased on initial needs analysis:
• COPD, CHF, Stroke, Pneumonia, UTI, MentalHealth
• Rapid cycle testing and modeladjustments have expanded criteriato enrol more patients each month
4 8 9 1424
As the model matures, NYCHL is actively transitioning patients back to regular care
Jul Oct NovAug Sep Dec Jan Apr MayFeb Mar Jun Jul Aug
Cumulative # of patients that have been transitioned off Health Links
• As patients achieve goals and/or stabilize we are transitioning them back to their Family Physician
• Ongoing support by the CCAC is provided at a lower intensity of care
• Patient onboarding and transitions back to their medical home are monitored for outcomes
Initiated transitions 29
For patients, small strategic action can have a big impact
Care Coordinator continues to work with patient to address unmet goals, and will be hosting another case conference for the team to regroup.
big impact
“Health Linkschanged my
life”
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Preliminary outcome analysis of NYCHL patients indicates a reduction in ED visits
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• Early data suggests an average reduction of ~4 ED visits per patient after the CCP is initiated, although sample size is small to be conclusive
3131
Although length of stay is not impacted, NYCHL
patients have fewer inpatient admissions
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• Early data suggests an average reduction of ~3 inpatient admissions per patient after the CCP is initiated, although sample size is small to be conclusive
Surveys also show that centring on the patient
and their medical home is providing value
• In the 11th law, Senge states: “People commonly see themselves as the
center of the process, and they blame others for their problems”
• Patients surveyed when they start with NYCHL and every 4 months feel:• Valued and supported by health care team• Assured that health care providers are working as a team• Still don’t always know who to call if they need help
• Family Physicians with active Health Link patients also found value:• Over 80% find Health Link is helpful in managing patient care• The introduction of case conferences for every patient is rated as the most
beneficial aspect of Health Link• Most physicians use the CCP on an occasional basis or never, especially
those who already work in an EMR environment,• Interest in an electronic CCP that is not integrated into their EMR is limited
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Audience Poll: Whiteboard Session
• Consider examples of where you have faced challenges in bringing stakeholders to a systems thinking approach to managing complex patients
• Describe the challenge in achieving that change in a few words
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Advancing the
North York Central Health Link
Rapid cycle improvement and model expansion
will guide activities for NYCHL
• Our NYHCL Steering Committee continues to assess aspects of our model to enhance care coordination and delivery for patients
• Over the next 6-months of the NYCHL pilot, key activities will include:1. Optimizing care for Mental Health patients
• Community MHA prioritizing Health Links patients• Need to increase shared care between psychiatry and primary care
2. Increasing End of Life discussions• Hosting CME for primary care• Training Health Link Care Coordinators
3. Expanding Health Link knowledge across CCAC care coordinators4. Enabling electronic access to CCP and secure messaging5. Improving access to specialists for case conferences and through e-Consults6. Engaging differently with patients who decline Health Link participation
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NYCHL is shifting focus on ‘quick fixes’ to an
archetype committed to long-term sustainability
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Technology
Ease of Access
Privacy
Communication
Education
Support
Commitment
Connections
In-Kind Value
Governance and
Leadership
Physician Engagement
Active Partnerships
Information Sharing and Connectivity
Intensive Care Coordination for Complex Patients
Collaboration
Prioritization
Coordination
• Sustained success relies on champions to develop processes and systems that can continually adapt to the changing health landscape
