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Transitions of Care: Supporting You, Your Patients &
Your Priorities Primary Health Care Integration Network
Dr. Brad Bahler & Julie Schellenberg
Integration Live Live!
Integration & Management Continuity and Transitions
3
…a new approach to healthcare service delivery is needed — and Alberta is taking the lead.”
Dr. Verna Yui AHS President & CEO
“Alberta Health Services, like all health systems across Canada, will need to make
transformative changes to how we deliver services in order to improve quality and safety …
What matters to patients?
I’ll have what I need when I return home, I’ll know what I need to do, and my doctor will know what’s going on.
@PatientCommonSense
What patients are experiencing
ED notification
23%
Family physicians notification for ED visit and hospital discharge
(Commonwealth Fund)
Follow-up
35-56% within 1week
77-92% within one month
AMI, HF & COPD patients in AB/SK
(CIHI)
Hospital to Home
Transitions
System Foundations for Integration
Achieving Continuity through Integration
Keeping Care in the Community
Linking to Specialty and Back
Hospital to Home
Transitions
System Foundations for Integration
Achieving Continuity through Integration
Keeping Care in the Community
Linking to Specialty and Back
By Joe Zachs from Pune, India The Bombay Dabawalla) [CC BY 2.0 http://creativecommons.org/licenses/by/2.0
Integration Live Live!
Supported Transitions Committee CALGARY
Calgary Zone Primary Care Action Plan
Enhanced support for
at-risk patients
Web Registry
Enhanced Hospital
Discharge
Supportive Transitions Committee
Committee Members
Sandra Athron AHS
Leanne Kiss Chair, Informational Continuity, CFPCN
Peter Rymkiewicz Evaluation Lead, MPCN
Keith Bradford CFPCN
Jana Lait AHS
Dr Monica Sargious AHS
Lorraine Bucholtz Chair, CFPCN
Mandy McCabe AHS
Oliver Schmid Chair, Relational Continuity, SCPCN
Christopher Cameron Corresponding Member, CWCPCN
Allison Mirotchnik AHS
Dawn Shave CRPCN
Stephanie Crichton Corresponding Member, CRPCN
Regan Paddington HPCN
Shelly Storozuk SCPCN
Amy Deagle CRPCN
Yvette Penman Corresponding Member, BVPCN
Dr Ann Vaidya AHS
Rod Iwanow AHS
Wendy Pratch AHS
Stephen Wan CFPCN
Jake Jennings Co-Chair, Management Continuity, AHS
Janelle Richer Co-Chair, Management Continuity, MPCN
Gloria Wilkinson Public Member, PMHAC
It takes a team
Integration Live Live!
Let’s go exploring! Who’s up for a Expedition?
Let’s go exploring! Who’s up for an Expedition?
Travelling partners
Expedition interests
Travelling in harmony
Pick and plan
Travel and adapt
Post and recommend
Zone Journey
Planning
#4 What are the solutions you want to test?
#1 Are you ready to work together?
#5 Do your solutions work?
#2 What are your pain points?
#3 How will you work together to develop solutions?
#6 How will you build up (and build out) your successes?
Hospital to Home Transitions – PHCIN Supports
Stakeholder mapping
Where you’re at… What PHCIN can support…
Data to inform “the why”
Facilitator to support
collaboration
Facilitator to support
identification of pain points
Transition Mapping
Data to inform patient
population
Scoping
Facilitator to support process to develop your
solutions
Evaluation of potential
solutions to align with evidence
P l a n n i n g P h a s e
#1 Are you ready to work together?
#2 What are your pain points?
#3 How will you work together to develop solutions?
Development of integrated care model
Where you’re at… What PHCIN can support…
Support to develop and
choose measures
Facilitator to explore options
and design prototypes
Facilitator to support
identification of pain points
Change management
during implementation
Support to test prototypes:
“test small & learn quick”
Business case for re-investing
gains
Facilitator for shared
decision-making on next
steps
Data analysis to quantify gains
and inform reinvestment
#4 What solutions do you want to test?
#5 Do your solutions work
#6 How will you build on and broadcast your success?
E x p e d i t i o n P h a s e
Regular Provincial Check-ins
It’s about the PHCIN Supporting…
Our commitment
We will work with you from your starting place
We will work with you at your pace
We will have fun and celebrate
Integration Live Live!
Coming PCN Leads Fall 2018 – Brad & Julie’s Excellent Adventure!
Integration Live Live!
Transitions of Care:�Supporting You, Your Patients & Your Priorities Slide Number 2Integration &Slide Number 4What matters to patients?What patients are experiencingSlide Number 7Slide Number 8Slide Number 9Slide Number 10Slide Number 11Calgary Zone �Primary Care Action PlanSlide Number 13Slide Number 14Slide Number 15Let’s go exploring! Who’s up for a Expedition?Let’s go exploring! Who’s up for an Expedition?Slide Number 18Slide Number 19Slide Number 20Excitement!Slide Number 22Our commitmentSlide Number 24Slide Number 25