complex schizophrenia pilots: evaluation report

Pathways to Better Care Improvement through Collaboration

Complex Schizophrenia Pilots:

Evaluation Report

V1.1 (Web version)

Aug 2017

A project in collaboration with The Royal – Schizophrenia Program, Pharmacy, Community

Mental Health Programs, The Ottawa Hospital, Regional First Episode Psychosis Program,

Montfort Hospital, Champlain LHIN, primary care physicians, clients and family members, and

Champlain Pathways to Better Care staff


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In a Glance:

4 patients ‘transferred’ care from On Track to a Primary Care setting

4 primary care physicians involved at 4 different primary care practices

Clozapine is being prescribed by 2 primary care physicians and one psychiatrist.

4 unique settings/pilots within a single pilot project

The ‘registry’ tool to identify patients was not useful to the clinics involved.

Other tools (data set, handbook etc.) were developed and have been used and found useful.

Leadership was identified and appreciated by participants in the development of the tools.

Leadership was a key component to the successes of the pilot

Strong appreciation for the dedication and work clinicians and staff have put into this work

Communications has been a key component of this pilot and needs to be done well to realize continued success.

Summary

Anticipated Short Term Outcomes

Result Findings Comments

Identifying if client has primary care access

?

Most clients of On Track, who are stable and on clozapine also have a primary care provider. However, most clients did not have access to a primary care provider willing to manage their clozapine and mental health follow up.

The initial assumption of the pilot was that On Track clients did not have adequate access to primary care.

Develop and test registry and assess feasibility of supporting a centralized approach.

X

A database/registry was developed and information was entered into the tool. However the tool was not able to be shared between sites and was not useful to the people using it.

The feasibility of a registry would need to be tested in a centralized setting.

Multiple locations participating

√

More primary care practices and physicians became involved than originally anticipated. There is a cohort of primary care providers interested in being involved in the collaborative care of an individual on clozapine.

Sample pathways / guidelines for ‘expanded’ clozapine care

√

Clinical leads developed a handbook to assist primary care comfort and knowledge in managing a patient on clozapine.

These tools and resources could be used as foundational items in a regional model.


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Communication tools were developed with the Montfort pilot. Data set for electronic medical records developed. Work breakdown study (WBS) for clozapine coordination was undertaken

Increased knowledge of clozapine care in primary care settings

√

4 primary care physicians in 4 different primary care clinics are involved in the pilot. Clinical leads have reached out to pharmaceutical company to address primary care education needs around clozapine.

Access to primary care when needed √

The post survey of 3 patients indicate they strongly agree that they can access their primary care when needed

Rapid access to psychiatry when needed

√

The post survey of 3 patients indicate they strongly agree that they can access services for their mental health when needed. A mock trial of rapid access to psychiatry at The Royal was undertaken and documented. After the mock trial staff involved felt confident that the process would work in a real situation. A real request for rapid access has not occurred at this time

Monitoring of quality care

√

3 of the 4 patients completed a pre and post transfer of care survey. Two of the patients indicate they prefer the new arrangements made for lab work and pharmacy. Clinicians involved have not raised any quality issues.

More client and family involvement was suggested if pilot moves forward.


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Identification of care team

√

Care teams have been clarified through On Track Staff and the Advanced Practice Nurse through Bruyere (acting as the clozapine coordinator)

There is still an issue of one patient who is still requiring clozapine prescriptions to be filled by a psychiatrist and the inability to have this file closed at the specialty clinic.

Improved access to collaborative care and treatments

√ 4 patients involved in the pilot See comment above

Feasibility of centralized approach accessed Identification of issues to be addressed if scaling up

√

Pilot identified some issues that could be addressed through a centralized approach (see section 2.2.4)

Anticipated Long Term Outcomes


Improved collaboration between sites and providers

√ Theme of positive collaboration identified in majority of interviews and focus groups

Risk of decreased engagement due to burn out, inability to scale up.

Infrastructure to support regional approach to psychosis

?

Early development of tools and technology to support approach. Pilots identified needed supports/infrastructure to scale project up.

See section 2.2.4 for identified factors for scaling up.

Clients with a primary care provider (for medical co-morbidities) ?

Most clients already have a primary care provider. Pilots did not impact access.

Recommend changing long term outcome to improved screening of co-morbidities.

Improved access to other supports X

Outside scope of the pilots, within scope of regional model

Decreased ED visits and/or hospital admits ?

Clients who participated in pilots were stable and continue to be so.


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1.0 Background/Intro

In the spring of 2015 the Complex Schizophrenia Project completed a rigorous process mapping of the current state of clozapine care and service provision in Champlain. From this exercise over 120 potential improvements were identified, many requiring a change in: how care for individuals with schizophrenia is delivered; by whom; and an alteration in patient flow in order to support individuals in the right environment (with the right supports). These changes would also open up access to care for individuals who require more specialized care. It was agreed by the core project team that changing patient flow for schizophrenia care, especially for those receiving clozapine as a medication was an almost insurmountable challenge; albeit, necessary in creating system change. Change would be required in order to open some of the bottle necks within the system and provide improved patient care. It was also felt that if this insurmountable challenge could be figured out, documented and evaluated, then other system change processes with other treatment protocols would come with greater ease. This would lead to an increased knowledge base and understanding would develop around the need and requirements for a regional approach to complex

schizophrenia. A suggestion was made to try doing things small and where there was interest and appetite to change. A clinician at the First Episode Psychosis OnTrack clinic suggested that it would be possible to build on the momentum of the TIPP-TOE1 research project already underway. This project was where stable and well patients without a primary care provider were having their care transferred to primary care. It was identified that there were interested primary care clinicians and potentially a number of clients on clozapine who could transfer to primary care settings. Thus, the idea of a pilot project to test this suggestion was born. The Complex Schizophrenia Core Team (Core Team) supported the pilot project, and resources from Pathways to Better Care were provided to facilitate the operationalization, documentation and evaluation of the pilot.

1 Transfer to Primary Practice – The Ottawa Experience

Clare is 24 years old and has

been receiving mental health

care and treatment from the

First Episode Psychosis

OnTrack clinic (part of The

Ottawa Hospital - TOH) for

the last six years. She has

been healthy and stable with

her current medication

(clozapine) for 5 years. She

has plans to start college

studying horticulture in the

fall and enjoys playing the

guitar. (Not a real individual,

summary case example)


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Initial Conception of the Pilot

1.1 A Developmental Evaluation Approach – Why?

A developmental evaluation approach was undertaken for this pilot phase of the complex schizophrenia project. The reason for this approach was to assist the project in more rapid feedback in the pilot setting. A development evaluation approach helps to frame and test innovations in complex and uncertain environments. It is less of an audit of “did we do what we said we would?” (Process evaluation) or “did we reach the goals we said we would” (Outcome evaluation) and is more of a quick reflection of what we have observed, learnt, and need to consider as we move forward into a regional approach to schizophrenia care.

1.2 Methods

Over the last 10 months different data collection methods have been undertaken to provide feedback to the pilot project team. The following activities have helped inform the project as it progressed and have also been reviewed and incorporated into this evaluation report:

Pre and post transfer surveys by participant clients of the pilot process

Meeting notes and tools developed during the pilot process

Stakeholder interviews

Two focus groups (Core team & Pilot Implementation Team)


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1.3 Evaluation Framework A comprehensive evaluation framework was developed for the pilot projects. This framework is available on request and informs this report. The framework was formed around three dimensions identified by Core Team members: Operational Factors; Quality of Care and Systems Change. The draft logic model for the pilot projects can be found in Appendix A.

2.0 Findings The findings from the evaluation activities are broken down into; an analysis of how the pilots occurred (operational) and where there was variation from the initial design and concept; the second section highlights what was learned from the pilot activities.

2.1 Operational Summary

2.1.1 How Was the Pilot Operationalized?

The initial assumption that there were numerous clients within the First Episode Clinic without a primary care provider, who were also receiving clozapine treatment, stable and ready to be discharged from First Episode was wrong. In fact, the majority of clients had a primary care provider; however, did not have access to a primary care provider willing to manage their clozapine and mental health status. Thus this fact

required a readjustment to the framework and information flows in order to accommodate patients ready and interested in having their mental health care provided primarily in a primary care setting. Initially, On Track staff identified 5 patients who could participate in the pilot. Four have initiated a transfer of care, with 3 individuals who have completed the transfer to primary care. There has been significant variation between the care flow for each patient, making the pilot actually 4 distinct pilot processes, where the learning from each situation has built upon the next client transfer. However, there has not been the opportunity to replicate a transfer of care from beginning to end. At this point in time 4 family physicians have been involved with the pilot by being care providers. The prescribing of clozapine for the pilot patients is either situated with a family physician (on the medical staff of a hospital) or remains with the original prescribing psychiatrist. Details regarding the various relationships between providers is available on request.

Cohort with no family

practitioner does not exist –

this was assumed and has

not been reality: interview


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2.1.2 What Resources Were Required for the Pilot?

A large number of individuals in various roles were involved in the pilots. The roles and highlighted

contributions are outlined in the table below.

Project Role Highlighted Contributions

Executive Sponsor • Accountable to Inter-Hospital Working Group for success of project • Provided leadership, direction & resources

Project Manager • Planned, executed & closed project • Led project-related activities • Ensured project objectives are met

Facilitator / Evaluator

• Led change management activities • Led evaluation activities

Clinical Lead • Pilot champions • Provided clinical leadership & expertise • Ensured project objectives are met • Participated in project-related activities

Operational Lead • Provided operational leadership & expertise • Ensured project objectives are met • Participated in project-related activities

Nurse / Clozapine Coordinator SME

• Identified pilot candidates • Provided nursing / Clozapine coordinator expertise

Primary Care SME • Pilot champions • Provided clinical leadership & expertise • Provided primary care provider expertise • Participated in project-related pilot activities

Client SME • Participated in project-related pilot activities

Operational SME • Provided operational expertise • Participated in project-related activities

Primary Care Nursing Staff

• Provided nursing support for pilot patients • Tested work products, enhanced for other populations

There have been 18 one hour meetings held for the pilots with on average 6 people attending each

meeting, with a total of 102 resource hours spent in the project meetings.

Considerable additional time and resources have been spent with the transfer of care for each patient as

well as the development of the tools and processes that have facilitated the transfer of care. The time

allotted to these resources was not captured during the pilots.

The resources provided by Pathways to Better Care was

mentioned in the majority of the interviews as being

instrumental to keeping the pilots on track and moving the

process forward. The Bruyère family health team identified that

they would not have participated in the pilots without these

types of resources.

They are the anchor, they

steer the boat. They point

out the pertinent points for

the project and keep us on

track. Without them the

project would drop.

interview


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2.1.3 What Tools/Materials Were Developed for the Pilot?

Tool Planned Usefulness Ready to broader distribution

Database/Registry of Patients Yes Low No

Troubleshooting Guide Yes TBD Almost

(Prescribing) Data Set Identified early in project

Family physicians and nursing staff using it. Transferred to another primary care setting and EMR successfully.

YES – Has occurred

Rapid Consult Form/ Mock Trial No Addressed “shadow chart” issue of how to maintain consult notes between visits/consultations at the Royal TBD – has not yet been used

TBD

Clozapine Coordination Work Breakdown Structure and Data Dictionary

No Clarified nursing roles and resource intensity for primary care settings

TBD

Clozapine One Page Scenario document

No Identified that a quick reference tool was needed by Bruyere nursing staff

TBD

Orientation Documents : • Letter of introduction

(physicians) • Letter of introduction

(pharmacists) • Clozapine quick references

No Supportive to community clozapine coordinator and other providers

TBD

Hub & Spoke Model Diagrams No (but in existence)

Identified in two interviews as helpful

Yes

Project Meetings Yes Yes N/A

Many of the tools developed throughout this project have been identified by participants as being useful and beneficial in bringing a standardized approach and understanding to a complex process in complex and multiple environments. Initially a database or registry was envisioned to support the various clinics and practices involved in the identification of candidate patients and support the transfer and sharing of similar information. In reality, the database/registry sat at two different locations and was completed quite differently depending of the perspective of the location (pre-transfer or post transfer). Staff completed the information in the registry because they had been asked to, not because it was of use to them. Based


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on feedback, the registry was updated in February as an attempt to improve it. Further conversations are recommended to identify how and if this tool is utilized moving forward as there is still a need for the locations to have an easier time accessing and acquiring information such as physician’s billing numbers. Several tools were created in the development of the pilot and leading up to initial transfer of care. The development of these tools showed a considerable amount of leadership and dedication to move the pilots forward. This leadership was identified and appreciated in many of the interviews. The primary psychiatrist and family physician involved with the pilot developed a “trouble shooting” handbook aimed at primary care providers involved with the care of someone on clozapine, or who are prescribing clozapine. For example, it developed scenarios on what to do when a patient stops clozapine or misses a dose or two. Early on in the pilot project the primary care physician lead identified the need for a ‘data set’ that identified the information that needed to flow between practitioners who were involved with the prescribing of clozapine and the primary care of a patient. This data set is designed to work with an electronic medical record (EMR) as a series of modules that could be attached to the original patient file to increase the capacity of family physicians and their team being able to care for patients.

One of the concerns expressed by primary care, both within the Core Team and the pilot working group, was guaranteed quick access to psychiatry, if a patient was not doing well, or there were specific concerns regarding their treatment. Ideally, these situations would be few and far between. However, it was suggested at a ‘mock trial’ be initiated to ensure that processes were understood, before there was a crisis or a real need. The trial involved staff at Bruyere FHT and the Royal and included opportunities for those involved to provide feedback on the test process,

this further identified modifications to the process and evaluated various staff comfort levels in actuating a real request for a rapid consult. As all the patients to date have remained stable, fortunately, this safeguard process has not actually been tested in a real environment. During the pilots there had been a fair amount of concern over whom and how clozapine coordination would occur. For the initial four pilots the advanced practice nurse associated with The Ottawa Hospital Shared Care Team would take on this role, with the understanding that this role would not be sustainable past four individuals. This issue was raised repeatedly during the pilot phase and in order to address the concerns of who does what a work breakdown structure (WSB) for clozapine coordination was developed, as well as, an accompanying WBS data Dictionary. The development of these documents assisted in the comfort level of understanding the different roles of coordination and how in an ideal future state (with a regional model) these tasks could be assigned. The issue of clozapine coordination is discussed in more detail in section 2.1.4 In conjunction with the implementation of the pilot projects was the development of a proposal for a Regional Model of Schizophrenia Care. This model was conceptualized as a hub & spoke approach

The triage form changed

slightly to accommodate people

coming from this project.

Therefore, they were seen as a

priority so that they weren’t

sitting though our queue for

months: interview


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where different settings were involved with an integrated model of care. Although, this model was not envisioned as being a tool for the pilot, some of the participants identified it as beneficial to understanding the vision and goals of the pilots.

Although not a tool specific to the pilots, five of the interviews

identified the role of the project management, facilitation,

communication and data collection as being very important to

the success of the four pilots. These tools and processes

helped participants make sense of the different roles of

everyone when transitioning a patient as well as refining the work people have done during the pilot

into something sustainable.

2.1.4 How was Clozapine Coordination Provided?

The issue of how the required intercommunication and

monitoring between the physicians, labs, pharmacy, Clozaril

Support and Assistance Network (CSAN) and the client was

raised early on in the project. This multifaceted role is often

identified as “clozapine coordination”. It is known that there

exists a great deal of variation in how this work is done and by

whom.

As already identified in the section above one of the ways to address this complexity was the

development of the Work Breakdown Structure (WBS) document for Clozapine Coordination.

Crucial in conduct of pilot –

could not have done this

without Pathways: interview

The role of clozapine

coordination is a difficult one

– when trying to transition

patients from psychiatry to

primary care: Interview


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Prior to the initiation of the pilots, the Advanced Practice Nurse at TOH Shared Care Team reached out

to the individuals who had Clozapine Coordination roles at On Track and at The Royal to increase her

knowledge and comfort with the tasks involved with clozapine coordination. Both individuals at On

Track and The Royal expressed their comfort with the skill and knowledge the Advanced Practice Nurse

has around clozapine coordination and are willing to be available for further support, if needed.

The importance of clozapine coordination done well is expressed

in many of the interviews. “People do not realize the amount of

work to be done for patients who are not doing so well, if they

are getting their blood work done and the communication

between the coordinator and all other professionals and systems

involved. They also ensure the patient does not fall between the

cracks and that communication with all the parties involved is

kept” (interview).

Found throughout the meeting notes and in interviews there is

an underlying theme of concern around the sustainability and

ability to scale the pilots up without proper resources for

clozapine coordination. The WBS document identified how some of the tasks that encompass clozapine

coordination can be distributed, but other tasks appear to require a more standard and efficient

approach, potentially at a regional level.

2.1.5 What was the Level of Quality of Care During the Pilots?

The pre and post surveys of the pilot participants do not indicate a change in their perceptions around

the quality of care they are receiving. Two indicated that they now preferred their locations for

receiving blood work and their medications (location and convenience). Two indicated areas of

improvement around the communication between On Track and their primary care locations.

Clinicians have identified concerns regarding patients potentially ‘falling through the cracks’ during a

transfer of care process and should be considered and mitigated if the project scales up through clear

communication strategies and processes.

Overall, clinical staff has observed that the individuals involved in the pilot processes are happy

throughout and after their transfer of care.

It would be worthwhile to

have a centralized clozapine

coordinator and to have the

human resources to do so.

It’s an integral role, which

ensures things are not

missed especially since each

patient is unique so it

becomes difficult to develop

a process transferable to all:

Interview


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2.2 Learning from the Pilot Project

2.2.1 What Went Wrong? What was Challenging?

Concern/Issue/Challenge Resolved? Solution

Proposed Solution

Eligible patients without a family doctor

Yes Project expanded to include patients with a family doctor

Level of effort No Resources secured to scale project up and implement pathways (Regional Model)

Reconciliation of TOH laboratory results with CSAN

No Family practice clozapine coordinator manually entering results into CSAN

TOH initiates LabLink with CSAN

Different clinical settings/perspectives

Partial Facilitated communications Facilitated communications

Family practitioner interest Partial Communication table at Primary Care Forum

Ongoing communications strategy with family practitioners

Family and client involvement

No Resources available to support family and client input into implementation of a regional model

Clients desire to remain attached to specialized clinic. Clinician’s and client’s relationships that have supported stabilized wellbeing and Recovery.

Partial Has not been identified as an issue with the pilot patients.

Communication to clients at onset of specialized care that they will be transitioned at some point. Excellent communication between providers during transition Regional model and approach in place to support

Single focus – treatment pathway and medication

No Regional approach to include additional treatment pathways.

The most significant issue of the project was the lack of eligible patients without a family physician. This

required the project to change and evolve into several different processes to link individuals either back

to their family physician, with the necessary supports, or transfer primary care to another family

physician.

Participants with the project had a fair amount of good will and willingness to try and test the processes.

However, it was clearly identified in the interviews and focus group feedback that the project took a

significant amount of time and it was difficult to commit the time needed for the project.


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This often led to inconsistent attendance at team meetings

and a failure to read minutes and get up to speed after

missed meetings. At times this situation led to a breakdown

in communication between the different stakeholders.

Pathways support was identified as mitigating some of these

issues by providing documentation and communication

support, but at times the volume of information was

overwhelming.

Although it was identified as beneficial to have different

perspectives at the table, this also added a level of complexity as the idea of “different language” was

identified between clinicians at different sites and administrators. There was also a sense from the

different clinical settings that there was not a full understanding how their settings worked by the other

sites.

A concern raised by several interviews is the level of effort

and resources involved to transfer 4 patients. This has

created an element of ‘participation fatigue’ and the energy is

not available to scale the project up to a larger number.

Concerns with scaling up include a sense that most family

physicians associated with stable individuals will not want to

take on the additional mental health care and monitoring for

these clients and that overall the majority of patients will remain ‘stuck’ at a specialized clinic, such as

On Track. Meanwhile clients of specialized clinics are reluctant to change care locations and do not

want to leave. As well as clinicians having developed relationships and want to maintain care for

patients and ensure that their mental health remains stable and are achieving Recovery goals. However,

these concerns have not been realized with the four patients and their care providers that have been

part of the pilot, it is not clear if these will be actualized issues if the project expands.

An ongoing tension with the overall core project and the pilots is the narrow focus on a single treatment

path and pharmaceutical. There is a strong desire to expand the work to other treatment paths that

support individuals with schizophrenia and psychosis.

It’s difficult to do this from

the side of your desk

especially with the many

other projects/work one is

involved and it makes one

feel you cannot contribute as

much as you would like:

Interview

Surprised it takes so much

time to transfer patients –

expected it to go faster:

Focus Group


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2.2.2 What Collaborations were Strengthened/Weakened during the Pilot?

The projects have opened channels between psychiatry and primary care. Relationships between the

lead psychiatrist and family physician have been strengthened through ongoing knowledge sharing and

clarification of their roles. They worked together on developing a handbook and datasets to facilitate

communication between psychiatry and family practitioners.

The various nursing staff who hold a clozapine coordination role identified each other as being

supportive and helpful during the pilots. They recognized each other’s professionalism and knowledge

base and offered ongoing support and availability throughout the project.

Another key collaborator identified during the interviews was the participating patients of the pilots.

These individuals were seen as wanting and willing to work with the clinicians and organizations to test

the clinical pathways and facilitated the processes greatly.

The family physician at the Bruyère Family Health Team has been a strong supporter of the project and

has reached out and facilitated conversations with other family practitioners informing them of the pilot

as well as gaining their interest and participation as the pilots has expanded. Through the collaboration

building undertaken by the lead primary care physician other primary care practices and practitioners

have expressed interest in becoming involved if the project continues.

Relationship Collaboration Change

Activities Supporting Change

Psychiatry & Primary Care Strengthened Development of handbook Development of dataset Participation at team meetings

Royal Ottawa & The Ottawa Hospital Strengthened Pilot patients

Royal Ottawa & Bruyère Family Health Team

Strengthened Pilot patients Mock Trial Clozapine Coordination education and support

Nursing & other clinical roles TBD Clarification of clozapine coordination activities

Clozapine coordinators at different sites Strengthened Knowledge sharing Common appreciation for professionalism and clinical knowledge.

Clients & participating organizations Strengthened Patients willingness to transfer care

Bruyère Family Health Team & other primary care practitioners

Strengthened Clozapine Coordination Clozapine education Clozapine prescribing

Ball is still rolling – thinking

about a patient-centred

model / not about who owns

the patient: Focus Group


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None of the interviews or focus groups identified a collaboration that had been weakened through the

pilot projects. However, it should be noted that team members have had frustrations at times,

especially in ensuring common understandings had been reached and agreed upon. It was identified

that clarity about communication channels is required as the work moves forward in order to ensure

that easy and quick communication occurs.

It was also identified that as the project moves forward and if it is scaled up there potential will be a

need to re-purpose resources at different organizations, which might impact existing collaborations.

2.2.3 What Knowledge Gaps Were Identified in the Process?

Knowledge Gap Solution Continued Concerns Suggested Next Steps

Primary Care providers and clozapine comfort level

Troubleshooting guide Discharge summaries

How to get rapid access to psychiatry

Mock Trial Has not been used in a ‘live’ setting

How informed and comfortable are patients with the change

“warm hand off” and orientation Pre/Post Survey

Will this be sustainable if scaled up? Was this done with all four patients?

How to provide ‘remote’ prescribing by psychiatrist

Testing with Patient 3

Not being able to discharge a patient

Monitor

How to transfer medication dispensing from hospital pharmacy to community pharmacy

Tested with Patient 1 and 2

Charge of couriering the medication Community pharmacies not accepting to dispense

Ongoing training/education made available to pharmacies

How to provide clozapine coordination

Training and orientation to Advanced Practice Nurse Development of WBS

Current process is not sustainable.

Regional program

How different disciplines and settings work

Needs to be continued

We provided the knowledge

and they [Pathways] brought

all the pieces together:

Interview


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The pilot process was identified as doing a good job of collecting data from all disciplines which

was reported in meetings in order to make sense of the different roles. This was especially

important as a patient was being transitioned.

2.2.4 What Did We Learn That Would Help Us in Scaling Up?

Processes:

Relationships and momentum towards change has occurred. Participants don’t want to loose these gains.

The complexity of the pilots was clearly understood by all of those involved. This has meant a great deal of documentation and tracking of the work that has been undertaken.

Clear communication channels are required to ensure that easy and quick communication occurs.

Communication standards and methods need to be formalized.

Coordination with various pharmacies and transfer of medication from hospital pharmacy to community pharmacies, might need to be streamlined

Clozapine Coordination requires some tasks to be centralized and have some dedicated staffing.

Monitoring rapid access to psychiatry requests.

Ensuring good consultation between primary care and specialized clinic prior to transfer of care.

Ensuring smooth transitions and coordination between different locations

Monitoring data flows between locations as activities scale up.

Clarity of what resources are coming from where. Tools:

Tools that might need to be created moving forward could include a safe patient plan, and a collaborative care document for patients and families to have

Improved documentation of pathways for patient scenarios, including a checklist for care providers.

Data Registry needs to exist in a shared format. Needs to be useful to organizations participating.

Appropriate training materials & documented protocols – so nurses know what is expected of them in primary care.

Utilization of communication technology such as OTN or e-consults.

A shared registry that exists within privacy legislation.

Work that has been done has

allowed us to refine what we

are doing into something

sustainable: Interview


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Clinical and Organizational: There need to maintain a willingness of Royal to maintain clients on books – if there are issues

re. clozapine / psychiatric illness

Improved access to secondary/community psychiatry.

Improved understanding how primary care works and could support clozapine care.

Ensuring that primary care is comfortable.

Ensuring that there are primary care practices willing to become involved.

Keeping clients and family involved to assist with access to care and flow of care perspectives.

Ensure clarity around geographic boundaries of organizations and location preferences of patients.

Suggestion to draft a letter thanking each patient for helping from Royal Director / Senior Management

Support from Pathways is pivotal. “They are the anchor, they steer the boat. They point out the pertinent points for the project and keep us on track. Without them the project would drop.”

An administrative lead or an operational and clinical expertise to help move forward in this whole project, while taking into consideration the many complex processes involved.

An advisory committee of the partners to provide direction and evaluate the progress and a clear sponsor.


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3.0 Recommended Actions/Workplan based on Findings for Scaling Up/Regional Model Recommendation Possible

within current system

Requires Regional Program

Technology Based

R1: Strong Stakeholder Relations

R1.1 Continue to build on initial momentum & relationships

X

R1.2 Clear resource expectations and requirements X

R1.3 Improved understanding of how primary care works X X

R1.4 Ensuring primary care is comfortable with roles and transfers

R1.5 Ongoing client and family involvement X (limited) X

R1.6 Thanking each client involved in current pilots X

R2: Robust standard documentation and information/knowledge transfer

R2.1 Shared client registry (within privacy regulations) X X

R2.2 Provider registry (medical staff/comfort with clozapine)

X X

R2.3 Consultations between primary care and psychiatry X X

R2.4 Monitored data flows between sites X

R2.5 Development of patient tools: • Safe patient plans • What to expect in a regional model • Coordinated care plan

X X

(care plan)

R2.6 Continued development of clinical tools: • Patient scenarios • Checklists • Training materials • Protocols • Task lists for nursing in clozapine coordination role

X

R2.7 Development of communication methods (e-consult / OTN)

X

R3: Streamlined and standardized pathways

R3.1 Between pharmacies, providers & CSAN X X X

R3.2 Rapid access to psychiatry X (limited)

R3.3 Clear process maps X (limited) X

R3.4 Consistency/continuity of care within primary care practices – one practitioner for patient.

X?


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Recommendation Possible within current system

Requires Regional Program

Technology Based

R4: System Coordination / Change

R4.1 Regional Model proposal X (completed)

R4.2 Implementation of a hub and spoke model X x

R4.3 Clear leadership and governance structure X

R4.4 Clear implementation plan X (limited) X

R4.5 Identification of patients at different sites eligible to flow into piloted pathways

X (limited) X

R4.6 Clozapine coordination aspects centralized X X

R4.7 Centralized intake and referral X X

R4.8 Smooth transitions between organizations X

R4.9 Maintaining clients within a program (connected not discharged)

X X

R4.10 Access to community psychiatry X x

R4.11 Clarity regarding geographic boundaries and alignment to LHIN sub-regions

X

R4.12 Strong administrative and program management support

X (limited) X

R4.13 Strong evaluation and quality improvement approach during changes

X X


Appendix A: Logic Model

Context (aspects that will not change with the pilot):

Multiple hospitals, physicians, ACC Teams, variety of pharmacy practices

Federal and provincial legislation regarding clozapine and funding for clozapine

Limited access to specialized psychiatric care.

Pilot Intervention:

10 initial clozapine clients

Assumptions:

Collaboration between sites/services/

providers.

Prescribing physician will be a psychiatrist.

Well functioning care systems have a strong primary care foundation

Mechanisms of Impact - Pilot

Key elements – all levels:

Collaborative (shared) service

provision (between sites, between

providers)

Infrastructure to support a

clozapine start

Common identifier

Defining pathways/guidelines with

initial pilot clients

Assess to monitoring

Intake and assessment of client

goals

Key additional elements – Hub

Knowledge sharing/support

Implementation of the Full Model

Key elements – all levels:

- Treatment by MH specialists in collaboration

with primary care

- Care, pharmacy and lab services provided in a

setting - based on preference of client

- Team supports transition of clients between

different levels of care – based on level of

functioning of client

- Common data collection

Key additional elements - Hub

- Specialized multi-disciplinary team including

psychiatry, nursing, pharmacy, lab, primary care

provider with specific training / expertise with

clients with complex schizophrenia

- Team educates / supports care providers from

spokes, with support of CSAN Nurse Educator

- Provides Clozapine coordinator (virtual) service

and psychiatry service to primary care spoke

- Review of complex schizophrenia patients and recommendations of best practices / treatment

pathways and clinical capacity building to support the identification of clients who might benefit from

clozapine / could be doing better within their current schizophrenia treatment

Outcomes: Short Term

Multiple locations participating

Develop and test registry and assess feasibility of supporting a centralized approach.

Identification of issues to be addressed if scaling up

Sample pathways/guidelines for “expanded” clozapine care

Identification of care team Short & Long Term

Rapid access to psychiatry when needed

Improved collaboration between sites, between providers

Improved access to collaborative care and treatments

Long Term

Infrastructure to support regional approach to psychosis.

Clients with a primary care provider (for medical comorbidities)

Improved access to other supports

Decreased ED Visits or Hospital Admissions /year


Appendix B: Potential Indicators for Further Implementation

Potential Indicators Stakeholder Relations

Documentation/ Information Sharing

Pathways Systems

Primary care is comfortable with roles and transfers

X X X

Nursing is comfortable with roles and expectations

X X X

Positive client and family experiences with: • Access to care • Transition points • Flow of care • Coordination of care

X X X X

Increased number of primary care sites involved X X

Increased number of physicians (psychiatry and primary care) involved

X X

Increased number of clients receiving care through a coordinated approach

X X X

Improved access to community psychiatry X X

Registry(ies) are useful to organizations and clinicians

X X