Supporting Innovation and Improvement Learning Series

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Supporting Innovation and Improvement Learning
Series

• Capturing Knowledge Gained From Collaboratives
• Dr. Chris Rauscher
• February 5, 2009

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No time cut off(i.e. patients in the CDM
Toolkit with a reviewed BB use flag at any
point are included)
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A current approach inBritish Columbia

• Population identification, sizing costing,
  registry development per General Practitioner
• Identify needs/gaps in care
• Develop a brief, specific clinical practice
  guideline (www.bcguidelines.ca/gpac)
• Quality Improvement implementation
  strategy-supported change and learning using a
  charter with aim, measures and a change package
• Evaluation and knowledge sustainability/spread

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Different Populations
Pilot Population (Frail Elderly) Focus for the BC
Collaborative
(Aim defines)
Small-scale tests of change
The Total Population of Patients and or Health
Care System (spread sites)
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Population of Focus

• Population segmentation
• Different populations may have varying needs and
  service configurations
• To start focus on 1 or 2 segments (categories)
• How to categorize?

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Population of focusCSHA scale (Rockwood et al)

• Very fit
• Well
• Well, treated co-morbid disease
• Apparently vulnerable
• Mildly frail
• Moderately frail
• Severely frail

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The AIM

• Through the introduction of a coordinated
  personal planned care approach, the initiative
  will support seniors-at-risk to remain safely in
  the home of their choice. The initial focus is
  on people who are mildly to moderately frail in
  Greater Trail and will result in a decrease in
  urgent management, as measured by a 25 decrease
  in hospital admissions and emergency room visits,
  and an increase in the ability of frail seniors
  to have health crises addressed in their own home
  or community.

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Measures and Outcomes

• Coordination Processes of Care (care plan)
• Specific best practice areas
• Quality of life
• 24/7 Clinical Responsibility
• Utilization ER, Acute

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APPROACH

• Select the population
• Identification ? Registry
• Assessment
• Develop a Care Plan
• Implement the Care Plan

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The 4 Levels of improvement

• Processes for coordinated care
• Clinical Best Practice in specific areas
• Local systems improvement
• Larger systems improvement

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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
Courtesy of Connie Sixta
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Building the change package

• From the measures- How will you know that a
  change is an improvement leading to
• What changes can you make that will result in an
  improvement
• Incremental tested changes captured in PDSAs
• Across Collaboratives

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Coordinated care planning pathway

• 1) General Practitioner meets with patient
• Discusses program and gets consent (if consent is
  needed)
• Completes Seniors Assessment Tool (SAT) with
  patient
• Completes long term care external referral (if
  not yet long term care client)
  
• GP office sends Community Care Nurse (CCN)
  referral form, problem list, SAT
• 2) CCN does client home assessment
• InterRAI-HC assessment
• Medications prescription, over the counter,
  herbals
• If requested in SAT, goes through end of life
  information sheet, no CPR form, My Voice
  Advanced Care Plan
• CCN office sends GP InterRAI-HC summary (form 81
  includes home support information), Gold Care
  meds page, No CPR form / Advance Care Plan (if
  completed)

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3) General Practitioner reviews meds If General
Practitioner, CCN or patient has concerns about
meds, General Practitioner sends Gold Care meds
page and problem list to patients community
pharmacist. Pharmacist reviews, develops meds
review form and sends form advice to GP General
Practitioner finalises meds list 4) GP and CCN
develop Coordinated Care Plan
CCN develops draft care plan General
Practitioner, CCN meet or discuss over phone /
fax General Pratitioner, CCN agree priorities,
strategies, responsibility, review date GP makes
referrals as required GP office sends copy of
care plan and meds list to CCN (QRN can access),
Nurse Practitioner, other health providers
involved, community pharmacist (meds list only)
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5) CCN completes Health Binder visits patient
at home Health Binder contains care plan,
problem list, meds list, urgent response plan,
information on community support resources,
signed Advance Care Plan No CPR form (from
patient if completed) CCN goes through urgent
response plan with patient / caregiver CCN goes
through Binder contents, answers questions and
ensures it is accessible in the home 6) General
Practitioner meets with patient Goes through
care plan, problem list, meds list
Signs No CPR form if patient wishes Copy
of No CPR form and/or Advance Care Plan placed in
chart if completed

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• 7) Care plan is implemented
• 8) Care plan and meds reviews are reviewed and
  updated on ongoing basis
• GP reviews care plan and meds with patient every
  3-6 months (as condition warrants)
• GP and CCN review care plan after 12 months,
  involving community pharmacist as necessary
• Any changes / updates are noted by GP, CCN, FNP
  updated versions sent to GP, CCN, FNP, other
  health providers involved, community pharmacist
  (meds list only)

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Capturing the learnings through

• Expert group/steering committee
• Learning sessions and action periods
• Quality improvement approach
• Across Collaboratives
• Evaluation
• Spreadable change package

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Spreading the Learnings-Strategies

• FE Collaboratives ? Integrated Health Networks
• Other initiatives-Integrated Health Networks -
  with this population
• Change Package with practical tools and
  approaches communicated
• Evaluation communicated
• Quality improvement approach - Impact BC, Health
  Authorities, locally
• Clinical practice development - BC, Health
  Authority, locally
• Presentations