Champlain CCAC

ACHIEVE EXCELLENCE THROUGH ACCESS: Supporting Peritoneal Dialysis

Patients in the Community

OACCAC June 10, 2014Presented by:

Karen Lapierre Champlain CCACFiona Wall Champlain CCAC

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Champlain CCAC

Overview

• Background• Objectives• Results• Next steps

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Champlain CCAC

BackgroundGap Analysis 2010• Communication challenges between hospitals and

community partners• Lack of single point of contact for PD clients and

hospital partners• Continuity and consistency

• Lack of confidence and/or knowledge of skill sets available to provide in community

• Lack of access to a broader range of services e.g. Allied health and respites services

• Access to long term care

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Champlain CCAC

Background

• 2012 New Model of Care to Support Home Peritoneal Dialysis (PD) Patients in Champlain LHIN

• An innovative partnership between the Champlain CCAC, Ottawa Hospital and Renfrew Victoria Hospital

• Reorganizing of work processes • PD Nurse Care Coordinator role developed

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Champlain CCAC

Objectives

• Dedicated Regional CCAC Nephrology Care Coordinator – single point of contact

• Develop common standards of care• Standardize documentation and

communication tools• Standardize training/education for

service providers

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Champlain CCAC

PD Care Coordinator

• Spring 2012 dedicated regional Care Coordinator housed on site at TOH as single point of access

• System navigation• Liaison with service providers• RAI tools determine need of patient • Collaborates with Hospital team e.g. morning

rounds, family meetings, clarify treatment goals

• Home visits post hospital and ER visits; discharge to home dialysis

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Champlain CCAC

Common Standards

• Nursing process frame works• Contextualized PD community based

population• Guidance in specified review timing • Guide care plan development and

evaluation

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Champlain CCAC

Standard of CareStep of the Nursing Process• Assessment• Planning• Intervention• Evaluation

Categories• Physical status• Decision making related to plan

of care • Social supports• Equipment• Patient learning needs

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Champlain CCAC

Standardized Documentation and Communication Tools• Collaborative process spearheaded by partner

clinical experts• Championed by CCAC Care PD Care

Coordinator• Three principle documents

• Intra-agency communication tools• Helpful hints resource• Care

• Reviewed with service provider

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Champlain CCAC

CommunicationTool

• Service provider indicates issue

• Reviewed by HDU RN at TOH clinic visit

• Guides telephonesupport conversations

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Champlain CCAC

Helpful Hints

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Champlain CCAC

MonitoringRecord

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Champlain CCAC

Service Providers

• Expression of interest offered opportunity to service Champlain PD patients 2012

• Two successful providers across Champlain

• Agency PD champions identified• Standards of care expectations

• dissemination of documentation tools• provider education template

• CCAC PD Care Coordinator point of contact

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Champlain CCAC

Professional Services

• Nursing• In Home services

• Focus of interventions: assessment & symptoms management, cycler set up, monitoring of PD supplies, support, PD exit site dressing

• Goal: promote independence & teach patient/family

• Frequency: based on needs• Joint home visit by HDU case manager &

community nurse (day 1 & 6 wk post)

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Champlain CCAC

Professional Services

• Other Professional Health Services• Occupational therapy• Physiotherapy• Speech therapy• Social work• Nutrition

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Champlain CCAC

Support Services

• Personal support (ADLs)• Respite Care• convalescence• Assisted Living (IADLs)• Retirement Home• Dressing supplies• Equipment rental (commode, walker)

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Champlain CCAC

Results of Partnership• CCAC Care Coordinator 2012

• Single point of access to community based health• Improved access for dialysis patients

• PD case load numbers increase• Model of Care implemented –patient centered

• Service provider engagement• Better understanding of partner organization processes

• Improved communication hospital /community• Responsive ‘just in time’ and proactive problem solving

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Champlain CCAC

Results of Partnership

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Client Population74% Long stay

25 % Short stay

Champlain CCAC

Next Step?

• Continue with partnership• Continue to work closely with service

providers• Evaluate PD in LTC initiative• Streamline Intake of PD referrals

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Champlain CCAC

Questions

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