collaborating for quality care: partnerships for health/media/sites/sw/uploadedfiles... · 2015. 4....

Collaborating for Quality Care:

Partnerships for Health

Mike Hindmarsh, Partnerships for Health

Quality Symposium

April 28, 2011

1

A Healthier Tomorrow

Partnerships for Health (P4H) At A Glance

Overview of Teams and the Intervention

• Team structure: − Primary Care + CCAC + Diabetes Education Centers + Mental Health +

Pharmacy + Practice Coaches

• Differing Types of Primary Care Teams− Family Health Teams

− Community Health Center

− Aboriginal Health Center

− Solo practices

− Rural and Urban


P4H At A Glance (cont’d)

• Different Learning Modalities

− Learning Collaborative

− Knowledge Transfer

− Web-based Curriculum

• Wave One: 3 Family Health Teams

• Wave Two: 9 teams (FHTs, CHCs and solo practice)

• Wave Three: 61 more teams

Total Number of Patients with Diabetes Touched = 6500


A Recipe for Improving Outcomes: Waves 1 & 2

Select

Topic

Planning

Group

Identify

Change

Concepts

Participants

Prework

LS 1

P

S

A D

P

S

A D

LS 3LS 2

Action Period Supports

E-mail Visits Web-site

Phone Assessments

Senior Leader Reports

Event

A D

P

S

(12 months time frame)

Evidence-basedClinical ChangeConcepts

Learning Model

CDPMFramework

What are we trying toaccomplish?

How will we know that achange is an improvement?

What change can we make thatwill result in improvement?

Model for Improvement

Act Plan

Study Do

System change strategy

QI strategy


Ingredient One: Clinical Change Concepts

Evidence-based guidelines for

diabetes care:


Ingredient Two: The CDPM Framework

• Team building

• Improved care management with CCAC, DEC, MH, Pharmacy

• Self-management support at every encounter

• Planned visits (one-on-one or group)

• Use of population-focused information technology to manage patient sub-populations

• Building ties to the community to promote prevention, self-care and wellness

CDPMFramework


Ingredient Three: The Model for Improvement

• Move away from traditional health care planning

• Use practice data to guide improvement

• Embrace rapid-cycle methodology to test on a small scale

• Build on small tests toward an implementation strategy

What are we trying toaccomplish?

How will we know that achange is an improvement?

What change can we make thatwill result in improvement?

Model for Improvement

Act Plan

Study Do


Ingredient Four: The Chronic Care Learning Collaborative

Participants Engage

Select Topic

Planning Group

Identify Change

Concepts

Prework

LS 1

P

S

A D

P

S

A D

LS 3LS 2

Supports

Coaching Support throughout

E-mail Visits Web site

Phone Assessments

Senior Leader Reports

A D

P

S

(13-month time frame)

OutcomesCongress


Measurement for Improvement

• All teams required to collect data from the medical records to track performance monthly – no small feat!

• Decision support through performance data was an “ah ha” for the teams

• All Waves’ Measures and Reports− 14 process and clinical outcome measures for diabetes care

− Time Series Run charts

• 24 months for Wave One

• 17 months Wave Two

• Wave Three teams joined at various time in last year of P4

• Data for improvement versus research


Formal Evaluation

University Of Western Ontario

• Pre-Post Analysis*: Both Quantitative & Qualitative− Chart Reviews− Provider Surveys− Patient Surveys− Interviews

• All four coordinated to understand the complete picture of P4H

*Pre-Post for Waves 1 &2; Post Analysis for Wave 3

Quality in primary care STAR Family Health Team’s Journey

Sean Blaine MD CCFP

Lead Physician, STAR Family Health Team

Chief Family Medicine, HPHA Stratford General Hospital site


STAR Family Health Team

Avon Family Medicine Centre

Tavistock Community Health Inc

O’Loane Medical Centre


Outline

• What did we learn?− Process improvement from the team’s perspective

• What outcomes were achieved?− Measurable and non-measurable

• What were the barriers?− Challenges encourage growth

• Where do we go from here?− PDSA is the new lingo


Numbers (Sept 2010)

16,206 Patients 890 Diabetes

1,340 Pre-diabetes

The Team…

• 11 FPs• 2.25 NPs• 8 RN / RPN • 1 SW • 0.5 Psychologist• 0.5 Pharmacist


Harness the Power of the Team

• Expanding the circle of care− Team Integration – Pharmacist, Mental Health, Admin staff…− Involving South West CCAC, DEC, PDHU

• Expanding practitioners roles to full scope & competencies

− Process mapping & PDSAs− Medical Directives - hs insulin starts by pharmacist

• Challenges - time, communication, meetings, congestion, parking!

− Being flexible

• Transferrable to other chronic conditions− OA, Depression, COPD, others− The Hallway Huddle, “red flag days”


Harness the Power of the Team (cont’d…)

Patient did not know about ulcer!

• Footcare now done routinely by nursing staff for diabetic clinics

• P4H facilitated the launch of footcare clinics

• Team members working to full scope

• This is not (yet) measurable


Data Management in Primary Care

• Agree on terms, strive for consistency of documentation

− ICD9 codes, comorbidities− Record it, track it, clean it, trend it – A1C, BP, wt, LDL (14

indicators)

• Capitalize on LHIN eHealth integration strategy – SPIRE

− Hospital electronic data transfer – labs, DI, pathology, consult…− Diabetes indicator reports in Excel

• Challenge – 3 sites, 3 servers, 11 physicians

− Time to review/respond to the data summaries

• In-house epidemiology support needed – practice data management experts

− Team to review and respond to trends in data− Effect behaviour change in providers


April

2010


June 2010June 2010


December 2010


Advanced Access

• Gone are the days of booking a physical in __ months

• Gone are the days of booking appointments in __ weeks

• Need to provide care at the right time, at the right place and with the right provider

− Patient’s regular primary care provider (FP, NP, RN)

− Accessing care within 24 hours


Self Management

• Enhanced active involvement by patients & family

− Individualize the plan - building upon previous successes

• Setting achievable goals with patients

− What do they see as important? ID patient incentives− Bring folders/logbooks/meters to individual/group visits

• Challenge – awkwardness of group setting

− Group dynamics, booking nightmare

• Practice coaching – a new clinical skill

− Focus on what the patient is willing to work on


Self Management

RICK

Readiness

Important

Confidence

Knowledge


• Expanding Circle of Care beyond the FHT

− Vital role reviewing complex patients –innovative approaches− ID community resources - link with supports

• Personal communication between CCAC and Primary Care Team

− Enhancing knowledge of shared clients / patients− Patients recognizing relationship between CCAC and their FHT

• Challenges – time, and administrative coordination

− Participation in DM clinic/group days, case conferences− Still some differences re geography / territory covered

• Future – greater collaboration, based on personalrelationships

CCAC - Part of the Team


Conclusion

• Harness the power of the team

− Expand interdisciplinary roles - encompass full scope of skill sets

• Data Management Infrastructure

− Epidemiology support – statistical expertise is key

− IT infrastructure and support must be funded

− New approaches to communication with patients, booking appts

• Time management

− Rethink the way the office is run, how you spend your time

• Expanding the circle of care (beyond the FHT)

− Must be based on personal relationships


Partnerships for Health … We thank you!

The CCAC Perspective: A New Era in the CCAC’s Partnership

with Primary Care

Sandra Coleman, CEO, South West CCAC

Life before PFH

•Many primary care patients receive CCAC services

– but only 12% of all referrals came from family physicians, usually for acute complications

•CCAC not focused on health promotion or self management

• Communication with CCAC seen as confusing and complex – a black hole at the end of a fax machine

• Little sharing of information among system partners

•CCAC not used to full potential – physicians did not know why CCAC was in this Project or what we could bring to their practice

What did CCAC do?

• Case managers as integrated on-site member of primary care team

• Attended learning opportunities regarding diabetes and quality improvement

• Attended improvement sessions and helped implement changes

• Diabetes days, case conferences, shared care planning, insulin starts at home

• Common screening tools, links with community resources, self management

• Made technology changes, including e-referral, sharing from CCAC CHRIS system, and hospital discharge summaries

• 30 case managers linked with 73 physicians

• 108 CCAC staff members attended PFH learning sessions

•Diabetes education for all CCAC staff

• Engaged in 117 PDSAs

• 2 Project Managers

• Internal CCAC team

• CEO and Senior Director on Steering Committee

• Relentless story telling

and sharing the vision

Leadership at all levels

Benefits

• Increased understanding of CCAC role:

– 100% physicians say case manager improves patient care

• Improved communication with partners:

– 33% satisfied to 100% satisfied

• Improved screening and early identification, and better care coordination:

– >25% increase in referrals

– 5% annual reduction in ER and hospital visits by CCAC clients with diabetes involved in P4H

• Increased use of practice guidelines and indicators

• Improved clinical outcomes

Perspectives from Participants

From a Patient

“I learned a lot from everyone on how to stay healthy and how to stay alive. It feels so good to

hear my doctor say I„m coming along great and I„m doing well. I could not have done it alone.”

From a Primary Care Team

“The best thing that has come out of the project is our relationship with CCAC.”

“Having CCAC part of the team has made the large organization more real for us.”

Our new normal

• The CCAC will continue existing support and ongoing quality improvement with the 73 primary care teams

•How do we spread to the other 600 physicians in the South West?

Integrating Chronic Disease

Care through Quality

Improvement

Kelly Gillis, Senior Director, South West LHIN


Challenges

• Recruitment of primary care practices – even with incentives available

• Alignment of processes for teams involved in both QIIP and PFH

• Realignment of CCAC approach along side of growing financial challenges

• Role of Diabetes Education Centres vis a vis provincial focus and approach

• Engagement and integration with community mental health providers (lack of incentives and capacity)

• Ability to do QI across sectors when significant challenges exist within sectors


Key Success Factors

• Strong leadership and physician engagement

• Significant support to primary care teams –Information Management

• QI infrastructure – website for data reporting, cataloguing PDSAs, coaching, expert clinical faculty

• Role of CCAC – case management and education regarding community resources/self management support (I&R)

• Formal provider education through action oriented collaborative process

36


Overcoming Challenges and Building on Success

Factors – Spread and Sustainability

• Integration of quality improvement approach – South West Quality and Process Improvement program (Aging at Home) and overall quality approach

− Practice and IM coaching resources

− Learning collaboratives and booster sessions

− Quest for Quality website (www.questforquality.ca)

− Data analysis and support

http://www.questforquality.ca/


Overcoming Challenges and Building on Success

Factors – Spread and Sustainability

• Development of integrated care teams implementing best practice

• Implementation of CCAC population-based approach to case management and care delivery

• Engagement of clients in care team – self management strategy

• Greater emphasis on system-wide performance measures – RCC role through CCAC supported by QPI program

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A Healthier Tomorrow39

Engaging Primary Care - “Network of Networks”

• Primary care providers will also be connected through a regional “Community of Practice” e-discussion group and leveraged use of existing networks

• Level of engagement is determined by specific regional issues

• Membership represents the breadth of primary care practices and geography of the LHIN and includes representatives from the OMA, OCFP and NPAO

• South West Primary Care Network model will be enhanced by developing the role of each network member locally in a “Network of Networks” model

• Local physician leaders engage other primary care practitioners in regional initiatives


For more information…www.questforquality.ca

Follow the activities of the South West LHIN at www.southwestlhin.on.ca

http://www.questforquality.ca/

http://www.southwestlhin.on.ca/

http://www.linkedin.com/groups?gid=3033277&trk=hb_side_g

http://www.youtube.com/southwestlhin

http://twitter.com/SouthWestLHIN

http://www.facebook.com/pages/London-ON/South-West-Local-Health-Integration-Network-LHIN/244421940744

collaborating for quality care: partnerships for health/media/sites/sw/uploadedfiles... · 2015. 4....

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