Patient Engagement: One Health Link’s Perspective

North East Toronto Health Link

Presented by: Lisa Priest, Director, North East Toronto Health Link (NETHL) Stephanie Greco, Member, Patients’ Advisory Council, NETHL Bruno Geremia Co-chair, Patients’ Advisory Council, NETHL Walter Leahy, Liaison Care Coordinator, TC CCAC, NETHL

Presented at: Longwoods Ways & Means | Health Links Feb 26, 2015

North East Toronto Health Link

Continuum of Engagement Levels of Engagement

Consultation Involvement Partnership and Shared Leadership

Direct Care

Better Care System

(Better Tracking and Triage for Equitable, Reliable Care)

Information Management System - Better Care - that identifies, tracks and notifies Health Links patients in real time

Patients are enrolled and engaged simultaneously

Health Links patients identified in real-time develop the care plan with coordinators/clinicians

Governance

Patients’ Advisory Council

Unmet needs of Health Links patients and their caregivers are brought to Patients’ Advisory Council

Caregiver is co-chair of Patients Advisory Council and sits on NETHL Advisory Council

Questions for program evaluation created by Patients’ Advisory Council; changes made based on results

Policy

“Conscience of Health Links” talks

Recommendations driven by patients

Patient stories highlighting issues and system solutions

Patient and caregiver-driven priorities

Factors influencing engagement: Patient (beliefs about patient role, health literacy, education) Organization(policies and practices, culture) Society(social norms, regulations, policy)

Adapted from: Carman, K., Dardess, P., Maurer, M., Sofaer, S., Adams, K., Bechtel, C., & Sweeney, J. (n.d.). Patient And Family Engagement: A Framework For Understanding The Elements And Developing Interventions And Policies. Health Affairs, 2013, 223-231.

Framework for Patient Engagement

3) Administrative Functions

Update Notification

Settings

1) Identification & Reporting 2) Notifications

Notify NETHL Program/Care Coordinator

Notify Care Team (internal/external)

Identification by Classification Algorithm

Display on System Report(s)

a) Initial Notification

c) Provider Notifications

Direct Care: Health Link Better Care Program Initiation: Emergency Department

BETTER (Better Tracking and Triage for Equitable Reliable) Care System

Future Phases (Community Partners)

Patient is engaged in the ED by the TIP nurse or Sunnybrook staff or CCAC coordinator (if already in their care) that she/he qualifies for additional services as part of a Better Care system and that their primary care physician will be notified and they may opt of that service. We can then communicate risks to patients of opting out and request that family doctor be contacted about care planning without patient. Brochures will be mailed out to patient. NETHL Office is notified of Enrolment status. Should the Patient Opt Out, process ends, but will be revisited at future ED Visits. If patient not contacted while in ER ( time of day, weekend or staff not available) then patient will be contacted at home by one of the above to offer the program.

If patient does not opt out, primary care physician is then notified by TIP nurse or

NETHL office that the patient has been identified and that a Care Coordinator (where

available) may be assigned or additional services may be available through NETHL

partners. Assessment is scheduled through Care

Coordinator/PCP. Assessment determines Care Team Requirements. Care Team augmented through referral request or consultation (via

PCP/TC CCAC Care Coordinator). TC CCAC will contact patient in real-time

NETHL is notified of additions to Care Team.

PATIENT ENGAGEMENT & ENROLMENT

PROCESS/OPERATIONS

Better care

patients

Frailty patients

ICCP patients

ED Care Coordination

Better Care System - Identification of target population - Flagging - Notification

Better Care System

Quality Improvement: Health Quality Ontario

Patient Co-design

Source: Smart Health Messaging NETHL’s Patients’ Advisory Council

Health Links Program Evaluation Answers to questions developed by Patients’ Advisory

Council Patient interviews, Feb.

20th

“There’s somebody that needs the emergency service and it’s not me”

“I thought [the Better Care] program was wonderful. They had asked me questions that hadn’t been asked before”

“My goal really is to get back on track- to have a normal day, I don’t know what it is. It’s been like that for the last 5, 3 months. It’s a long time.”

Stephanie Greco Member, Patients’ Advisory Council,

North East Toronto Health Link Stephanie is a member of the Patients’ Advisory Council of the North East Toronto Health Link. She has been involved in co-designing a coordinated care plan, consulting on a patient workbook and helping guide questions for Health Links patients who are identified and provided care plans in real-time. Most recently, she created an “All About Me” patient card to help providers communicate better with patients. As someone who has interacted in the health care system since birth, she is expert in understanding the gaps that can occur. Through her work, she hopes to make the patient voice heard from the hospital to the community.

•  Patient since the day I was born

•  Providers talking to family members, not me

•  Asked the same question over

•  Instead try:

•  What should I know about you? •  What are your goals? •  How can I help?

Life as a Patient with Complex Needs

“All About Me”

Bruno Geremia Co-chair, Patients’ Advisory Council

North East Toronto Health Link Bruno is the co-chair of the Patients Advisory Council. In this capacity, he has led the group to co-design a care plan, enforced governance standards and insisted on transparency of information for patients and caregivers. He comes to this role with significant experience: as the father and a caregiver of a child – now an adult - with complex medical issues, Bruno knows well the gaps that can occur from hospital to community and now, palliative care. Bruno has worked with community and hospital organizations to better integrate the family, patient and caregiver voice to the health care system. He has spent almost two decades in this role, working as a family leader at Holland Bloorview, co-chairing the Family Advisory Committee from 2008 to 2012.

Walter Leahy Liaison Care Coordinator, TC CCAC,

North East Toronto Health Link

Determinants of Health

Patient

Social factors English is not first language Poor social supports

Socially isolated

Economic Factors Limited

finances/income

Physical environment

Lives in Toronto Supportive Housing

Limited Mobility

How We Worked Together with the Patient:

TC CCAC Liaison Care Coordinator (most responsible provider)

Core Care Team(approaches patient in Sunnybrook ED and initiates Care plan)

Patient in the ED

Telemedicine IMPACT PLUS

Nurse

Women’s College Hospital

(Pain Clinic)

SPRINT Supportive

Housing Virtual Ward Meals on

Wheels Family Doctor ---- ----- ----- -----

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Appreciation North East Toronto Health Link

Patients’ Advisory Council • Executive Lead: Malcolm Moffat, EVP Programs, Sunnybrook

• Medical Lead: Dr. Jocelyn Charles, Chief, Family & Community Medicine, Sunnybrook

• Administrative Lead: Lisa Priest, Director, NETHL (also leads patient engagement) NETHL Program Office: • Linda Jones-Paul • Kittie Pang • Adwoa Rascanu

Better Care Project Team •  Richard Mraz •  Navin Goocool •  Ashley Silver •  Ken Nwosu •  Anita Tang •  Mark Fu

NETHL Partners •  Anne Johnston Health Station •  Bellwoods Centres for Community Living •  Don Mills Family Health Team •  Flemingdon Health Centre •  Providence Healthcare •  Scarborough Academic Family Health Team •  Sunnybrook Academic Family Health Team •  Thorncliffe Neighbourhood Office •  Toronto Rehab Toronto •  Toronto Paramedic Services (EMS) •  TC-CCAC •  SPRINT Senior Care

•  Kurt Rose, Director, Corporate Strategy & Information, Sunnybrook •  Jeff Curtis, Chief Privacy Officer, Sunnybrook •  Rebecca Morison, Legal Counsel, Sunnybrook Special thanks: Dr. Joshua Tepper