South West Primary Care Alliance: Oxford November 29, 2017swpca.ca/Uploads/ContentDocuments/PCA June 2018.pdf · Regional Team • 2 Advanced Practice Leads • 1 Spine (ISAEC) •

SOUTH WEST PRIMARY

CARE ALLIANCE: OXFORD

JUNE 7TH, 2018

Sub Regional Clinical Lead: Dr. Jitin Sondhi

Primary Care Alliance Co-Chair: Dr. Gerry Rowland

Agenda

• Review of Previous Minutes (completed online)

• Update on MSK engagement

• Review of SRIT

• PINOT and CHC

• Health Links

• New Structured Psychotherapy services

• Big White Wall

• BounceBack®

• Health Links

MSK Strategy

• Strategy is being rolled out provincially

• Based on numerous successful pilot projects illustrating

improved patient experience

• Initial roll out is based on provincially standardized model

with goal to evolve to the needs of the subregion

• Decision regarding Assessors is based on funding

What actions are required to Improve Ortho

wait times?

MSK Assessment Demand to Funded Staffing Resources

• Each assessor works a 37.5 hour paid week with 4 weeks vacation and 12 statutory holiday days off (228 working 7.5 hour days) = 1710 hours

• Assessments are 60 minutes long

• MOHLTC allocations are based on each assessor completing 1150 assessments per year (represents ~65% of total available working hours)

• 60% of hip and knee referrals & 10% of spine surgery referrals are surgical

• Approx. 50% of low back pain (L spine surgery referrals) meet ISAEC program criteria

MSK

Pathway

Actual surgical volumes

(16/17 actuals)

# of

assessme

nts

required

# of

assessors

required

Hip and Knee 3664 6106 ~5.3 FTEs

Lower non-

emergency

spine

surgeries

658 (~50% ISAEC)(Non-Instrumented Day Surgery, Non-

Instrumented Inpatient Surgery, and

Instrumented Inpatient Surgery)

3290 ~2.85 FTEs

Regional Team• 2 Advanced Practice Leads

• 1 Spine (ISAEC)• 1 Hip/Knee (CIAC)

• 8 Assessors for the regiono 5 Hip/knee Assessors

(population based allocation)o 1 Grey Bruceo 0.8 Huron Pertho 0.6 Oxfordo 2.1 London/Middlesexo 0.5 Elgin

o 3 Spine Assessors(population based allocation)o 0.8 North (GB & HP)o 1.2 Central (LM)o 1.0 South (Elgin & Ox)

Recommended Home Base & Coverage:

GBHS– 1 Hip and Knee AssessorLWHA – 1 ISAEC Assessor (cover GB & HP)HPHA (Stratford) – 1 Hip & Knee assessor (1 day/week at SMGH)STEGH – 1 ISAEC assessor (2.5 days/week at WGH)WGH – 1 Hip & Knee Assessor (2.5 days/week at STEGH)LHSC – 2 Hip & Knee Assessors, 1 Spine Assessor*APLs provide additional assessment supports across the region where needed*

South West LHIN Population• 925,300 (2011 census)

• 20.6% of the pop. Self-report OA• 16.6% of the pop. are 65 years and

older (150,289)• 29,944 live in Grey Bruce (20%)• 24,158 live in Huron Perth (16%)• 17,549 live in Oxford County

(12%)• 64,994 live in London Middlesex

(42%)• 13,644 live in Elgin (10%)

Hip and Knee Assessor

Spine (ISAEC) Assessor

Advanced Practice Lead

Next Steps/Key Planning Milestones

• Finalizing recruitment approach of assessors across all sub-regions in the

South West LHIN

• Finalize referral forms

o Support for building new forms into EMRs will be enabled by Partnering for

Quality

• Implementation and central intake “go-live” in September, 2018/19 – waitlist

management vs. new referrals to be finalized.

1

SRIT Updates

• Transition for patients across sectors

• LENS (ED notification tool)

• Discussion around improving thehealthline.ca

• Improving accessibility, interface and validity of data

• Reviewed importance of Housing as a priority and to

improve knowledge of resources in order to better inform

our respective sectors

• Access to Team Based Care

• RAAM clinics in Oxford

• CSSN (Community Support Services Network)

Access to Team Based Care

• Access to Team Based Care (Previously PINOT)

• Model of access to resources for Primary care provided by London

InterCommunity Health Centre

• Counseling

• Dietitian/nutrition

• Diabetes educators

• Foot care

• Physiotherapy

• Etc.

• CHC may be able to provide the same resource to our

numerous physician groups regardless of their model

• Respect physician autonomy for decision on types of practice and

ensure patients in that practice have equal access to resources.

• Had our first meeting with plans for second meeting in Fall.

RAAM Clinic Oxford

• Rapid Access Addiction Medicine

• Plan is to utilize CHC with a provider

• Dr. Ken Lees willing to mentor provider in suboxone

prescribing.

• Currently in early phases but may be able to implement

• Points to review

• Renumeration of providers working in clinic

Community Support Services Network

• One number for support services

• VON is lead agency

• Help patients, caregivers and providers navigate services

and resources needed

• No multiple phone calls and multiple documents and brochures

• No coordinating services by recepients

• One number to review care and services

Community Support Services

in Oxford• Meals and Nutrition – includes: Community Dining; Hot Meals on Wheels; Frozen Meals on Wheels; Nutrition

Screening

• Education and Supports – includes: Adult Day Program; Individual and Group Support; Education; Information and System Navigation, Caregiver Support

• Safety and Reassurance – includes: Visiting & Telephone Reassurance; Education & Behavioural Supports; Support on Hospital Discharge; Personal Emergency Response System; Shopping Services

• Health and Wellness – includes: Social Programs; Group Fitness; Self-Management; Bathing; Health and Education; Falls Prevention; Medication Management Supports; Counselling and Social Work Supports

• Support in the Home – includes: Personal Support; House Keeping; In-Home Meal Preparation; In-Home Exercise; Respite; Caregiver Relief;

• Transportation – includes: Medical; Social; Errands; Escorts

• Intensive Support Programs – includes: Assisted Living; Adult Day Programs; Overnight and Day Respite; Supportive Housing

• Specialized Services – includes: includes: Memory Loss/Dementia; Acquired Brain Injury; Adults with Developmental Disability

Alzheimer's Oxford

Chesire

Dale Brain Injury

Ingersoll Services for Seniors

Participation House

Tilsonburg Multi-Service Centre

VON


in Oxford

Work in

Progress….

.

• All sub-regions have Lead Agencies who are coordinating CSS network’s central intake

• All will be using the same Central Intake Application

• The Lead Agency in Oxford is VON

• The Intake Team is housed at VON Oxford office

• The model has been developed as a pilot in Huron-Perth. In the other sub-regions the work has been occurring for the last year

• The Intake Team is just beginning to work together and testing out its processes

• It is anticipated that the Intake Team will be fully operational by June 2018

• When it is fully operational you will be notified and further information will be provided to you

• Information to you is important so that you are aware of what is coming


in Oxford

What this means

for you….• A resource to contact if you are

unsure what services could

support a client through one

number

• The ability to work with CSS in

a cohesive way (vs. one service

at a time)

• Stronger connection between

SWLHIN delivered services and

CSS as the Home &

Community Services sector

• Stronger connection with

primary health care, hospital,

mental health & addiction and

other community services

Meeting the demand in Ontario for faster access to psychotherapy services

Andrew FairbairnCanadian Mental Health Association (CMHA) Ontario DivisionJune 7, 2018 – Presentation to PCA

Funded by the Government of Ontario

Mental health facts

• 1 in 5 Canadians will experience a mental health or addiction issue in their lifetime

• By the time Canadians reach age 40, 1 in 2have – or have had – a mental illness

• Individuals aged 15-24 are more likely to experience mental illness than any other age group

• Men experience higher rates of addiction than women, while women experience higher rates of mood and anxiety disorders

• Depression and anxiety can be managed, but if left untreated, tend to get worse

Meet Sarah

• 30-year-old new mom• Has difficulty coping with motherhood• Reports sadness, low energy, anxiety, sleeping

problems to primary care provider at checkup• Is diagnosed with mild to moderate

depression• Is prescribed cognitive behavioural therapy

(CBT) without medication• Incurs long wait time to access in-person

counselling

Sound familiar?

Good news for more than 60,000 Ontarians

Primary Audience: Family Doctors and Nurse Practitioners in Ontario

Expansion of two self-helppsychotherapy services

Big White Wall, an online peer support andself-management tool, coordinated by theOntario Telemedicine Network (OTN)(Service available in English only)

BounceBack®, a telephone coaching program, managed by the Canadian Mental Health Association (CMHA) Ontario and CMHA York and South Simcoe

Client considerations forself-help psychotherapy services

• Client’s age• Level of depression or anxiety (must be in the

mild to moderate range)• Therapeutic treatment options• Client’s motivation level• Client’s profile

24/7 access to other mental health services across the lifespan

Contact the Mental Health Helpline at ConnexOntario

1 (866) 531-2600mentalhealthhelpline.ca

Big White Wall

Big White Wall:What is it?

Online peer support and self-management tool:

• 24/7 online support from the peer community• Can talk anonymously with other clients feeling the same way• Can take courses on depression, anxiety, weight management• Can express feelings using images, drawings and words to make bricks

that are posted to the Wall

Big White Wall:Benefits

Study conducted by Big White Wall revealed:

of clients saw improvement in at least one aspect of their well-being

70% 46%of clients reported sharing an issue for the first time

35%of clients experienced mental health-related absence from work; 51% of those clients reported that using Big White Wall reduced their time away from work

Big White Wall:Benefits (con’t)

Research study led by OTN with Lakeridge Health, the Ontario Shores Centre for Mental Health Services, and Women’s College Hospital revealed in some users:

A decrease in levels of reported depression and anxiety

An increase in perceived mental health recovery, which includes self-rated ability to self-manage

Big White Wall:How to refer

Suitable for clients:• 16 years and older with mild to moderate depression and anxiety• At low risk of suicidal self-harm• Who have a basic level of literacy and comprehension• Who can access a phone or computer with Internet• Seeking an adjunct to face-to-face individual or group therapy• Seeking community peer support• Looking for after-hours mental health support

Sign up at otn.ca/bigwhitewall (enter email, user name and password)Any questions? Email [email protected]

BounceBack

BounceBack:Background

• Developed by Dr. Chris Williams, a psychiatrist at the University of Glasgow in Scotland

• First adopted by CMHA British Columbia in 2008. Since then, more than 40,000 clients have been referred

• Two years ago, CMHA York and South Simcoe piloted the program in Ontario, with funding from the Central LHIN

• In October 2017, as part of the Government of Ontario’s investment in psychotherapy services, BounceBack was launched across Ontario

BounceBack:The approach

Developed by Dr. Chris Williams, psychiatrist, expert in cognitive behavioural therapy,Professor of Psychiatry at the University of Glasgow.

BounceBack:Telephone coaching & workbooks

Telephone coaching using skill-building workbooks:

• Referral is primarily by family doctor, nurse practitioner, or psychiatrist

• Clients can also self-refer• Clients are called within 5 business days of referral being

submitted• Coaches conduct 3-6 sessions with clients using workbooks

chosen collaboratively and based on clients’ current needs• Popular workbooks: Being assertive; Changing extreme and

unhelpful thinking; Overcoming sleep problems• Coaching is available in 16 languages

BounceBack:Workbooks

BounceBack:Short format & youth booklets

BounceBack:Telephone coaching & workbooks

• Coaches are not counsellors, but trained in educational and motivational coaching

• Coaches assist clients with skill development, provide motivation, and monitor progress

• Coaches are overseen by clinical psychologists• Coaches assess and monitor clients for risk of harming themselves or

others on every call• Primary care providers are clinically responsible for client care and are

kept informed of client progress

Initial Contact(within 5 business days of referral)

Session 1 Assessme

nt(within 2 weeks of

initial contact)

BounceBack:Client journey

Close case, post-program scores, letters sent to participant and referrer (30 min)

Session 2(2-3 weeks

from S1)

Sessions3-6

(2-3 weeks between sessions)

Completion Session

(2-3 weeks from final session)

Booster Session

(within 6 months of completio

n)

Further support, reinforce skills (15-30 min)

Coaching, send next workbook(s) (15-20 min)

Coaching, send next workbook(s) (15-20 min)

Eligibility assessment & pre-program scores + send initial package including introductory workbooks or short format booklets & a short letter to referrer (45 min)

Establish contact & confirm contact details (If unreachable, letters sent to referrer and client)

BounceBack:Online videos

BounceBack Today online video series:

• Offers practical tips on managing mood, sleeping better, building confidence, increasing activity, problem solving, healthy living

• Available in English, French, Mandarin, Cantonese, Punjabi, Arabic, and Farsi

Watch videos at:bouncebackvideo.ca(access code: bbtodayon)

BounceBack:Evidence-based benefits

Pilot program in CMHA York and South Simcoe with 461 clients who completed the program from August 2015 to December 2017 showed coaching-program effectiveness:

Depression and anxiety

decreased by almost 40%

11.610.6

7.2 6.5

0

2

4

6

8

10

12

14

Pre-BounceBack Post-BounceBack

Patient Health Questionnaire(PHQ-9; depressive mood)

Generalized Anxiety Disorder(GAD-7; assessment scale)

BounceBack:Benefits

Satisfaction survey conducted by CMHA York and South Simcoe with119 clients who completed BounceBack showed:

would recommend BounceBack to a friend or family member

92%found the CBT workbooks easy to read and helpful

94%liked receiving the service by telephone

95%

Referral form can be accessed or submitted online at: bouncebackontario.ca

Suitable for clients:• 15 years or older• With mild to moderate depression (PHQ-9) score

between 0-21 (with or without anxiety)• Not at risk to harm self or others• Not significantly misusing alcohol or drugs• With no personality disorder or manic episodes

within 6 months• With sufficient concentration and motivation to

engage in the program

For telephone coaching + workbooks (referral required)For online videos (referral not required)

BounceBack:How to refer

BounceBack:Who to contact

For more information on BounceBack or to access the referral form or resource materials:Visit: bouncebackontario.ca

Questions about telephone coaching or referral form:Contact BounceBack team at: 1 (866) 345-0224

Questions related to marketing opportunities:Contact BounceBack engagement coordinators at: [email protected]

mailto:[email protected]

Thank you! Any questions?

BounceBack ®

• For Fillable PDF, Telus and Accuro versions of the form

click on the link to the SW PCA website

• http://www.swpca.ca/15/EMR_Resources/

COORDINATED CARE PLANNING:

BETTER TOGETHER

Oxford Health Link

Health Links Approach to Care

• The Health Links philosophy of care centres around a

process called Coordinated Care Planning.

• This approach brings team members together to develop

new and better ways to support individuals whose care is

not well-managed.

How CCP differs from traditional Care

Planning

Patient/Client:

• identifies his/her goals

• identifies who should be

present

• consents to allow those

outside the (medical)

“circle of care” to

participate

• goals drive the conference

Why do we need Coordinated Care

Planning?

Patient/clients:

• Most people with complex care needs see a lot of different

people for support and it can be difficult to manage.

• Coordinated Care Planning (CCP) brings all of the people

a person needs for their care, together, in one meeting.

• The coordinated care plan is based on the person’s

goals.


Planning?

Collaborative care:

• Shared accountability & improved communications across providers/sectors.

• Flexible options to join the CCP meeting.


Planning?Sustainable Healthcare:

• 5% of the population account for 66% of health care costs; 1%represents 30% of the spend.

• 75% of complex patients see six or more physicians, with 25% of those seeing more than 16.

• Cost of care for a senior is three times higher.

• Oxford specific, of the top 1% of high cost users 48% are 75+ years old (2015/16 data)

• With no changes, the impact of demographics alone would add $24 billion in spending within 20 years, 50% increase, not including inflation.

Health Links: Initial Focus July 2013 Ministry of Health & Long-Term Carehttp://ocfp.on.ca/docs/default-source/newsbriefs/hl102-initial-focus.pdf?sfvrsn=0

Coordinated Care Planning: Sustainable

2017:

"By Ontario's estimates, we'll spend $29 billion over the

next five years alone on mental health and home care.

The federal government has offered to provide roughly

seven per cent of that total, or $1.9 billion...”

- Canadian Health Coalition, 2017, p. 10

Provincial Identification: Who might benefit

from a CCP

• Palliative care - 90% of those at end of life are in the Target Population• Mental health - more than 50% of clients in the Target Population have

mental health conditions• Frail seniors - 70% of frail seniors are in the Target Population

1 Sepsis 28 Ischaemic Heart Disease2 Brain Injury 29 Cardiac Arrhythmia3 HIV/AIDS 30 Congestive Heart Failure4 Malignant Neoplasm (cancer) 31 Stroke5 Blood disorders (anemia, coagulation) 32 Peripheral Vascular Disease & Atherosclerosis6 Coma 33 Influenza7 Diabetes 34 Pneumonia8 Cystic Fibrosis 35 Chronic Obstructive Pulmonary Disease9 Mental Health conditions 36 Asthma

10 Dementia 37 Ulcer11 Substance-related disorders 38 Hernia12 Schizophrenia & delusional disorders 39 Crohn's disease13 Depression 40 Liver disease (cirrhosis, hepatitis)14 Bipolar 41 Arthritis & related disorders15 Anxiety disorders 42 Osteoporosis (pathological bone fracture)16 Eating disorders 43 Renal Failure17 Personality disorders 44 Low Birth Weight18 Developmental disorders 45 Other Perinatal Conditions19 Huntington's disease 46 Congenital Malformations20 ALS (Lou Gehrig's disease) 47 Fracture21 Parkinson's disease 48 Amputation22 Multiple Sclerosis 49 Palliative Care23 Epilepsy & seizure disorders 50 Pain Management24 Muscular dystrophy 51 Hip Replacement25 Cerebral Palsy 52 Knee Replacement26 Paralysis & spinal cord injury 53 Transplant27 Hypertension 54 Hemiplegia

97.6% of high cost users have at least one condition

Average cost per patient by number of

conditions

Exploring Social Determinants

• Coordinated Care is not just meeting medical needs.

• Housing, social isolation & the need for social

supports have been identified as barriers to optimizing

outcomes.

• Understanding the role that social determinants play in

the health of an individual is key to holistic care.

Applied Health Research Questions

(AHRQs)

Data

• The next couple of slides include data from Laura

Rosella, ICES Scientist and her research team via the

Applied Health Research Questions (AHRQs)

• With this data they created a report titled, Characterizing

Users of Health Care in Oxford County by Health Care

Expenditure Categories

Proportion of Total Annual Health Care

Costs, Oxford County 2015/16

Summary of Key Characteristics Oxford

County High Cost vs. Mid Cost Users

• The two characteristics that we are able to influence include:

• “Likely to have perceived their health and community ties as poor”

• “Likely to have had unhealthy behaviours that are modifiable (e.g., obesity, physical inactivity)”

• Chronic disease prevention and a strong focus on health equity is important for reducing the high cost user burden

• Lower cost groups (top 6-10%) are an important target for prevention efforts –this group shares characteristics that put them at risk for becoming a high cost user

2017 Utilization Data for Oxford County

2017 Oxford patient level data: 4+ high

cost conditions

502 people

• 4 – 18 high cost conditions

• individuals aged 0 – 101

• 270 female; 231 male; 1 other

• 72 were never admitted

• 1536 admissions (430 individuals)

• 1 individual was admitted 12 times

• 185 have active home care referral

Frequent ED utilization in Oxford

502 individuals:

• ED/UCC Visits: 12 – 152

• ED/UCC Visits (since 2008): 13 - 704

2017:

• 121 visited the ED 12 times

• 27 visited the ED 20+ times






Frequent ED utilization in Oxford

Individual A

• ED visits (12 months): 112

• Since 2008: 584 ED visits

• How many institutions: 9

• ED visits: COPD, MH/SA

• Age: 22

Individual B

759 individuals:120 have been to the ED 10+ times15 have been to the ED 20+ times

• ED visits (12 months): 74

• Since 2008: 261 ED visits

• How many institutions: 5

• ED visits: MH/SA

• Age: 31

Q4 – 2017-2018: Oxford Outcome

Measures

Benefits of Coordinated Care Planning

• Patient/client identifies what is important to drive their care plan.

• Holistic care, inclusive of physical health, mental health (addictions) and social determinants of health.

• Provincially standardized data collection tool that will allow information to be shared.

• Clinical Connect (web-based data management) supports sharing data in “real time”.

• Future development that could be used to share across the provincial EMR (CHRIS, Client Health Related Information System).

Better Together: a patient/client

story…

Background & Referral Source

• Individual is 60 years old

• Oxford County Human Services (Ontario Works) made

referral to Community Health Centre for Outreach

Worker

• After discussion with client, Outreach Worker made a

referral for a CCP

Get to know Sally*…• Has Primary Care

• Sally would call Physicians office multiple times a month and when she met with Physician it would common for her appt to be 1 hour in length

• Transportation is a barrier

• Resides in rent geared to income housing by herself

• No faith in social services “I have tried every resource there is and no one can help me with what I need”

• No social connections, Sally has a daughter who lives at a distance though their relationship was estranged

* name has been changed to protect client identity

Get to know Sally*…

• Medical: Fibromyalgia

• Mental Health Diagnosis: depression, anxiety, bi-polar, borderline, complex grief, suicidal

• SDoH: Income and Social Status, Social Support Networks, Employment/Working Conditions, Social Environments, Physical Environments, Personal Health Practices and Coping Skills.

* name has been changed to protect client identity

Sally’s Goals

1.Get her drivers license back - has been unable to pay

the renewal fee

2.File for the past 2 years of income tax

3.Relocate to Peterborough - closer to her daughter

• Note – Sally was not comfortable using the language

“goals” and identified the items listed above as her “wish

list”

Coordinated Care Planning TeamCCP Care Team:

• Home & Community

• Social Worker

• Primary Care

• OCCHC - Outreach

• CMHA - Case Manager

• Public Health – Smoking Cessation

Action that resulted from initial CCP

meeting

• Social Worker – supported Sally in completing her

income tax and inquired if Salvation Army is able to assist

financially & gathered information re: housing list for

Peterborough

• Care Coordinator – contacted Sally’s physician re: his

capacity to join client’s care team

• Outreach/Health Link – researched drivers licence fees

& advocated for CMHA to complete Sally’s intake for case

management in her home (as per her request)

On-going Progress

• CMHA Intake complete; Sally is now receiving Case

Management support

• CMHA Case Manager now attends Sally’s Primary Care

appts with her and helps to prioritize her needs

• Tillsonburg Tax Clinic agreed to process Sally’s taxes.

Tillsonburg Salvation Army agreed to cover the cost to

allow Sally to file

On-going Progress

• Advocated to ensure Sally’s ODSP medical report was

completed, she has now been approved for ODSP

• Contacted Service Ontario, re: drivers licence and

confirmed no eye exam necessary (Sally had anxiety re:

eye exam)

• Connected Sally to dental care and she is receiving

ongoing treatment

On-going Progress

• Encouraged Sally to make and attend an optometrist appt, advocacy to Lion’s Club to assist in covering the fee for new glasses

• Provided Sally with winter clothing items (coat, hat and mitts)

• Completed housing application for Peterborough area and is currently on the waitlist

• Daughter spent Christmas with Sally and supported Mom in purging items from her apartment

• Sally now receives support from the Integrated Hoarding Response

• “I had to share my news with you. I got up at 10:00 a.m.

and it is now 11:12 a.m. and I haven't shed a single tear. It

feels like I'm in someone else's body and get this .... I

caught myself singing to my cat!”

Identification Strategy & Next Steps

• Are their people on your caseload whose care is not well

managed?

• Do you have the Sally’s who call your office multiple times

a week/month and/or consume much of your time?

• Referral form for CCP’s

http://healthcareathome.ca/southwest/en/partner/Docume

nts/Referral%20South%20West%20LHIN%201-1-

16%20FORM%20V2.pdf

http://healthcareathome.ca/southwest/en/partner/Documents/Referral South West LHIN 1-1-16 FORM V2.pdf

1 Sepsis 28 Ischaemic Heart Disease2 Brain Injury 29 Cardiac Arrhythmia3 HIV/AIDS 30 Congestive Heart Failure4 Malignant Neoplasm (cancer) 31 Stroke5 Blood disorders (anemia, coagulation) 32 Peripheral Vascular Disease & Atherosclerosis6 Coma 33 Influenza7 Diabetes 34 Pneumonia8 Cystic Fibrosis 35 Chronic Obstructive Pulmonary Disease9 Mental Health conditions 36 Asthma

10 Dementia 37 Ulcer11 Substance-related disorders 38 Hernia12 Schizophrenia & delusional disorders 39 Crohn's disease13 Depression 40 Liver disease (cirrhosis, hepatitis)14 Bipolar 41 Arthritis & related disorders15 Anxiety disorders 42 Osteoporosis (pathological bone fracture)16 Eating disorders 43 Renal Failure17 Personality disorders 44 Low Birth Weight18 Developmental disorders 45 Other Perinatal Conditions19 Huntington's disease 46 Congenital Malformations20 ALS (Lou Gehrig's disease) 47 Fracture21 Parkinson's disease 48 Amputation22 Multiple Sclerosis 49 Palliative Care23 Epilepsy & seizure disorders 50 Pain Management24 Muscular dystrophy 51 Hip Replacement25 Cerebral Palsy 52 Knee Replacement26 Paralysis & spinal cord injury 53 Transplant27 Hypertension 54 Hemiplegia

97.6% of high cost users have at least one condition

How to make a referral

The provider experience…

• “Literally unlike anything I have ever participated in

before – it’s a dialogue instead of a monologue”

• "I feel the client was able to hear from all parties how

her goals could be achieved and could feel the

support of all involved. I feel this conference was a great

success“

• “Very client centred with the goals and client driven”

• “Great to meet other supports"

• “Better understanding of my client”

QUESTIONS?

Abbie Boesterd, BSW, RSWEngagement & Adoption LeadOxford Health LinkOxford County Community Health Centre(formerly the Woodstock & Area Community Health Centre)519.539.1111, x246

[email protected]

What Are We Finding in the South West LHIN?

As of September 30, 2017, the rate of unscheduled visits to the emergency department for residents supported by a Coordinated Care Plan (CCP) declined by 32% within 3 months, and 23% within 6 months of their initial care conference date1.

1 Data is compared to utilization in the 3 and 6 months prior to CCP conference date. Source: CHRIS; NACRS.

Rate of Unscheduled Emergency Department Visits for Residents Supported by aCoordinated Care Plan (CCP), South West LHIN: 2014-2017.

(n = 1,440) (n = 1,440)(n = 937) (n = 586)

157.4

106.9

0

50

100

150

200

250

300

0-3 Months Prior to CCP Completion 0-3 Month Post CCP Completion

# E

D V

isit

s p

er 1

00

Ind

ivid

ual

s

264.4

204.8

0

50

100

150

200

250

300


# E

D V

isit

s p

er 1

00

Ind

ivid

ual

s

CCP Completion Date CCP Completion Date

32%

23%

As of September 30, 2017, the rate of unplanned admissions to hospital for residents supported by a Coordinated Care Plan (CCP) declined by 33% within 3 months, and 29% within 6 months of their initial care conference date1.

1 Data is compared to utilization in the 3 and 6 months prior to CCP conference date. Source: CHRIS; DAD.

(n = 1,440) (n = 1,440)(n = 937) (n = 586)

68.6

46.3

0

20

40

60

80

100

120


# A

cute

Dis

char

ges

per

10

0 I

nd

ivid

ual

s

102.0

72.0

0

20

40

60

80

100

120


# A

cute

Dis

char

ges

per

10

0 I

nd

ivid

ual

s

Rate of Unplanned Admission to Hospital for Residents Supported by aCoordinated Care Plan (CCP), South West LHIN: 2014-2017.

CCP Completion Date CCP Completion Date

33% 29%

On average, the total number of days stayed in hospital for residents supported by a Coordinated Care Plan (CCP) declined by 4.1 days within 3 months, and 5.8 days within 6 months, of their initial care conference date1.

1 Data is compared to total hospital days stayed in the 3 and 6 months prior to CCP conference date. Source: CHRIS; DAD.

Average Number of Days Stayed in Hospital for Residents Supported by aCoordinated Care Plan (CCP), South West LHIN: 2014-2017.

(n = 1,440) (n = 1,440)(n = 937) (n = 586)

8.5

4.4

0

2

4

6

8

10

12

14


Aver

age

# D

ays

Sta

yed

in

Ho

spit

al

12.3

6.5

0

2

4

6

8

10

12

14


Aver

age

# D

ays

Sta

yed

in

Ho

spit

al

CCP Completion DateCCP Completion Date

4.1 days 5.8 days

Hospital use declining for clients

supported by a CCP

• Outcomes are restricted to those who were alive over the complete follow-up period (E.g.: those that survive to 3 months post CCP; 6 months post CCP).

• Follow-up is focused on the immediate time surrounding the CCP

• We expect service use was lower for some time period before the CCP, and, will increase again in the future as the patient’s diseases progress.

• All acute hospital utilization is counted: no exclusions for mental health visits/admissions; use associated with injury

Return on Investment (RoI) – Grey Bruce

Health Link

CCP - Return on Investment – Grey

Bruce

• Reduction in ER visits 55.6%

• Reduction in Hospitalizations 29.3%

• Reduction in Total Acute Hospital Days 27.4%

• Reduction in Acute Hospital Days 44.3%.

Grey Bruce - Impact Analysis – Hospital

resources

Grey Bruce - Impact Analysis – Home &

Community

Grey Bruce - Systemic Costs

Grey Bruce - Systemic Costs