The New Brunswick Extra-Mural Programand MY Health Plan

REACH Conference 2015David Arbeau & Mary Williams

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The New Brunswick Extra-Mural Program

Mandate

Provide an alternative to hospital admissions; facilitate early discharge from hospitals; and provide an alternative to, or postponement of, admission to nursing homes.

Services:•acute, •palliative, •supportive and maintenance care, •rehabilitation services, •coordination & provision of support services &•home oxygen program

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The New Brunswick Extra-Mural Program

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The New Brunswick Extra-Mural Program Team

RHA Extra - Mural ProgramDirector

RHA Extra - Mural ProgramDirector

Secretarial SupportSecretarial

Support

NursingNursing OccupationalTherapy

OccupationalTherapy

PhysiotherapyPhysiotherapy SpeechLanguage

SpeechLanguage

Social WorkSocial Work

RespiratoryTherapy

RespiratoryTherapy

Clinical NutritionClinical Nutrition

Clinical Coordinators/Unit Managers

Clinical Coordinators/Unit Managers

Registered Nurses

Registered Nurses

Licensed Practical Nurses

Licensed Practical Nurses

Rehabilitation Assistant

Rehabilitation Assistant

Physicians

Clinical Nurse Specialists

Liaison Nurse

Quick Response

Nurse

Personal care aids

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The New Brunswick Extra-Mural Program

Long Term Care Services

•Single Entry Point: Social Development, MH & EMP

•A range of personal support & physical/mental health services required by residents age 19+

•Long term functional limitations

•Need assistance to function as independently as possible •Coordination of & access to a range of services

Reduce the premature institutionalization of seniors

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The New Brunswick Extra-Mural Program

Care Coordination

• Client-focused process – Appropriate care; at the right time; in the right place; by the right

provider

• Involvement of other team members & partners• Case management

• System navigation

• “My Health Plan”

Timely & responsive care to meet the client’s goals

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Our patients…

• 64.6% over the age of 65– 23% over the age of 85

• Acute (36%), Rehabilitative (25%), Supportive Care (Chronic) (34%)

• Palliative Care• 62.1% of home care clients with household

income less than $ 25k

EMP Indicator Report, 2014/15

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Chronic conditionsChronic condition Citizens receiving

home care (%)NB General Population (%)

Hypertension 56.8 25.7

Arthritis 48.3 18.0

Chronic pain 40.7 15.0

Heart disease 35.3 8.3

Gastric reflux 31.5 16.1

Diabetes 30.4 9.2

Cancer 26.2 7.0

Depression 24.5 12.7

Emphysema/COPD 18.3 2.7

Stroke 15.8 2.0

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Our patients…

Staff gave information needed for clients to take

care of themselves (% strongly agree) 49.3%

How often providers seemed informed about all

care/treatment received at home [Among clients

with services from more than one person]

(% always) 77.1%

NB Health Council, 2012

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Our patients…

• Confidence: Ability to control and manage health condition

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Citizens receiving Home Care (%)

NB General Population (%)

Very confident 25.5 39.6

Confident 55.9 53.5

Not very confident 12.2 5.8

Not at all confident 6.4 1.1

The New Brunswick Extra-Mural Program

“My Health Plan”

• Client’s goals & wishes• Client choice in decision making• Client self-care & family participation• Open exchange of information within client’s circle of care

Care is coordinated, integrated & supports individuals to remain in their homes and communities

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What do you need to know?

• My Health Plan encourages clients and their families to actively participate in service delivery.

• The health plan is related to client goals and service provision that will enhance the resources that they already have.

• Utilizing one common plan enhances interprofessional practice so each member of the client’s team is aware of what the client’s plan is, who is involved, and what actions need to be taken.

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Why is it important to engage our clients in care planning?

•Enhances client motivation to make changes

•Involves the client more directly in the decision making

•Put the client in the driver’s seat and the health clinician acts as a coach and a guide.

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Clients motivation to change starts with their confidence that they can do it.

success with goals client confidence

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“All EMP team members play an important role in carrying out tasks, identifying what other members of the client’s circle of care team can do to help achieve the goals, promoting independence, working toward the client’s goals in a flexible, responsive way, encouraging clients to perform an activity, & stepping in to provide more hands-on help when appropriate, such as in the event of illness or deterioration in the person’s condition.”The EMP Client My Health Plan backgrounder and tips

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Goal Setting

• Focuses on client’s strengths and what they want to be able to do.

• Is a joint responsibility between the client and the EMP provider. Where appropriate involving the client’s family and circle of care.

• Requires sensitivity, negotiation and professional judgment.

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4 main steps of goal setting

• Identifying an end point

• Working out what steps are needed

• Establishing what structures must be in place

• Constant reiteration throughout the period of care.

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Goal

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I want to be able to stay at home. I would like to be able to go to the Sunday church service with my wife.

Strengths

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My wife and kids are a big help. A lady comes in to help a couple days a week

Challenges

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I rely a lot on my wife. She’s tired and has her own health concerns; If I could do more for myself it would be easier on her; My breathing makes getting around difficult and I’m not as strong as I used to be because of my stroke.  

Steps to Focus on

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 Jan 25, 2015  

Every morning, I want to be able to get myself dressed   

1.Wanda will help me get out of bed and get  my clothes for me2.I’ll get dressed the way Connie showed me and use the aids she gave me to make it easier3.Wanda will be there in-case I need help4.I’ll do the arm strengthening exercises Connie recommended  with Amanda every day for at least 10-15 mins. (see care plan for exercise program)

Wanda – PCA Connie – OT Amanda – RA 

 

Another example

DateWhat do I 

want to focus on?

What steps will we take to achieve this?

Who will help me do this?

Date goal reached or revised

   Jan 27, 2015

On a daily basis, I want to be able to manage my breathing 

1. Mrs. Clause will help me get my medications and watch that I take them right2. I’ll check how I’m doing everyday using the monitor Linda set up for me. 3.I’ll do my lung hygiene daily, Linda will teach me how to do it right4. I will learn more about my COPD  and how to do things easier ways

Mrs. Clause - wife Linda – RT Linda – RT Amanda  - RA

 

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Follow up

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Once a week Linda or Patty

: 9 weeks

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Professional's storyFocused

Assessments/Intake assessment

Client’s Story

Client Goals

My Health Plan(over-arching plan for the

client)

EMP Care Plan(specific clinical plans i.e. Skin and wound, COPD management, rehab

exercise program)

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The New Brunswick Extra-Mural Program

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The New Brunswick Extra-Mural Program