lliinton jswedak - 2015 cachc conference presentation
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Triple Aim in Health Care Strategic Role of CHCs
Lyn Linton, Executive Director Julia Swedak, Director of Quality & Decision Support
Gateway Community Health Centre
Presenter Disclosures
RELATIONSHIPS WITH COMMERICAL INTEREST None
DISCLOSURE OF COMMERCIAL SUPPORT This session has received no commercial support
MITIGATING POTENTIAL BIAS None
ACKNOWLEDGEMENTS
Institute for Healthcare Improvement (IHI) – Triple Aim Framework
Rural Hastings HealthLink (RHHL) South East Local Health Integration Network Association of Community Health Centres (AOHC) ThinkLink Graphics
WHERE YOU LIVE MATTERS
Marginalization Indexes – Rural Hastings HealthLink
Economic Deprivation Index Social Deprivation Index
Combined Deprivation Index
TRIPLE AIM FRAMEWORK
POPULATION HEALTH
PATIENT EXPERIENCE
COST
Population Health
Reduction of Costs
PATIENT
Patient &
Provider Experience
Adapted from: IHI Triple Aim Framework
CHC MODEL OF CARE & WELL BEING A Shared Purpose
Adapted from AOHC Model of Health and Wellbeing
Building the Bridge
Healthcare Sectors
Provincial/ Regional Integrated Healthcare System
Health System Transformation Health Links
PRIMARY CARE
Transitions In Care Integrated Care Systems
System Thinking, Planning, Barriers & Alignment
Focus on 1- 5% Medically & Socially Complex
Population Needs Based Health Equity SDH
Patient Experience Care Coordination Plans
Patient Goals Patient Stories Patient Forums
Accountability Performance / Knowledge Management
Education / Continuous Improvement
System Cost Shifting from Acute Care to Primary Care System
Decreasing ED & Hospital Utilization
Transitions in Care
Primary Care
Social Support Services
CCAC
CSS
A&MH
Specialists
Hospital
RHHL Approach
Population Health
Reduction of Costs
Patient & Provider
Experience
Improved health outcomes Seamless Transitions System Integration
Return on Investment
Integrated Plan of
Care
Medically Complex
Socially Complex
Age Material & Social Deprivation Medical Complexity
Listening and Understanding the Patient Experience Improving Patient Experience through system integration, Care Coordination & Navigation Maximize provider skill and time Improve quality, communications and patient confidence in provider
Knowledge Management ↓ ED Visits ↓ Hospitalization Right Patient, Right Place, Right Time
Adapted from: IHI Triple Aim Framework
Navigating Transitions in Care The Role of System Navigation in Primary Care
A Registered Nurse System Navigator was embedded in each of our four RHHL sites. The role of the System Navigator focuses on:
Identifying complex patients, Collaborating with primary care providers, Acting as a liaison between transition points in care, Follow up with patient’s post-discharge from hospital, Ensuring that medication reconciliation has been completed after transitions in care, Identifying, integrating, and addressing social economic factors impeding the patient’s ability to achieve optimal health outcomes, Facilitating shared-care planning between transition points of care, Monitoring and evaluating the patient’s care coordination plan against expected outcomes, Advocating on behalf of the patient/family/caregiver, and Creating spread across the continuum of care by engaging practitioners and broader health and social sector partners.
Patient Experience – Patient Voice
Care Coordination Plans Patient Story Boards
Listening to Patient Experience – Engagement
Patient Story Board
15
Patient Engagement Forums
15
Conversation Guide
Having the Conversation
KNOWLEDGE MANAGEMENT
Accountable to Communities and Funders
Capture & Measure Work
Develop and Implement Meaningful Indicators
Reporting and Evaluation
E-tools
Data Discipline
and Integrity
CHC
Regionally Integrated Model
Data Management Coordinators in 4 Primary Care Sites
Indicators & Common
Definitions
Data Discipline
& Integrity
Reporting &
Evaluation
RHHL Knowledge Management
Quality and Continuous
Improvement
Information Flow Across
Sectors &
E-Connectivity
Privacy
RHHL Complex Client Criteria
4 or more co-morbidities
3 or more Emergency Department visits in the past year
2 or more hospital admissions in the past year
5 or more prescription medications
Palliative/End of Life
RHHL Patient Population
RHHL Patient Population
23
RHHL Complex Patient – Age Demographics
0
20
40
60
80
0-17 18-59 60-79 80+ Age Group – RHHL Q4 Data , n=151
Number of Patients in each age group
RHHL Complex Patient - Co-Morbidities
0% 10% 20% 30% 40% 50% 60% 70% 80%
RHHL Q4 Data, n=151
% of Patients with Complex Conditions
RHHL Patient Social Complexity - Q4 14/15
26
Patient Experience with System Navigator – Q4 14/15
System Navigator Explanation of Treatments
85% Very Good
System Navigator Listening to Patients
85% Very Good
Time Spent with System Navigator
88% Very Good
System Cost – Hospital Diversion
ED Utilization
652
87
Visits Reduced
by 87%
Pre Care Coordination-Data Collected for each patient in the previous year
Post Care Coordination-April 1, 2014- March 31, 2015
System Cost – Hospital Diversion
197
33
Complex Patient Hospital Admissions Pre and Post RHHL Care Coordination Plans
Admissions Reduced by
83%
Hospital Admissions
Pre Care Coordination-Data Collected for each patient in previous
year
Post Care Coordination-April 1, 2014-March 31, 2015
Return on Investment
Complex Problem – shift mindset to
systems approach
Focus on relationships
between organizations
– Joint approach and agreed actions
Backbone Support –
Infrastructure to support the
initiative (people, skills, structure)
Continue to influence
primary care model for system change
Continuous improvement
and Communication
Lessons Learned…
Shared performance
and knowledge
management
CHAMPIONS HAVE A RESPONSIBILITY IT’S YOUR TIME
Lead from experience Teach how to scale, spread and build capacity
Stewards for Change
Adaptive Leadership
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