transforming pathways to service at cnib

seeing beyond vision loss

Transforming Pathways to Service at CNIBService Pathways Project TeamJune, 2014 (Revised)

Passionately providing community-based support, knowledge and a national voice to ensure Canadians who are blind or partially sighted have the confidence, skills and opportunities to fully participate in life.

Community-Based SupportHelping people who are blind or partially sighted develop the confidence, skills and opportunities they need to fully participate in life.

National VoiceCreating an inclusive and barrier-free society with access to rehabilitation services and technology.

KnowledgeImproving the eye health of Canadians and eliminating avoidable sight loss.


• Registered Charity • Funding – about 30% from Government• 53 offices across the country, divided into 6

regional management centres, each with an ED, plus a national support services office in Toronto

• Employees – 850• 200,000 volunteer hours/year

CNIB – Who We Are


• Independent Living Skills• Low Vision Services• Independent Travel: Orientation and Mobility• Child &Family Services: Early Intervention• Library Services• Deafblind Services• Peer Support Programs• Consumer Products & Assistive Technology

CNIB Vision Rehabilitation Services


• Rehabilitation Services integrated and funded within the continuum of care

• “Rights” (rehabilitation services) vs. “Enhancements” (other than rehab services)

• Professionally delivered and customer-focused services for all

Why Create Pathways to Service?


• 35% better than 20/70 (considered mild vision loss or near normal, but we are not sure if they were “best corrected.”)

• 55% better than 20/200• 31 % legally blind (20/200 or worse or documented field

loss of less than 20 degrees.)• 2% 20/1200- NLP

• In 2012, 40% at time of registration have no eye report

All new clients by FVC 2013


• The foundations for modern day Vision Rehabilitation were established at the end of WWI, when many returning from the war were totally blind.

• We have assimilated low vision rehabilitation within the model of service delivery designed for those who are blind

• We have a history of encouraging “all who need us” to come for our help

The Need for Transformation


• Today’s Accepted Standard- Low vision rehabilitation begins with a careful evaluation by an optometrist or ophthalmologist

• We allowed new referrals to bypass this fundamental requirement prior to the start of rehab services, and this number appears to be increasing:

– In 2012, we had 6% of all new clients with no eye report; in 2013, it has been 13%, more than double.

• In 2014, we introduced the requirement of an eye report prior to service



• 1600 of the new clients we served in 2012 have an “Unknown” cause of vision loss but still received nearly 10,000 hours of service

• 3,000 new clients with vision better than 20/70 participated in rehab service delivery


Current Pathways-Adults

• Self-referral (including family member)• Practitioner referral

Leading to…

The Buffet--

Current Pathways-Adults

• Self-referral (including family member)• Interest, based on choices offered• Practitioner referral

• Range of services offered through Intake Interview• If interested, those services are “assigned”• Perhaps many or most have a FVA done first, but NOT

ALL


• By endeavoring to assist everyone in the same manner, we risk offering similar service to all who come to us (a “smorgasbord”)

• Proper assessment and case management guidelines are needed

• We will be challenged in our efforts to be integrated within the continuum of care if we continue to operate outside of it

• We must transition access to and the delivery of vision rehabilitation in order to effectively meet the needs of those we seek to serve



We have evidence, through our research, and EVRR, of:

• Client confusion-who does what? What does each discipline do? Why is there so much to choose from?

• Some clients getting service they do not need; some clients not getting service they do need, or waiting too long for it, and an inability of the system to adjust the intensity as needed

• Inability for us to justify the rehabilitative nature of our work to health funding sources

• Ordering of devices that do not meet the need• Lack of follow-up with clients• Many clients getting only 1-2 hours of service, and then no more

(but do some need more?)

Resulting in…


• Models we visited (or had information sharing with) as part of the data gathering process:

• MAB-Mackay, Montreal• Lighthouse International, New York• University of Waterloo Centre for Sight Enhancement• Vision Australia• RNZFB

Collaborators


This model of care has been designed to improve outcomes for clients by:

1. placing clients on the Service Pathway that is appropriate to their level of functioning, level and type of vision loss, and urgency of the individual situation

2. delivering client-centered care according to individualized needs; and

3. for the first time, coordinating service for clients through one point of contact (Service Coordination Specialists), aims to decrease reports of client confusion and/or overwhelm when coming to CNIB.

Improving Client Experience


• Phase 1-Implementation of the Eye Doctor Referral Form-launched July 22, 2014

• Phase 2-Implementation of the new Triage Tool, the Comprehensive Assessment of Needs (CAN), and the pathways referral processes-will launch late fall, 2014

• Phase 3-Exit Survey, Follow-up Centre, and Discipline Based Assessments revised

SP Phased-In Approach


• “Adjustment to Vision Loss”• “Sight Enhancement”• “Sight Substitution/Urgent Care”

Proposed New Pathways


“Adjustment to Vision Loss” Pathway

Triage • Client into system-Regional centres, Helpline (back-up)

EYE DR. REFERRAL FORM• From eye doctor• If Yes…• If No…

Adjustment to Vision Loss• Website/E-Learning• Peer Support• Shop CNIB• Library


“Sight Enhancement” Pathway

Triage• Regional centres, National

Helpline (back-up)• Client registered in Database

• Eligibility assessed• If not-Adjustment to Vision Loss

(AVL)

Qualifies for/Requests Rehab• If not, Adjustment to Vision Loss

(AVL)• If yes, Low Vision Assessment



Low Vision Ass’t.• Requires other services?• If not, AVL pathway• If yes…

Service Coordinator• Conducts the CAN (Comp

Assessment Needs)• Refers and Coordinates Service

Rehab• Independent Living Services• Orientation and Mobility• Technology training



AVL Pathway• Website-Shop CNIB, e-Learning• Library• Peer Support

Rehab Services • As needed


“Sight Substitution/Urgent” Pathway

Triage •Client registered in Database

EYE DR. REFERRAL FORM •Yes…•No…

Qualifies for Rehab •And requests it…


“Sight Substitution/Urgent” Pathway

Service Coordinator

• CAN (Comp Assessment Needs)

• Referral for service and AVL Pathway

• Service Coordination

Rehab Services

• Rehab Teaching• Orientation and Mobility• Technology training• Other


• Original form reviewed by 5 eye doctors (one ophthalmologist, 3 optometrists in private practice, and 1 academic/clinical optometrist); Feedback was also collected from a small LV leadership group

• Final form includes items desired by both groups: e.g. primary reason for referral.

Doctor Referral Form-Development


• Drs have been asking for a “click and submit” option

• The Eye Doctor Referral (EDR) may be completed online (click and submit) and will be directed to data entry people

• If the EDR is received before the client has called us, the client will be registered in database, then phoned to conduct the Triage Tool

Notes-Doctor Referral Process


• The Triage Tool contains the list of items about functioning for determining the person’s needs quickly, will help determine pathway and urgency

• Triage Tool - four areas: • Safety• Employment and academic success• Emotional and social well-being• Functioning with vision loss

Triage Tool Development


• Development included review of: • Our Current Intake• Vision Australia Common Intake Tool (CIT)• Functional Vision Screening Questionnaire items

(Wisconsin Department of Health Services)• VF25-QOL• VFQ 14• MacKay Global Assessment Form• University of Waterloo Centre for Sight Enhancement

Patient Information Form

Triage Tool Development


• The Triage tool will now be separate from the Eye Report (which will be called the Eye Doctor’s Referral Form)

• Triage will be handled almost exclusively by the Registrars and similar positions (as designated by Service Managers); there will be occasional exceptions (Eg. Deafblind services; children’s services)

Notes-Triage process


• All those conducting triage will be fully trained: new Eye Docs’ referral, triage tool, pathways processes

• National Helpline will provide back-up to the registrars and the rest of the service team, for the triage process

Notes-Triage Process


• Triage form will be completed over the telephone in EVRR in real time, with the registrars and similar position titles. Registrars will create the EVRR record as they do presently.

• The Eye Doctor Referral form will continue to be scanned in; and the eye information entered into the database by hand.

Notes-Triage Process


• Purpose: Stream rehabilitation clients to appropriate services

• Development included review of: • Our Current Intake• Our Current EVRR discipline based assessments• Vision Australia Comprehensive Assessment Tool (CAT)• VF 25• VF 14• Veterans Affairs LV VFQ 48• Veterans Affairs LV VFQ 20• MacKay Global Assessment Form

Comprehensive Assessment of Needs (CAN)


• Affects slightly the role of LV Specialists• Affects the role of the current Intake

Coordinators • Intake coordinators will take on role of

Specialist, Service Coordination-all have been briefed as of late October

Notes-The CAN process


• True service coordination will be the hallmark of this position

• Following clients through the process of rehabilitation, and carefully managing these cases

• A flag will be put into EVRR to deal with when a client needs the next service on their list

Notes-The CAN Process


• Those slated for training are:Service Coordination SpecialistsRegistrars/Back-upsLV Specialists

• Those slated for e-learning module on Pathways-all staff

Notes- Training


Slated for summer, and fall 2014Training sessions:

1. Pathways overview2. Interviewing skills; conflict resolution3. Processes4. Forms review and having the conversation5. Client records management6. Outlook scheduling

Notes-Training


• Building in outcomes measures• Fulfilling reporting requirements• Creating an Evaluation plan for the new project• Turning “on” certain functions-automation (e.g.

priority switches)

Additional Considerations

Evaluation of the project“Age Related Vision Loss”

Biljana Zuvela, CNIB Research

Quality is never an accident; it is always the result of high intention, sincere effort, intelligent direction and skillful execution; it represents the wise choice of many alternatives.

William A. Foster


Your Questions!

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