julie kille, operations leader brynn grierson, msn, clinical nurse leader dr. sarah stone, idc...
DESCRIPTION
CM restructuring Restructure of CM team with more defined roles for each team member Complexity score created CM form and database changed to include complexity score IndicatorsUnstableIn transitionStable Housing/Food/Income □ 0 □1□1 □ 2 Addictions & Mental Health □ 0 □1□1 □ 2 Engagement & Adherence □ 0 □1□1 □ 2 Medical Complexity □ 0 □1□1 □ 2 Score:_______________TRANSCRIPT
Julie Kille, Operations LeaderBrynn Grierson, MSN, Clinical Nurse Leader
Dr. Sarah Stone, IDC PhysicianElizabeth Barrett, Administration Coordinator
Neil Fowler, Program Assistant
What we’ve been working on:
Case management (CM)
Patient Advisory Group
Addictions Group
CM restructuringRestructure of CM team with more defined roles
for each team memberComplexity score created
CM form and database changed to include complexity score
Indicators Unstable In transition Stable
Housing/Food/Income □ 0 □1 □ 2
Addictions & Mental
Health□ 0 □1 □ 2
Engagement &
Adherence□ 0 □1 □ 2
Medical Complexity □ 0 □1 □ 2
Score:_______________
CM Restructuring: Why?IDC team retreat
Evolving mandate of clinic to see patients with higher levels of medical and psychosocial complexity
Creation of complexity score gave us an idea of overall complexity of IDC patients
CM Restructuring: How?After the IDC retreat we realized we need more
than anecdotal/qualitative measures to evaluate CM and complexity of patients at the IDC
STOP evaluators shared with us the indicators used by the STOP outreach team.
THANKS!!
Modified these indicators to suit our needs
CM Restructuring: QIBeing able to quantify and measure CM. Not
just staff and patient reports
Helps determine patient care plan
Ensures appropriate team members are involved in patients care
Other changes/new initiativesRestructuring of Patient Advisory Group
New time and new location (at clinic)More frequent meetingsLess formal settingFood available
Changes made to increase patient engagement and patient voice
Creation of Addictions GroupDuring addiction clinic hoursLow barrier group (new members always
welcome)Support, education, and treatment options
provided by interdisciplinary teamFood available
Group created to increase engagement of our most marginalized addiction patients and to
offer alternative support and treatment options.
Other changes/new initiatives
Lessons LearnedBe creative when
developing evaluation measures
Importance of ongoing evaluation of own process (current process, groups etc). We now have the tools to do it!!
Importance of engagement and including patient perspective
We are not afraid of change!