C4 – Centralized Collaborative Complex Care Redesigning Care with the Institute for Healthcare

Improvement (IHI) Triple Aim Collaborative: Better Health and Lower Cost for Patients with Complex Needs

Dr. Tammie Dewan, Pediatrician, BC Children’s Complex Care Clinic Rita Janke, RN, Quality Leader, Sunny Hill Health Centre for Children

Kate Thomas-Peter, Project Manager, Children and Women’s Mental Health

Sunny Hill Health Centre for Children Behavioural Conditions

BC Children’s Hospital Neurology

BC Children’s Child and Youth Mental

Health

Breakout Session G7

Shaking the foundation of how we deliver complex care

Disclosure

Partial funding for year 1 of the collaborative received from the Canadian Foundation for Healthcare Improvement

No other disclosures

The Triple Aim and BHLC Roadmap

OUR BHLC SUB-POPULATION

Subpopulations of BHLC population (56-100 children/year)

Children with behaviourally/developmentally complex needs accessing BCCH Neurology, Child and Youth Mental Health (NeuroPsyc /Infant Psych) and SHHC BC Autism and Complex Development/Behaviour

Subpopulations of BHLC population

Children with behaviourally/developmentally complex needs accessing BCCH & SHHC

BHLC population: Patients at risk of high costs and poor health outcomes who would benefit from enhanced care

Children with Complex Needs accessing BCCH and SHHC

Triple Aim population: Everyone in your organization’s reach

All Children seen by BCCH & SHHC

Lucy’s Story Lucy is an 8 year old girl with Angelman’s

Syndrome diagnosed at age 3 after a 2 year history of her mother knowing “something wasn’t right”.

Lucy’s family lives 5 hours away from a major health center, so accessing specialized services requires waiting for outreach services or significant travel.

Lucy received community support until she turned 5 and started going to school. During this transition, Lucy “fell through the cracks” until her needs became unmanageable by the school.

Lucy’s physical and behavioral support needs have continued to increase resulting in several referrals for specialist assessments and services at age 6 and again at age 8.

There have been significant waits to be seen by these specialist clinics (6mos-1yr).

None of these services have been provided in a coordinated manner.

While she waits - both school and family life are being impacted

PATIENT

C4 Aim Statement

By July 2017 create an integrated care model to: Achieve the best health outcomes and experience for

children with behaviourally complex needs and their families.

Ensure that children have minimal wait times, a streamlined assessment process and an early diagnosis where possible.

Increase system-wide efficiencies

Ultimate goal is to enable children to access crucial early intervention and much needed support to maximize their overall development and participation within their family and community setting.

Learning about our population

Moving from retrospective to

prospective patient identification

Identifying Candidates for Care Design

Identifying Lucy At diagnosis Presentation of key symptoms Crisis

PDSA 1 Review of

Triage Lists

PDSA 2 Joint

Physician Case

Review

PDSA 3 ID

Algorithm

PDSA 4 Refine

Algorithm

Develop an Enhanced Care Model to Fit Needs & Assets

BCCH Neurologist

Nurse Clinician Admin Support Mental Health

Psychiatrist Psychologist

Social Worker Occupational Therapist

Nurse Clinician Admin Support

SHHC Developmental Pediatrician

Social Worker Psychologist Intake Nurse

Occupational Therapist Psychologist Physical Therapist

Admin Support

Child Journey

Coordinator

Child in Need Services coordinated

“Seen by the right people at the

right time”

Possible Model to Test: Coordinated “Clinic Team”

Virtual or Physical Space Clinic

Community Team

Learning from 5 Patients – co-creating care plans to help design care.

Recruit and Engage

Individual

Process

System

Dimension Proposed Measure Data Source

Population Health

1. PedsQL 23 questions 2. Proxy self-rate health status: In general, how would you rate your child’s current

health (where health includes physical, behavioural, mental health? (Excellent, Very Good, Good, Fair, Poor)

3. Proxy Functional Status: In the last 30 days how many days of school did your child miss? (0-1, 2-5, 5-10, greater than 10 days) If in preschool or daycare – ask how many days the child is scheduled to attend a week)

4. Parental Burden of Care: During the past 30 days, how many days did your child’s condition keep you from your usual activities – work, social engagements, household activities? (0-5, 5-10, greater than 10 days)

5. Parent QL survey

• Family survey

Experience of Care

1. Family Experience of Coordination of Care standardized Tool (AHRQ) – select questions

2. How confident are you in managing your child’s physical/behavioural/mental health? (Very confident, Somewhat confident, Not at all confident).

3. How confident are you in managing the systems and services which support your child’s health (where health includes physical, behavioural, mental health) (Extremely confident, Very confident, Confident, Somewhat confident, Not at all confident).

4. Timeliness of care to: Wait time 1 (W1) – referral to 1st Clinically relevant appointment

• Survey •Pt Survey •Performance Measurement & reporting (PMR)

Per Capita Cost

1. Patient utilization cost of services within the integrated C4 clinic model over time and within a fiscal year.

2. Baseline cost data of historical utilization pattern (MIS costing methodology – CIHI 2011).

3. Utilization of Mental Health, Neurology & CDBC/BCAAN services over a fiscal year. • Costs of referrals • Cost of assessment

•Performance Measurement and Reporting

•Business Planning Financial Database •STAR Database – SHHC BCAAN/CDBC

Develop a

Learning System

Lessons Learned We are still learning…

IHI faculty support has been invaluable Learning together has been important

Start by understanding your broader populations and how you plan to segment

Understand who your partners are Listen to the patient voice, data and the care team Understand patient centred approach Scale-up approach to service design

Need the vision, commitment and time to support movement toward full scale

Importance of Senior Management/Clinical Support Culture Change

References

Pursuing the Triple Aim: The First 7 Years JOHN W. WHITTINGTON , KEVIN NOLAN , NINON LEWIS, and TRISSA TORRES

IHI White Paper

Care Coordination Model: Better Care at Lower Cost for People with Multiple Health and Social Needs Catherine Craig, MPA, LMSW: Faculty, IHI; Director of Health Integration, Community Solutions, Inc. Doug Eby, MD: Faculty, IHI John Whittington, MD: Faculty, IHI

IHI Triple Aim Collaborative – Better Health Care Lower Cost Webinar Series

Dr. Tammie Dewan, Pediatrician, BC Children’s Complex Care Clinic TDewan@cw.bc.ca Rita Janke, RN, Quality Leader, Sunny Hill Health Centre for Children rdjanke@cw.bc Kate Thomas-Peter, Project Manager, Children and Women’s Mental Health kthomaspeter@cw.bc.ca

Contacts