Adaptations of Collaboratives for Innovation

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Adaptations of Collaboratives for Innovation

• Supporting Improvement and Innovation Learning
  Series
• Connie Sixta, RN, PhD, MBA

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Collaborative adaptations

• Learning Collaborative
• Self-directed learning
• 11 Consultation Model Coaching
• Innovation Communities
• Others??

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Integrated Health Network definition

• Sustainable systems and processes that support
  the evidence-based care for the target population
  are implemented
• Community services and support are integrated
• Continuum of care is covered
• A defined geographic area is targeted

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Aim of Integrated Health Networks

• Quality, timely and coordinated care that is
  focused on patient needs
• Linkages between patients, General Practitioners,
  VCH and community services
• Optimum health outcomes for people with multiple
  chronic conditions

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What is an Integrated Health Network?

• Between a patient, family doctor, specialist
  physicians, selected health health care providers
  community-based providers
• Partners work as a team with patient as a key
  partner
• Through linking/ streamlining/ adding resources
  and services
• Relationship between patient and GP is pivotal in
  developing IHNs

Formal Partnership
Patient as Key Partner
Increased Primary Care Capacity and Coordinated
Care
IHN Development starts with Patients their GPs
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Expected results of Integrated Health Networks

• Increased patient knowledge
• Improved patient experience
• Improved health professional experience
• Better use of health care dollars
• Improved quality of care, improved quality of
  life
• Healthier population

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Innovation community for the frail elderly where
do we start?

• Identify the problem, the gap in care
• Establish a Planning Committee to guide
  improvement
• Members
• Chair physician champion, interested in
  improving care, invested in the success of the
  teams
• Mayor supportive of local work
• Experts Physicians who have expertise in caring
  for seniors
• Several interested physicians, nurses, other
  health care providers and IHA administration

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Innovation community for the frail elderly where
do we start? Cont

• Role of the committee
• Establish the parameters of the improvement work
• Obtain expert faculty to teach/coach the teams in
  clinical improvement work
• Remover barriers for teams
• Monitor and support the work of the teams
• Physicians establish own team and work along side
  other teams to gain improvement

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Innovation community for the frail elderly where
do we start? Cont

• Expectations of Planning Committee
• Are not expected to come up with the answers
• Are not expected to know all the answers
• Are expected to accept the answers teams have
  tested and implemented
• Are expected to provider support for the teams

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Plan for innovation community work

• Aim Statement
• Teams
• Office team Physician and one other office
  person (MOA, Office Manager)
• Community Integration team home health, long
  term care, assisted living, other community
  resources work with 1 or 2 physician offices to
  create/test new processes
• Measures ---- no more than 7 measures
• Change Package the Expanded Chronic Care Model
• Individual Monthly Team Conference with
  coordinator or coach talking with each physician
  team individually
• Monthly Team Report written by the Coordinator

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Build a system of care for the frail elderly

• Characteristics
• Reliable
• Consistent
• Automatic
• Is documented
• Can be replicated

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Seniors At Home
Crisis Management
Quick Response Nurse
ER
Palliative or Hospice
Home Visit
End of Life Care
Physiotherapist Fall Prevention
Advanced Directives
Pharmacist Med Review
Patient And GP
Patient GP
Long-term Care
Case Manager Function/ADL
SAT
Medical Home
Plan of Care
Connie Sixta PhD, RN, MBA
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Seniors At Home
Crisis Management
Quick Response Nurse
ER
Home Visit
Palliative or Hospice
End of Life Care
Physiotherapist Fall Prevention
Advanced Directives
Pharmacist Med Review
Patient And GP
Patient GP
Long-term Care
Case Manager Function/ADL
SAT
Medical Home
Plan of Care
Connie Sixta PhD, RN, MBA
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Seniors At Home
Crisis Management
Quick Response Nurse
ER
Home Visit
Palliative or Hospice
End of Life Care
Physiotherapist Fall Prevention
Advanced Directives
Pharmacist Med Review
Patient And GP
Patient GP
Long-term Care
Case Manager Function/ADL
SAT
Medical Home
Plan of Care
Connie Sixta PhD, RN, MBA
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Frail elderly tools/processes developed

• Physician Office Tools
• Cover Sheet (Problem List)
• SAT (Senior Assessment Tool)
• Careplan
• Med Review Sheet
• End of Life Packet (My Voice)
• GAT (determination of cognitive functioning)
• Forms that need to be sent to referral agencies
  (as part of the referral process)
• Pharmacy need Med Review Sheet, Careplan, and
  Cover Sheet
• Long Term Care need Careplan and Cover Sheet
• Audiology no specific tools

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Frail elderly tools/processes developed Cont

• Pharmacy Intervention
• Review patient Meds
• Send an updated Med Review Form, their
  recommendations, and any queries to the Case
  Manager and to the MD Office
• Set up med schedule and use of blister pac as
  necessary to prevent med errors
• Arrange a revisit for additional drug counseling
• MD may elect to do own med review
• Pharmacist may request a home visit with the
  patient or ask the patient to meet at the
  pharmacy

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Planning committee of COPD

• Dr. Phil White, General Practitioner
• Lorne Yelland, Interior Health
• Todd Gale, Interior Health
• Dr. Graeme McCauley, Respirologist
• Dr. Douglas Rolf, Respirologist
• Peter Taylor, COPD Patient
• Gerald Barr, COPD Patient
• Glenn Kissmann, Interior Health
• Jason Kennedy, Interior Health
• Dr. Chris Rauscher, Vancouver Coastal Health
  Authority
• Judy Huska, Northern Health Authority
• Bryan Melnyk, British Columbia Ministry of Health
  Services
• Dr. Treena Chomik, Consultant
• Pat Camp, Consultant
• Kelly Ablog-Morrant, BC Lung Association
• Michael Roch, British Columbian Ministry of
  Health Services
• Connie Sixta DSN, RN, MBA, Collaborative Coach

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COPD aim statement

• Through the introduction and use of the COPD
  Flow sheet in COPD care delivery, the initiative
  will provide best practice care to COPD patients
  of participating collaborative physicians. The
  initial focus is on a small group of General
  Practitioners in the Central Okanagan and Nakusp
  and will result in a decrease in urgent patient
  management , as measured by a 20 decrease in
  emergency room visits and a 20 decrease in
  hospitalization for their COPD patients during
  the duration of the initiative.

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COPD service framework

• A patient-centered approach to improving health
  outcomes across the conventional boundaries of
  the health system.
• It addresses services from all providers across
  the health continuum, including the contributions
  from health and community agencies.
• A set of action-oriented comprehensive
  recommendations (companion document to clinical
  practice guidelines)
• Describes practices for individuals and the
  health system that provide patient-centered,
  evidence-based care, using the Expanded Chronic
  Care Model (ECCM).
• Recommendations cover the spectrum from targeted
  prevention of future COPD cases to advance-care
  planning and end-of-life care.

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The steps to system development

• Test/Implement each new change (PDSA)
• Test/Build each new process
• Test/Implement each new program
• Test/Implement each component of the new system

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COPD System of Care
Red Medical Home
Lung Association
Crisis Management
Exacerbation Plan
ER
Palliative or Hospice
Home Visit
End of Life Care
Advanced Directives
Respiratory Therapist
Pulmonary Rehab
Patient And GP
Patient GP
Long-term Care
Case Manager Function/ADL
Medical Home
Specialist Support
Plan of Care COPD Patient Care Flow Sheet
Connie Sixta PhD, RN, MBA
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COPD System of Care
Red Medical Home
Lung Association
Crisis Management
Exacerbation Plan
ER
Home Visit
Palliative or Hospice
End of Life Care
Respiratory Therapist
Advanced Directives
Pulmonary Rehab
Patient And GP
Patient GP
Long-term Care
Case Manager Function/ADL
Medical Home
Specialist Support
Plan of Care COPD Patient Care Flow Sheet
Connie Sixta PhD, RN, MBA
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COPD System of Care
Red Medical Home
Lung Association
Crisis Management
Exacerbation Plan
ER
Home Visit
Palliative or Hospice
End of Life Care
Physiotherapist Fall Prevention
Advanced Directives
Pharmacist Med Review
Patient And GP
Patient GP
Long-term Care
Case Manager Function/ADL
Medical Home
Specialist Support
Plan of Care COPD Patient Care Flow Sheet
Connie Sixta PhD, RN, MBA
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COPD change package

• Community
• Develop community coalition to support education
  about smoking
• Identify community resources that offer smoking
  cessation courses
• Develop office to community continuum of care for
  patients with COPD (communication and
  documentation practices)
• Identify effective programs and encourage
  patients to participate.
• Form partnerships with community organizations to
  support or develop evidence-based programs.
• Build healthy public policy
• Create supportive environments
• Strengthen community action

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COPD change package

• Organization of Health Care
• Develop Community Coalition Plan for COPD
• Integrate COPD prevention strategies into the
  annual plans community organizations and
  physician offices
• Communicate the COPD disease management plan to
  institutions and employees across the community
• Use effective improvement strategies aimed at
  comprehensive system change.

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COPD change package

• Clinical Information System
• Establish an office-based registry of COPD
  patients
• Develop processes for data entry and report
  writing
• Designate personnel for data entry and registry
  maintenance
• Use the registry to generate reminders about
  patient follow-up
• Identify relevant patient subgroups and provide
  proactive care
• Facilitate individual patient care planning
  through the registry

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COPD change package

• Decision Support
• Embed evidence-based guidelines in the care
  delivery system (office assessment form, flow
  sheet, progress notes.
• Provide a clinicians guide and protocol for COPD
  management
• Train office staff about COPD measures and
  improvement plan
• Give COPD action plan to patient and inform
  patients about guidelines pertinent to their care
• Integrate specialist expertise into primary care
• Use proven provider education modalities to
  support behavior change

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COPD change package

• Delivery System Design
• Design a chart identification system for the
  office that helps staff recognize patients with
  COPD
• Assign roles and duties to office staff to
  accomplish planned visits (group or individual)
• Use the registry to plan visits
• Implement chronic disease follow-up format(i.e.
  group visits, clinic, individual planned visits,
  or case management) based on patient needs
• Assure continuity by the primary care team

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COPD change package

• Self-management
• Use consistent COPD patient education tools that
  describe disease, symptoms, medications, and
  patient responsibilities.
• Use COPD self-management tools.
• Train staff to set self-management goals with
  patients, assign roles.
• Establish goal follow-up process.
• Emphasize the patient's central role in managing
  their illness.
• Assess patient self-management knowledge,
  behaviors, confidence, and barriers.
• Provide effective behavior change interventions
  and ongoing support with peers or professionals.
• Assure collaborative care-planning and
  problem-solving by the team

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Testing/implement change

• Testing changes on a small scale
• Evaluating each change to see if it works
• Doing lots of rapid tests of change
• Building new processes one change at a time
• Getting all team members involved with testing
  new changes
• Documenting your improvement

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Implementing change

• Test before your implement
• Implementation of a change
• Document the process (policies and procedures)
• Integrate the changes in role or responsibility
  (job description and performance expectations
• Educate the staff
• Monitor the process
• Spread the changes

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Questions