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Patient Engagement in Action:
Putting Patients, Families and Caregivers
at the Centre of the Circle of Care
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Presenter Disclosure
2
• Presenters: Leslee Thompson, Barry Brown, Isabella
Cheng, Saif Syed, Andrea Griener
• Relationships with commercial interests: None
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Disclosure of Commercial Support
• This session has received no commercial support
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Tweet with us
4
Use hashtag #HQT2014
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Learning Objectives
1. Develop an understanding of leading practices on
purposefully engaging patients, families, and caregivers
to inform care and improvements in the system
2. Discover opportunities and methods for engaging
patients and learn how others have successfully
implemented patient engagement initiatives in their
organizations
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Patient Engagement in Action:
What is Happening Locally and Globally?
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Seeking and Embedding
the Voice of the Patientat Sunnybrook Health Sciences Centre
Barry Brown, Patient Advocate
Isabella Cheng, Professional & Education Leader,
Occupational Therapy and Chair, Person-Centred Care Best Practice
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Barry’s Story
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Ask first what is important to me now,
share my story with those who need to know,
and do what matters most to me.
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Seeking and Embedding the Voice of the Patient
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Sunnybrook’s 2014/15 Quality Improvement Plan
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“Your Voice Matters” Brochure
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Call to Action
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15
0
20
40
60
80
100
Jan-Mar2012
Apr-Jun2012
Jul-Sep 2012 Oct-Dec2012
Jan-Mar2013
Apr-Jun2013
Jul-Sep 2013 Oct-Dec2013
Jan-Mar2014
Overall, how would you rate the care you received at the hospital?
Community
Schulich
TECC
Oncology
Holland Centre
Goal0
20
40
60
80
100
Overall, how would you rate the care you received at the hospital? - Holland Centre
6E
3E
7E
Target
99%
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16-Week Implementation Plan, Holland Centre
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Learning through Reflection, with Patients
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How do you involve the
interprofessional team to
meet patients’ needs?
How do you make sure
each person knows what
to do to follow through?
How do you work together
to take action?
How do you engage patients
to develop their care plans?
How do you enable patients
to make choices that matter
for them?
How do patients and their
families take part in what is
most important?
How do you get to know the person in
the patient?
How do you ask and listen?
How do you seek to know the
experiences of the patients you are
caring for?
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From Chart Audits and Surveys…
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…to “Conversations with Patients”
Chart Audits
Patient Surveys about Person-Centred Care experience
Time to connect and “just talk” to get to know the person
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What are we seeing, hearing, noticing?
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Patient Videos “You Said, We Did”
Saif SyedB.Sc. (Health Studies)
MBA (Health Management)
United Nations University: Water & Health Policy
Engaging Patients in Innovation & Quality Improvement
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The Question:
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How to engage patients
in change?
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The Question:
23
How to engage patients
in change?
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Patient Videos: The Story
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The good. The bad.
The ugly. The better
Capture the unique
patient experience
3 – 5 minute video
interview
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Patient Videos: The Change
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3. Act
2. Discuss
1. Capture
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Patient Videos: The Video
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Patient Videos: The Why
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Experience Empathy Empower
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Patient Videos: Journey
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Take Away
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• Simplicity
• Humanizing health care
• Experience vs process
• Empowering the patient
• Model the way
Get Started
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Resources
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• Patient video toolkit : How to guide
• Patient video policy
• Waivers
• Templates
• Patient videos
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Patient VideosSaif Syed: [email protected]
“I've learned that people will forget
what you said, people will forget
what you did, but people will never
forget how you made them feel.”- Maya Angelou
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Timmins Health Link:
Patient Discovery Interview Process
Andrea Griener, BA, MPA
Timmins Health Link Project Manager
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Timmins Health Link Partners
• Timmins Family Health Team (lead)
• Timmins and District Hospital East End Family Health Team
• Canadian Red Cross
• Porcupine Health Unit
• Community Care Access Centre
• VON
• Misiway Community Health Centre
• Timmins Native Friendship Centre
• Canadian Mental Health Association
• Alzheimer Society
• South Cochrane Addiction Services
• Jubilee Substance Abuse Centre
• Access Better Living
• Cochrane District Social Services Administration Board (DSSAB) –Housing & Income Support
• North East Local Health Integration Network (LHIN)
• Paramedicine Emergency Medical Services
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Timmins Health Link Criteria and Statistics
• Approved as Health Link: Spring 2013
• Start date for Health Link referrals from Timmins and District Hospital: Late Nov 2013
• Number of patients assessed by Oct 2014: 60
• Ages of clients: 1-100, 40% mental health; varied diagnoses
Assess the Highest Users at Timmins and District Hospital
Criteria for Health Link assessment: o 15+ Emergency Department visits or
o 4+ Admissions
o Live in Timmins, not in Long Term Care or Alternate Level of Care
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Tracking Health Link Clients
• 37 clients agreed to the Health Link assessment; 4 of the 37
still high users:
• 2 frail elderly
• 1 with significant mental health challenges
• 1 had no Primary Care provider (Emergency Department visits
stopped in July when he acquired a Primary Care Physician)
• 4 clients refused the Health Link assessment; 3 of these are
still high users at Timmins and District Hospital.
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Between Nov 2013-May 2014 had 41 referrals of high use clients
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Timmins Health Link: Patient Discovery
Interview Process
36
CHART AUDIT
Hospital, Primary Care, Pharmacy, Community Organizations
CREATE SPINES
Outline of the patient’s experience with illness or a specific event
COMPLETE INTERVIEW
Home visit, Motivational Interviewing Techniques, focus on patient’s experience
IDENTIFY OUTCOMES
Successes, Barriers, Gaps,
Emotional Touch points
GOAL SETTING
Readiness, SMART Goals,
Responsibilities
BUILD CARE
PLAN
Case
Conferences,
Circle of Care,
CCT
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Patient Discovery Interview Process
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1st step: CHART AUDIT
• Hospital, Primary Care, Pharmacy, Community
Organizations
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Patient Discovery Interview Process
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2nd Step: CREATE SPINES
Outline of the patient’s experience with illness or a
specific event
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(Name of Disease Process/Event lived) e.g., “COPD”
Outline of experience Patient’s Perspective
Thinking something was wrong “I started to have trouble breathing at night”
Seeing the Primary Care provider
Having test to figure out what was wrong
Being told what was wrong
Receiving treatment
Living with your condition
Getting follow up
Successes: Supportive family
Challenges/Barriers: Difficulty affording medications on a consistent basis
Gaps: No primary care provider
Emotional Touch Points: (Emotions experienced with associated triggers)
Emotion: Confused
Trigger: When being discharged home, no one explained my list of medications
Example of the PDI Spine
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Patient Discovery Interview Process
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3rd Step: CONDUCT INTERVIEW
• Home visit
• Use Motivational Interviewing techniques
• Focus on patient’s experience
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CHART AUDIT
Hospital, Primary Care, Pharmacy, Community Organizations
CREATE SPINES
Outline of the patient’s experience with illness or a specific event
COMPLETE INTERVIEW
Home visit, Motivational Interviewing techniques, focus on patient’s experience
IDENTIFY OUTCOMES
Successes, Barriers, Gaps,
Emotional Touch points
GOAL SETTING
Readiness, SMART Goals,
Responsibilities
Timmins Health Link:
The Patient Discovery Interview
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Timmins Health Link:
The Patient Discovery InterviewCHART AUDIT
Hospital, Primary Care, Pharmacy, Community Organizations
CREATE SPINES
Outline of the patient’s experience with illness or a specific event
COMPLETE INTERVIEW
Home visit, Motivational Interviewing Techniques, Focus on patient’s experience
IDENTIFY OUTCOMES
Successes, Barriers, Gaps,
Emotional Touch points
GOAL SETTING
Readiness, SMART Goals,
Responsibilities
BUILD CARE PLAN
• Case Conferences
• Circle of Care
• Provincial Coordinated Care
Plan Template
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• Epilepsy
• No family doctor
• 90 Emergency Room (ER) visits in last year
Diagnosis: Frequent
reoccurring seizures
Actions: Transfer care to
Neurologist for reassessment
Outcome: Continued ER visits
and epileptic episodes
Clinical
Assessment
Tool (CCT)
Diagnosis: Severe anxiety
related to isolation
Actions: Referral to Canadian
Mental Health Association and
planned support with family
Outcome: Reduced anxiety, ER
visits, epileptic episodes
Patient
Discovery
Interview“No one
listens, or
cares”
John’s Story
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Benefits to the Patient
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Customized care plans co-designed with patient. Focus on patient directed
needs
Patient feels heard and experience is improved
Outcomes are improved and gains are measurable
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Benefits to Organizations and System
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Patient Engagement
Thematic Analysis of Real Experiences
Identifying Gaps
Quality Improvement
Future Planning
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Common Factors for Health Link Patients
I can’t go see my
Primary Care
Provider (PCP)
• 25% cannot get timely
access to PCP
• Have limited personal
mobility
• No PCP home visits
• Limited access to
transportation
50%
Housing
issues
50% Low
income
70% Lack
information
about
community
services
37%
Poor
informal
supports
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Health System Transformation
• Development of Primary Care Model for Care Coordination
– Primary Care providers asked to coordinate care for their own patients
– These are patients we know!
– Linking patients without Primary Care provider to provider
• Implementing a Health Link Approach in Primary Care Environment
– Early identification of high users through hospital data or electronic medical record data
– Engagement of Primary Care team to assist
– Training of nursing staff to complete patient discovery interviews on home visits and in effective patient centred care coordination techniques
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Sustainability
• 13 nurses trained in Health Link approach from Family Health Team, Canadian Mental Health Association and Community Health Centre
• Accessed local experts to provide training in mental health, addictions and frail elderly
• Online training to support safe home visits
• Training manual, link to online Motivational Interviewing techniques, filmed training session
• One-on-one shadowing/mentoring (current)
• Shared links to community resources (ongoing)
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Next 6 months for Timmins Health Link
1. Solidify Health Link approach with Family Health Team,
Canadian Mental Health Association and Community Health
Centre
2. Identify sustainable solutions to support Health Link clients who
have:
• Solo practitioner
• No Primary Care provider
3. Share our system learnings with other planning tables
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Discussion and Q&A
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Final Thoughts:
Advice from the Panelists
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