Winnipeg Regional Health Authority(WRHA)

About the WRHA:• One of the largest health

regions in Canada• Providing care to ~ 650,000

people• Specialty services for ~

500,000 Manitobans outside its boundaries

• Annual operating budget of nearly $2.4 billion CAD

• Approximately 28,000 employees

• 3 pre-existing care models for Hospital Home Teams (HHTs)

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Purpose and Goal

Across Winnipeg, each community area has patients with complex, medical and mental health needs. These patients are often high users of Emergency Medical Services (EMS), Emergency Departments (EDs), and acute care inpatient beds. These patients also often experience challenges with care coordination as well as navigating access to health care and social services.

Our purpose for participation in the IHI-BHLC initiative is to:

1. Identify persons with complex medical, social and mental health needs who

are most likely to benefit from access to community-based interprofessional

outreach teams;

2. Identify appropriate interventions and available existing resources that will

improve the patient experience and lower overall system cost;

3. Develop a sustainable service with embedded evaluation and monitoring.

Our goal is to:

To achieve a standardized care model for the Hospital Home Teams (HHTs) based on IHI’s learning system.

2

Population

3

Total Triple

Aim Population

Size BHLC Population Full

Scale

Scale

Feb-2016

Scale

Mar-2016

Scale

June-2016

Three targeted

community areas

in the City of

Winnipeg

(population

approximately

700,000)

13,576a Must meet at least one of the following criteria:1) ED visits ≥ 6 (last

12mths)2) Hosp. Admits ≥ 33) Bed Days ≥ 304) Complex

Biopsychosocial needs score ≥ 21b

300 140

(46%)

240

(80%)

300

(100%)

Notes:a Cui, Y., Metge, C., Forget, E., Oppenheimer, L., & Moffat, M. Development and validation of a prediction model for all-cause hospital readmissions. J Hlth Serv Policy Res, April 2015: v20(2). Cui, Y., Metge, C., Forget, E., Oppenheimer, L., & Moffat, M. Geographical variation analysis of all-cause hospital readmission cases in Winnipeg, Canada. BMC Health Service Research (2015) in press

b Humboldt County IPA and Care Oregon adaptation of the INTERMED scale: De Jonge P, Huyse FJ, Stiefel FC, Slaets JP, Gans RO. INTERMED--a clinical instrument for biopsychosocial assessment. Psychosomatics. 2001 Mar-Apr;42(2):106-9. PubMed PMID: 11239122.

Data-driven referral process to be launched Feb. 2016 - will automate referral of high system users.

Collaborative care planning and goal setting – patients, family and care givers are integral to care planning and delivery

Patients identified by cross-sector health care professionals and data

Intensive case management with interdisciplinary team-based care, care coordination and communication with existing partners*

Patients are transitioned to appropriate community resources which may include primary care upon achievement of goals

*Partners (internal and external to the WRHA): Those involved in the care of HHT patients per regular roles, collaborates with HHT core team member, and acts as consultants for challenges with care planning and equipment needs

Patient-centred integrated collaborative care service, including home care, allied health and primary care

Hospital Home Team (HHT) Model

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ServicesPatient Issue/Need Services Required Partners Required

No primary care provider (PCP) Attach client to PCPLocal primary care clinics; Family Doctor Finder; My Health Teams

Cannot perform ADLS or IADLs In-home PT and OTCommunity Therapy Services; WRHA Home Care

Insufficient in-home support to manage health condition(s)

Timely, reliable, and creative in-home support (i.e., PCP home visits)

WRHA Home Care; Geriatric Program Assessment Team

Need for Med Rec In-home consult with pharmacist Community pharmacies

Need for mental health care; Sometimes psychological trauma

Referral (and warm handoff) to mental health services

WRHA Mental Health (GPAT, GMHT, & others); Community counseling service (Klinic); CMHA

Substance abuseReferral (and warm handoff) to addictions services

Addictions Foundation of Manitoba

Difficulty with trustRapport-building; reliable, regular contact with client

WRHA Mental Health (GPAT, GMHT, & others); Community counseling service (Klinic); CMHA

Resistance/refusal of careAssessment; particularly if there is a possibility of cognitive impairment

Public Trustee; Geriatric Program Assessment Team

Limited social support; sometimes social isolation

Reliable, regular contact with client; support with day-to-day decision-making

Client’s caregiver or family members (if applicable); Public Trustee; Community groups; WRHA housing experts

Inadequate/unsafe housingHelp client find and arrange housing-related solutions

Manitoba Housing; Residential Tenancies Branch; Community Wellness Initiative (CMHA)

Food insecurity Donation of food; Income assistanceFood banks; Food delivery and special diet services; Community groups

Inadequate transportationHelp client find and arrange transportation options

Handi-transit; Taxi services; community groups

Poverty, low-incomeHelp client with applications for income assistance, Cdn Pension Plan, Income Tax etc.

Employment and Income Assistance Services; Non-insured health benefits; Public Trustee; Community Income Tax Services

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StartDate

Intervention Step in Framework*

1. 12/15 Completed inter-reliability testing for HHT Triage Form Identification

2. 01/16 Implemented two-tiered scoring (i.e., pre and post consultation scores) for Risk Prediction Assessment on HHT Triage Form

IdentificationRecruitment/ Engagement

3. 11/15 Conducted in-person site visits (Measurement Lead) for data quality control

IdentificationCare ModelRecruitment/Engagement

4. 10/15 Identified data generated referral process at three community hospitals

IdentificationPartnering

5. 12/15 Networked with many existing service providers and programs to communicate about HHT services and for care delivery

Partnering

Five Interventions Tested since October

6

Strategies to Increase Institutional Support

Engage Winnipeg Regional Health Authority (WRHA)’s IT systems support

Increase visibility of Hospital Home Teams (HHTs) via internal (intranet) postings and updates

Communicate with Community Program’s Team Managers to increase understanding of appropriate referrals for HHT service

Increase awareness and understanding of HHTs in the community, hospitals, and long term care, and engage in more collaboration and partnerships among programs and services

Increase visibility of HHTs via presentations to WRHA Program Operations meetings (Home Care, Public Health, Primary Care, and Emergency) andother site operations tables

Collect data and evaluate impact of HHT services on population outcomes, patient experiences, and costs

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Strategies to Engage Payers (Manitoba Health)

• Encourage representation from the payer (MB Health) across the layers of HHT’s governance (learn as we learn)

• Scale up effectively with inclusion of clearly articulated deliverables from MB Health and demonstrate benefit in target areas

• Promote open, transparent sharing of data collection and evaluation

Provider Adoption Strategies (Engagement)

• Promote and support communication within the WRHA and Primary Care clinics (i.e., community Primary Care Physicians) to improve the understanding of the HHT referral process and client population for HHT’s service

• Collaborate with physicians, managers, and staff from My Health Teams to increase awareness and facilitate referrals

• Develop and educate stakeholders through effective communication about HHTs

• Use utilization data to initiate referrals from primary care providers

• and support communication within the WRHA and Primary Care clinics

(understanding of the HHT referral process and client population for HHT’s service

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Strategies to Engage Individuals in HHTs’ Service(Patients and Teams)

Include the client/family/support system in goal setting and regularly revisit and revise the goals with their input to ensure they are relevant and being actively worked on

Support patients’ navigation and build trust and relationships

Assist with patients’ attachment to existing resources such as: Employment and Income Assistance, Primary Care Providers, WRHA community programs & partners(community-based and citizen-organized community programs such as schools, churches, senior centres, and support groups)

Be creative in accessing financial support for low income individuals and families

Educate patients about available services such as First Nations coverage and application procedures

Ensure that HHT team members work together to achieve client goals via regular communication, weekly to biweekly team rounds, and daily team huddles

Incorporate team building and bonding ‘fun’ activities to build team relationships and morale

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Scale-up Grid BHLC Collaborative: Scale Up Nuts and Bolts Worksheet

Consider IT, Human Resources, Facilities

Key Change Area Individuals 5 25 125 625

(anticipated)

Patient Identification

- Highest users of 1 Community Area in Winnipeg - Patients identified by community hospital in that community area

- Referrals from Home Care Program, and Hospital using Referral Form developed by HHT teams

- Referral Forms received from Home Care, Primary Care, Community MDs, Hospitals - Triage Form developed, looking specifically at eligibility criteria (ER visits, Hospital bed days, and number of Hospital admissions) and risk Referral Form and Triage Form developed with learning through IHI BHLC process

-Integrated data systems for real time patient identification - Appropriate patients are identified from all stakeholders

Care Model Care coordinators (2 at 3 sites) Current caseload:: Varies from 10 to 26

Predicted: 50

-Virtual Ward (VW) Pilot (2011-2012) -8-10 patients -MD, RN & SW Case Coordinator

-MB Health (Gov’t) funding for 2 geographic teams in Winnipeg (2013) -funded positions: 1 Case Coordinator and 1 Admin full time per team -Additional position of .7 EFT OT to one team

- Team composition varies between sites and being studied based on target pop and needs identified - Co-location of HHT staff key in building shared vision of goals

- Consistency achieved among HHTs - Model can be replicated by additional HHTs and sites - Well integrated with services for complex patients

Community Partnerships

-Community Therapy Services (OT) -Church Groups -Salvation Army -Age and Opportunity

-Community Therapy Services -Community Mental Health

-Community Mental Health -Age and Opportunity -Seniors Resource Councils

- Partnerships become more refined - Agencies and community groups become more familiar with HHTs and its service

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Scale-up Grid BHLC Collaborative: Scale Up Nuts and Bolts Worksheet

Consider IT, Human Resources, Facilities

Key

Change

Area

Individuals 5 25 125 625

(anticipated)

Financing -MD, RN and SW worked a few hours per week in addition to their full time employment

-MB Health funding for 2 geographic teams to work with 50 patients per team

-Goal with current funding is for teams to manage 100 patients per team

- Target recruitment is achieved and funding for HHTs continues

Data -Manual data collection -tracked ER visits and hospital bed days in Excel for pre VW involvement and during VW intervention -EDIS (Emergency Data Information System): real time alerts when HHT patients present to any ER in Winnipeg

- Gained more access to resources and existing data for evaluation and IT -EDIS (Emergency Data Information System): real time alerts when HHT patients present to any ER in Winnipeg

- Currently developing a secure HHT Access data base that can interface with ED, Hospital and EMS data -EDIS (Emergency Data Information System): real time alerts when HHT patients present to any ER in Winnipeg

-Ongoing measurement of outcomes and evaluation - Continued focus on PDSA’s to learn by testing - Ongoing development of an integrated database that supports HHTs and other groups serving complex patients and patient flow Data: *Arrival of evidence-based data

Oversight -3 person team -access to historical data on small patient group

-pilot project team and WRHA made funding request to MB Health -data from pilot project supported funding request -program renamed Hospital Home Team - Formation of HHT Steering Committee with key stakeholders in WRHA -Operational Team formed with team members from each

- Ongoing improvements to structure of HHTs -BHLC Collaborative (IHI) process begins June 2014 -Core Team is formed with members of 3 HHTs and operational support

- Core Team members are champions in ongoing HHT service provision - HHT Steering Committee supports and evaluates HHTs

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Our Learning About Scaling Up

#1 Consider: Rollout of processes for identification and recruitment of patients - Scale up can be slower when there are system changes with adoption of

new processes

#2 Consider: Staffing complement- Staffing challenges (vacations, staff turnover, sick leave)

- Need to match levels of care with the appropriate resources

#3 Consider: Understanding the population is ongoing- Having sufficient data to analyze requires time

- Monitoring data collection needs to be ongoing

- Partnering with appropriate resources requires knowing the population you are serving

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Dimension Proposed Measure Data Source Data plotted (Y/N)

Population Health1) Self-reported health:“Would you say in general your health is…?” Excellent, Very Good, Good, Fair, Poor2) Self-reported mental health:

“In general, would you say you mental health is…?” Excellent, Very Good, Good, Fair, Poor3) Functional Status:

Karnofsky Performance Status Scale allows patients to be classified according to their functional impairment 1-100

1) Intake, 3-month, 6-month and/or discharge

2) Intake, 3-month, 6-month and/or discharge

3) Intake, 3-month, 6-month and/or discharge

Yes

Yes

No

Experience of Care

1) Global experience/National Research Corporation Canada (NRC) Picker: Overall impression of care:• While you were a part of the hospital home

team, were you able to get all the services you needed? Yes, completely; Somewhat; No

• Overall, how would you rate the care you received while with the hospital home team? Excellent, Very Good, Good, Fair, Poor

2) Readmission to hospital or the ED within 30 days3) Focus on effectiveness as a measure of quality of care. Goals of care (medical & patient-centred) are being met? Yes/No

1) Regional survey sent out monthly for

the next year by NRC Picker

2) EDIS/DAD3) From EMR macro documenting patient contact (at least monthly)

No

No

No

Per Capita Cost1) Utilization rates (EMS/ED/Hosp)Possible to measure use and assign costs (based on proxy):• ED utilization per 1000 user population• Hospital bed days per 1000 person years by

month• EMS (ambulance) use

1) Admin data Yes

Population Measures Worksheet

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Hospital Home Teams (HHTs): WRHA

Linking process to data collection

Patient Identification (2 sources)

Referral from Acute care,

Community services

(HC/CMH/FFS Drs)

Centrally-collected data

<high utilizers>

Referral

FormTeam

Review

Triage

form

Intake Criteria≥ 6 ED visits

≥ 30 Bed days

≥ 3 Hosp Admits

Risk prediction:

Intermed ≥ 35?

INTAKE

Yes/No

Provide

Needed

CARE

Process &

Outcomes

Analysis

Data Source/Flow

Referral data + regional source for ED visits, hospitalizations, etc.

MS Access (secure) databaseDTAT: Data tracking & Analysis Tool

Triage Process: “meets criteria for admission to an HHT”

EMR

Capture outcome measures: MDS/RAI (HC)(e.g. MAPLeS Score), SF-1&2, ZBI

Discharge

Processes

These criteria “populated” from regional systems

into DTAT

e.g.,#/type patient contacts

-Home visit-MDS/RAI HC administered-Goals of care determined

May involve a home visit or other preliminary intervention(s)

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Cumulative Number of Clients Served

15

Self-Rated Physical & Mental Health (N=91)

32%

58% 57%70%

68%

42% 43%30%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Self-RatedPhysical Health

Baseline

Self-RatedPhysical Health

3-month

Self-RatedMental Health

Baseline

Self-RatedMental Health

3-month

Poor/Fair

Good/V.Good/Excellent

|------p = .000-----| |------p = .027-----|

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ED Visits and Hospitalizations

0.00

0.10

0.20

0.30

0.40

0.50

0.60

0.70

0.80

0.90

1.00

-12 -11 -10 -9 -8 -7 -6 -5 -4 -3 -2 -1 1 2 3 4 5 6 7 8 9 10 11 12

ED Visits (N=163)

Hospitalizations (N=147)

12 months before service start

12 months after service start

service start

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Ave

rage

Nu

mb

er p

er c

lien

t

Hospital Bed Days (N=147)

0

200

400

600

800

1000

1200

1400

-12 -11 -10 -9 -8 -7 -6 -5 -4 -3 -2 -1 1 2 3 4 5 6 7 8 9 10 11 12

service start

18

Tota

l Nu

mb

er o

f B

ed D

ays

(N=1

47

)

12 months before service start

12 months after service start

Key Accomplishments

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Using enabling factors like IHI processes to help identify target populations and delivery of services

Improving patient flow with targeted intervention for persons with complex health and social needs

Using data to uncover insight and motivate change. Data is available for use by other services in the region

True demonstration of cross sector interprofessional collaboration among health and social service teams and community groups working specifically with complex patient populations

Continued work and dedication towards demonstration of effectiveness of the service via ongoing data collection and initial analysis of pre and post outcomes (i.e., ED visits, self-rated health, bed days)

Our MilestonesAchieve target recruitment of patients for HHT Service (scaling up) • Flagging processes for referrals are implemented• Achieve consistency with referral processes by HHTs• PDSA’s to achieve consistent application of the HHT Triage Form among all three HHT sites, appropriate risk

criteria, and administration of Stanford Domains Assessment tool (to minimize regression to the mean)

Improve work processes to support effective delivery of enhanced care to the target population• Begin exploration of Levels of complexity including workload, frequency of involvement of disciplines, and

type of contact are identified to achieve role clarity• Ongoing networking with key partners as HHT patient population is further segmented

Continue to refine our learning systems with participation in the Scale Up and Sustainability Track (Year 2)• Ongoing engagement of the Core Team to complete the work of the BHLC-IHI Year 2 Collaborative

Continue to collect data in the newly developed HHT Data Analysis and Tracking Tool • Promptly respond to challenges and incorporate corrective measures

Analysis of data to assess impact and effectiveness of HHT on Triple Aim outcomes including economic net benefit analysis • Comparison with a matched control group for examining effectiveness of HHT service

Form a HHT working group to explore opportunities for publication

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We wish to acknowledge the following organizations for their support:

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