Transitions of Care: Supporting You, Your Patients &

Your Priorities Primary Health Care Integration Network

Dr. Brad Bahler & Julie Schellenberg

Integration Live Live!

Integration & Management Continuity and Transitions

3

…a new approach to healthcare service delivery is needed — and Alberta is taking the lead.”

Dr. Verna Yui AHS President & CEO

“Alberta Health Services, like all health systems across Canada, will need to make

transformative changes to how we deliver services in order to improve quality and safety …

What matters to patients?

I’ll have what I need when I return home, I’ll know what I need to do, and my doctor will know what’s going on.

@PatientCommonSense

What patients are experiencing

ED notification

23%

Family physicians notification for ED visit and hospital discharge

(Commonwealth Fund)

Follow-up

35-56% within 1week

77-92% within one month

AMI, HF & COPD patients in AB/SK

(CIHI)

Hospital to Home

Transitions

System Foundations for Integration

Achieving Continuity through Integration

Keeping Care in the Community

Linking to Specialty and Back

Hospital to Home

Transitions

System Foundations for Integration

Achieving Continuity through Integration

Keeping Care in the Community

Linking to Specialty and Back

By Joe Zachs from Pune, India The Bombay Dabawalla) [CC BY 2.0 http://creativecommons.org/licenses/by/2.0

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Supported Transitions Committee CALGARY

Calgary Zone Primary Care Action Plan

Enhanced support for

at-risk patients

Web Registry

Enhanced Hospital

Discharge

Supportive Transitions Committee

Committee Members

Sandra Athron AHS

Leanne Kiss Chair, Informational Continuity, CFPCN

Peter Rymkiewicz Evaluation Lead, MPCN

Keith Bradford CFPCN

Jana Lait AHS

Dr Monica Sargious AHS

Lorraine Bucholtz Chair, CFPCN

Mandy McCabe AHS

Oliver Schmid Chair, Relational Continuity, SCPCN

Christopher Cameron Corresponding Member, CWCPCN

Allison Mirotchnik AHS

Dawn Shave CRPCN

Stephanie Crichton Corresponding Member, CRPCN

Regan Paddington HPCN

Shelly Storozuk SCPCN

Amy Deagle CRPCN

Yvette Penman Corresponding Member, BVPCN

Dr Ann Vaidya AHS

Rod Iwanow AHS

Wendy Pratch AHS

Stephen Wan CFPCN

Jake Jennings Co-Chair, Management Continuity, AHS

Janelle Richer Co-Chair, Management Continuity, MPCN

Gloria Wilkinson Public Member, PMHAC

It takes a team

Integration Live Live!

Let’s go exploring! Who’s up for a Expedition?

Let’s go exploring! Who’s up for an Expedition?

Travelling partners

Expedition interests

Travelling in harmony

Pick and plan

Travel and adapt

Post and recommend

Zone Journey

Planning

#4 What are the solutions you want to test?

#1 Are you ready to work together?

#5 Do your solutions work?

#2 What are your pain points?

#3 How will you work together to develop solutions?

#6 How will you build up (and build out) your successes?

Hospital to Home Transitions – PHCIN Supports

Stakeholder mapping

Where you’re at… What PHCIN can support…

Data to inform “the why”

Facilitator to support

collaboration

Facilitator to support

identification of pain points

Transition Mapping

Data to inform patient

population

Scoping

Facilitator to support process to develop your

solutions

Evaluation of potential

solutions to align with evidence

P l a n n i n g P h a s e

#1 Are you ready to work together?

#2 What are your pain points?

#3 How will you work together to develop solutions?

Development of integrated care model

Where you’re at… What PHCIN can support…

Support to develop and

choose measures

Facilitator to explore options

and design prototypes

Facilitator to support

identification of pain points

Change management

during implementation

Support to test prototypes:

“test small & learn quick”

Business case for re-investing

gains

Facilitator for shared

decision-making on next

steps

Data analysis to quantify gains

and inform reinvestment

#4 What solutions do you want to test?

#5 Do your solutions work

#6 How will you build on and broadcast your success?

E x p e d i t i o n P h a s e

Regular Provincial Check-ins

It’s about the PHCIN Supporting…

Our commitment

We will work with you from your starting place

We will work with you at your pace

We will have fun and celebrate

Integration Live Live!

Coming PCN Leads Fall 2018 – Brad & Julie’s Excellent Adventure!

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Transitions of Care:�Supporting You, Your Patients & Your Priorities Slide Number 2Integration &Slide Number 4What matters to patients?What patients are experiencingSlide Number 7Slide Number 8Slide Number 9Slide Number 10Slide Number 11Calgary Zone �Primary Care Action PlanSlide Number 13Slide Number 14Slide Number 15Let’s go exploring! Who’s up for a Expedition?Let’s go exploring! Who’s up for an Expedition?Slide Number 18Slide Number 19Slide Number 20Excitement!Slide Number 22Our commitmentSlide Number 24Slide Number 25