sustaining improvement: interior health authority breathe well respiratory liaison
Post on 14-Jul-2015
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Sustaining Improved Care: The Breathe Well Program
Respiratory Liaisons
Accelerate Funding Purpose
Accelerate the work being done by community integrated health services MOH looks at total health costs : Health Authority, Pharmacy and Physicians Care of People with COPD not just Disease Specific Interventions Summary Evaluation After 3 years Formative Evaluation Every Quarter
Breathe Well Case Management Model
Moderate to Severe COPD with 2 ED visits
AND/OR
One Hospital Admission related to COPD in the last 12 months
∗ level 3: Enhanced services for
complex COPD patients most at risk for hospital admission
∗ level 2: Build Capacity
∗ level 1: Triage to Avoid
Progression
Breathe Well Regions
Meet Ed
2/24/2014 5
∗ Insert Video Here.
∗ Provide enhanced care and community resources to COPD clients who would otherwise return to acute care for service.
∗ A home based program that provides collaborative case management for moderate to severe COPD clients.
∗ Our goal is to reduce barriers and help change behavior to avoid acute care, or reduce a needed length of stay.
Purpose of Breathe Well
∗ Aims to preserve a low client to clinician ratio to enable the continuation of a case management model.
∗ Allows respiratory clients to be referred to appropriate respiratory or community services with the addition of a triage therapist.
∗ Allows for a better client experience and a fluid transition between acute and community services.
Respiratory Liaison
Breathe Well Physiotherapists
Mobility/home exercise for homebound BW Clients
Symptom control,
improved capacity for
improved QOL
Build access to Pulmonary Rehab in
regional hubs
Acute utilization data includes all ED visits and acute admissions regardless of CTAS or CMG codes.
Acute Care Utilization
Clinical Measures
12%
63%
68%
80%
81%
Have stopped smoking since being admitted to the program
Have medications attached to their COPD Action Plan
Have COPD Action Plan in place
Patient diagnoses confirmed by spirometry
Adhere to a CTS recommended inhaler regime
∗ “Having the RT as case manager has been very beneficial to my clients. As a team, we have been able to prevent clients from going to ER or being admitted to hospital.”
∗ “This program was a god send to us so that we could navigate the hospital and come home with more support.”
∗ “We are the glue that holds Respiratory services together – all services coordinated : Acute, Home Oxygen, Breathe Well, Community RT, Diagnostics and Rehabilitation.”
∗ Breathe Well is responsive to patients in a holistic manner and walks
clients through the process in a very focused way to increase their success to have optimal health outcomes and life they deserve.”
Patient & Provider Surveys: The Liaison Role
Patient Pathway
Together
We are enabling appropriate care, building capacity & sustaining the ability to
Breathe Well! Thank You
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