Home is BestHome is BestA New Integrated Primary and Community Care System

Diane MillerExecutive DirectorExecutive DirectorPrimary Health Care

Dr. Grace ParkMedical DirectorMedical Director,Home Health

OverviewOverview

• Introductions: who are we?

• Why we are here: ‘Home is Best’

• What are our challenges?

• Integrated Primary and Community Care

• Home Health Integration / Care Management

• Inspiration for Changep g

The B.C. Landscapep

HealthHealth AuthoritiesFive regionalgOne provincial

About Fraser HealthAbout Fraser HealthBC’s largest and fastest growing health region

1.5 million residents 1400+ Family Physiciansand Specialists

Home Health: 14,000 clients / year, / yLong-term cases approx = 8,000 Short-term cases approx = 6,000Residential Care = 7,484 bedsAssisted Living = 1,350 beds

Why are h ?we here?

Home is best“Sleep in my own bed, eat at my own table”

What we know…Long hospital stays are not ‘best’g p y

Patients are safer and recover more quickly at home; they q y ; ygenerally want to go home

And they want to stay at homey y

Our challengesg

A rapidly growing, aging population population to grow 47% over next 20 years, greatest growth 65+

Increasing complex, chronic and mental health conditions 39% of the population have one or more chronic conditions and use more than 80% of health care resources

F t d P id ki t lFragmented care: Providers working separately People who want a family doctor can’t always find oneGPs and community health providers at capacity

Residential CareShould be the ‘last resort’

Occupancy rate: 98.5+%

Average LOS:- 2.5 years

The first option for patients who need

i i h d il li iAverage LOS: 2.5 years

40% of residential care clients have never accessed Home Health Services many

assistance with daily living upon discharge from acute care should be home support not residentialHealth Services - many

likely admitted to residential care too early.

support, not residential care.

“I was making decisions gand didn’t know what to do. You don’t know who to call, where to go, what the system is.”

- Family of elderly client

“I f d lli h“I am frustrated telling the same things to my family d t S i li t ddoctor, my Specialists and the Home Care Nurse.”

- Client with several conditions

“M i i f ll I“My practice is full; I don’t have enough

lit ti t dquality time to spend with some patients who have morewho have more complex needs.”

- Family Physician

Meeting these challenges g gRequires a major shift in how we deliver health care

From independence to collaboration From silos to integration

F h it l fi t t ‘h fi t’ From hospitals-first to ‘home-first’ From an acute to community services

Good care in the community … prevents disease from starting or progressing prevents ER visits and hospital admissions keeps people living safely at home

Transformation“To change the nature or g

function of one form into another; to

change position or direction of a system.”

B.C.’s commitmentAll health authorities participating

GOAL: “British Columbians have the majority of their health needs met by high-quality community-based health care and support services”services

…to be achieved through the creation of an integrated primary and community care system

Behind the changegNot just a ‘good idea’ but…

ResearchResearchPolicyP tiPractice

Redesign of community careg y

N hi ki d h d l

Changing what we do, and how we do it

New thinking around how we deploy resourcesShifting traditional approaches, roles and resources

• Home and Community Care• Mental Health and Addictions

Old Ad lt d G i t i S i• Older Adult and Geriatric Services• Public Health, Aboriginal Health• Deeper collaboration with GPs,

communities

New partnershipsp pCollaboration across traditional boundaries

Community Services(Re-designed)

Primary Care+(Re designed)

Primary care + y

• First time Primary Health Care has moved

Revived, a provincial priority+

• First time Primary Health Care has moved into a strategic operations role

• Family physicians now formally recognized for their role in the system

• Relationship between a GP and their patient is central to future planningpatient is central to future planning

• Physicians supported with structure and funding: GPSC, Divisions of Family P tiPractice

• Shared planning, solutions, accountability

Patients as partners+ p+Active involvement and responsibility

Clients, patients and families engage with their family physician around health decisions

Take responsibility for healthy lifestyle choices

Supported to self-manage conditions

Patients’ bring their perspectives to system re-design: Patient Voices Network

Community partners+ y p

N i

Broadening the circle+Non-government community partners i.e. Alzheimer Society, Heart and Stroke

Foundation, Canadian Mental Health Association

H lthi it t hiHealthier community partnerships Formal, action-oriented partnerships with

municipalities

Aligns with integration and forms a ‘big picture’

VisionFor an integrated system

A community-based system of care and support services built around a patient’s attachmentaround a patient s attachment to their family physician.

Family Physicians, Specialists, Nurse Practitioners, Pharmacists, Community Care Nurses, Allied

Key services link to form extended integrated team;

Health, Home Care, Mental Health and Addictions staff

‘wrap around’ GP and patient

Integrated modelgRelationship-based care

Continuous, coordinated care, ease of accessease of access, seamless system navigation

Flexible for local customization

All communities by 2015

Integration in Action“A new model for

Home Health”

Care managementg

Current B C Model

Shifting directions

Current B.C. Model• Service focus • Reactive• Reactive• Single Sector• Focus on Eligibility/

Interventions

Future goals:• Client-focus

Interventions• One-to-One home

approach• Case Manager as

• Proactive, outcomes-oriented• Team approach / multiple

disciplines/ community• Case Manager as

defined role • Enhance chronic disease mgt• Support self care• Improve client experienceImprove client experience

Fraser Health visionMaking people’s lives easier

Partner Home Health Case Managers with local familyManagers with local family physicians, to improve the outcomes of clients with long term health conditionslong-term health conditions that impact their function and well being.

Who do we want to help?pPopulation-based

The fragile elderly and other adults with chronic or complex health conditions

…who are most at risk, and require comprehensive coordinated care andcomprehensive, coordinated care and supports

…so they can stay out of the hospital, maintain independence and remain living at home.g

Defining populations in needg p pThe “complexity of needs” triangle

Population characteristics

Helps identify who is mostHelps identify who is most at risk for acute care admissions and where to put resources for greatestput resources for greatest impact

Case findinggJohn’s Hopkins Predictive Modeling Tool

Uses acute care data, GP data, pharmacy,pharmacy, population data

Identifies • clients who can benefit from care management and targeted interventionsg g• future risk of resource use, future medical and pharmacy expenses• needs of current client’s complexity as well as service gaps

Care Manager/GP Partnershipg / pA shift of traditional roles

Case Manager embedded in family practices (rather than geographic district)

Each GP aligns with one Case ManagerManager

Care Manager caseload aligns with GP practice patient panel

The partnership at workp pDesigned around GP/Patient and attachment

P ti t / Cli tPatient / Client and Family Care Managers go to GP offices

/ GPs make office space

Group planning: GP + patient + p p g pfamily + Care Manager

Intent to build productive, meaningful interactions between the GP and Care Manager to meet patient needs

Creates capacity for the GP bl / d tt h t

Family Physician GPCase Manager

enables / deepens attachment

The partnership at workp p

C M

Designed around GP/Patient and attachment

Care Manager:

Provides intensive care management Care coordination navigates services including Home Health Care coordination, navigates services including Home Health Referrals to community Health promotion Proactive monitoring and early detection of illness Proactive monitoring and early detection of illness Intervention of declining status Post-hospital care

Connects with future Integration:Geriatric Services, Mental Health and Addictions, Acute Care

Making it possibleg p

Add Surveillance RN

Redeployment of traditional functions

Add Surveillance RN Proactively monitor and support clients by phone according

to the care plans developed by care managers M li t t l i t i t d l Move clients to a less intensive care support model once they are stable

Use a self-management (coaching) framework.

Add Business Support Perform non-clinical functions currently done by care Perform non clinical functions currently done by care

managers, such a financial assessments Free up care manager’s time for intensive clinical work

Stepped approachpp pp

TARGET POPULATIONAIM

T t HH C M ith

Monday, September 27, 2010Stepped Collaborative Care Model for CM-GP Initiative

Collaborative care model TARGET POPULATION

Frail Seniors & other adults with chronic disabling health conditions

who require supports & coordinated care to maintain their

independence living in the community

To partner HH Case Managers with GPs to improve the outcomes of clients with long term health conditions which

impacts their function & well being.A.k.a – working with clients to make

their lives easier

Test

Re-align Caseloads

Cluster CareCoach for Self Local GP division

& Home Health

Enhanced CM tools & skill development

CM Attach to GP

Enhance CM SkillsIntensive CM for High Risk Clients

Enhance CM SkillsProactive Monitering of STABLE LTC

clients

Develop

Hand-offs to

Manage Transitions

Phone surveillance position prototype developed

Management SupportSupport geriatric focussed Chronic Disease Mgt

Dementia Delireum Depression

& Home Health identify priority clinical skills needed

pProactive care provision Goal is to stabilize clients for handoff to surveillance nurse

Same stuff, less people to talk to3 GP-CMCollaborate on all LTC clientsAdvise/educate regarding options for ‘at risk’ clients

Steps toward collaborative

care

Ti ( )

Hand offs to HospitalLink while in hospitalTransition Care back home

Sept 2010 June 2011Feb 2011Dec – Jan 2010Oct 2010

Supporting A ti iti

Time (mos)

GP-CM Partnerships: Prototype 3 GPs, Develop CM-GP ‘compacts’, Design & develop referral process, Case Load analysis, Re-align caseloads

Develop phone surveillance nurse prototype, develop Clinical Decision Support Tools (CDSTs), mechanisms for communication & define STABLE LTC clients

* Note: Above ‘steps’ indicate starting points and may take place over several months time (i.e. some activities will be continuous over time

Page 1

ActivitiesDevelop CM education and CDSTs and review Clinical Practice Guidelines - GP

Develop Business Support Person Prototype, map HH business processes & identify clinical vs administrative tasks

Prototype communityyp yChilliwack, BC

M di i d h l ti 83 000 Medium sized, homogeneous population - 83,000 Good community resources Population aged 65+ higher than average for Fraser Health and BC

15% t tt h d t f il h i i 15% not attached to a family physician 20% have a chronic disease - Cardiovascular highest hospitalization High prevalence of depression and anxiety

Chilli k GP Di i i id tifi d f il i i it Chilliwack GP Division identified frail seniors as priority

Triple aimpExpected outcomes

Improved population health - improved individual health outcomes.

Improved patient/provider experience -effective access and navigation of the community-based health care system y yfor patients, families and caregivers.

Sustainability- Reduced per capita costs for target populations. Reduced ER visits and hospital length of stay.

Past Successes Building on evidence

A Physician / Case Manager Partnership model tested in one community in Frasermodel tested in one community in Fraser Health in 2007/08 showed a 33% decrease in ER visits and 61% decrease in hospitalizations.

Other international evidence supports these statistics

Looking to the futuregHome First: Completing the picture

KEY TO HOME – operational directions to decrease of length of stay in acute care

Liaison staff ‘pull’ patients and coordinate discharge and support ft di hafter discharge

Inspirationfor change

Real, lasting benefits, gPotential for significant, positive change

Upstream – Prevent ER visits and hospital admissions, shorter hospital stays

Downstream – Live at home longer Downstream Live at home longer, prevent residential care admissions

Better care in a lower cost environment, future cost avoidances Expanded capacity in our communities to support complex needs Greater efficiencies - better use of everyone’s time, resources, People get the full range of care they need People can stay independent as long as possible

Fulfilling our belief that HOME IS BEST.

Our clients and patientsUltimately, it’s about healthier people

“I feel more confident and in control. I’m living

f l t h ”safely at home.”

Home is BestHome is BestA New Integrated Primary and Community Care System

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