Seamless Transitions: Hospital to Home · Seamless Transitions: Opportunities & next steps...

Seamless Transitions: Hospital to Home

David FryVice President, Patient Care, Mississauga Halton CCAC

Patti CochraneSenior Vice President, Clinical Strategy & Chief Innovation Officer, Trillium Health Partners

Michelle SammJoint Senior Project Manager, Mississauga Halton CCAC/ Trillium Health Partners

OACCAC ConferenceJune 6, 2016

Seamless Transitions:Today’s presentation

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Agenda

1. Understanding the Issue

2. Establishing a Formal Partnership

3. Board and Operational Oversight

4. The Design Process

5. Evaluating Our Success

6. Opportunities and Next Steps

Seamless Transitions:Background – the issue

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• Hospital to home transitions can be challenging for patients, caregivers and health and social service providers

• Mississauga Halton region – one of Ontario’s fastest growing seniors’ populations, set to triple by 2035

• In 2014/15:

o Trillium Health Partners –no bed admits

o Mississauga Halton CCAC –10% more patients from hospital referrals

ESTABLISHING A FORMAL PARTNERSHIP

Where It Started:

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Seamless Transitions:Partnership

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Timeline

• 2011: Mississauga Halton CCAC identifies “Managing Systems Transitions” as a Strategic Plan priority initiative

• 2012/2013: Regional review of factors impacting system transitions for patients was completed

• January 2014: First meeting of Mississauga Halton CCAC and THP CEOs and senior leaders

LHIN endorsement

• Initiative supported by early endorsement and ongoing investment from Mississauga Halton LHIN

Seamless Transitions:Myths Busted

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Myths in Mississauga Halton CCAC about THP

Myths in THP about the Mississauga Halton CCAC

• The hospital does not know about the complexities of community care.

• It is as easy to deliver care in the community as it is in the hospital.

• Hospital does not understand that patients behave and heal differently at home.

• Hospital is not concerned with making available the necessary information to take proactive action.

• CCAC does not understand hospital pressures and process-driven approach creates inertia.

• CCAC puts economy ahead of quality and does not staff appropriately for surges in the patient load.

• The quality of care is not the same in the community: care is sub-standard and patients are not as safe in the community; services in the community are not provided with as much reliability as in the hospital; CCAC does not have the skills/knowledge to provide home care.

• Acute care can only happen in hospitals• CCAC does not communicate changes adequately.• It is not possible to manage the gap created by

the differences in the way different CCACs operate.

There is no predictability to the system.

Seamless Transitions:Partnership Principles

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Seamless Transitions:Partnership Mandate

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Mandate:

• Go out and be disruptive innovators.

• Strive for transformational change, not incremental change.

“Transformation is a deliberate, planned process that sets out a high aspiration to make dramatic and irreversible changes to how care is delivered, what staff do (and how they behave), and the role of patients, which results in substantial, measurable improvement in outcomes, patient and staff

satisfaction and financial sustainability.”

Seamless Transitions:Partnership

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“Transformation is a deliberate, planned process that sets out a high aspiration to make dramatic and irreversible changes to how care is delivered, what staff do (and how they behave), and the role of patients, which results in substantial, measurable improvement in outcomes, patient and staff

satisfaction and financial sustainability.”

BOARD AND OPERATIONAL OVERSIGHT

How We Governed:

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Seamless Transitions:Governance - Board

Board-level

• Mississauga Halton CCAC and THP Boards of Directors approved initiative work plan before design process began

• Both governing bodies had to endorse proposed changes to organizational structures

o Recognition that processes and procedures in both needed to change to improve transitions from hospital to home

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Seamless Transitions:Governance – Board

Mississauga Halton CCAC

• Board approves Strategic Plan

• Mississauga Halton CCAC Board of Director’s Patient Care Quality Committee reviews feedback from organization’s patient and family advisory forum – Share Care Council

• CEO provided frequent updates back to Board on initiative status because of system implications of the scope of work

THP

• Interested in exploring regional partnerships

• Discussion at sub-committee

• Monthly updates

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Seamless Transitions:Governance – Operational

• Joint, CEO-led Steering Committee (monthly meetings)

• Cross-organization Working Group (weekly meetings during pre-planning and early test phases; bi-weekly thereafter)

• Joint Project Manager (provided updates to Steering, Working Group, staff huddles; managed design process)

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Seamless Transitions:Governance – Operational

Operational

• Dedicated interdisciplinary design team: physicians, Mississauga Halton CCAC care coordinators, nurse, physiotherapist, occupational therapist, social worker, professional practice lead, performance management consultant, patient/caregiver advisor, communications specialist

• Led process design and testing; acted as project champions and change ambassadors

THE DESIGN PROCESS

What We Accomplished:

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Seamless Transitions:Define phase

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• Interview and observation:

o Design Team

o Patients and caregivers

o Staff, including physicians

o Primary care physicians

o Community providers

• Problem statement: We lack a shared understanding of patients’ needs to inform and execute a care plan that will give them confidence to leave hospital.

Seamless Transitions:Brainstorm phase

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• Patient engagement – Share Care Council

• Staff and physician engagement – five brainstorming sessions

o 154 staff attended

o 1,301 ideas generated

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Seamless Transitions:Prototype phase

• Objective: to create a consistent, integrated, person-centered approach for hospital to home transitions that improves patient experiences, while eliminating duplication in processes and gaps in communication and care.

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Seamless Transitions:Prototype phase

A traditional approach where hospital care teams are geographically based

and hospital and community teams are

siloed.

An integrated approach, grounded in leading practice,

designed to deliver high quality, efficient, effective,

integrated care that connects care providers across the continuum to improve the

patients’ experience.

Current State Future State

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Seamless Transitions:Prototype phase

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Seamless Transitions:Prototype phase

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Seamless Transitions:Prototype phase – Video

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Seamless Transitions:Test/Refine/Learn phase

• What: Key components of Seamless approach

• Where: Medicine program at Trillium Health Partners -Credit Valley Hospital (THP-CVH)

• When: September 29, 2014 to June 26th, 2015

• Who: Patients on two physician teams (started with one physician team, the test was expanded to include a second team on January 21, 2015)

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Seamless Transitions:Test/Refine/Learn phase

*March 2015

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Seamless Transitions:Evaluation phase – Patient Profile

*Sept. 29/15 to March 31/16

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Seamless Transitions:Evaluation phase – Patient Feedback

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Seamless Transitions:Evaluation phase – Key Findings

• Seamless patients had significantly lower readmission rates, compared to other THP-CVH Medicine patients.

o 52% decrease in 30-day readmission rates.

o Estimated that reduced readmission rate will save 0.9 days (potential conservable days) and reduce patient mortality rates.

• Increased utilization of community services.

• No difference in Length of Stay (LOS) or ALC rates between test and control groups.

EVALUATING OUR SUCCESS

What We Learned:

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Seamless Transitions:Lessons learned - Testing

People:• Build shared cultures to facilitate

work across sectors• Identify operational leads and

supports early• Establish expectations for new

attitudes and behaviours to sustain transformative change

Time:• Need adequate time to build and

strengthen relationships between partnering organizations and its people

Patient focus• Utilize partnership

principles to keep work focused

• Engage stakeholders continually

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Seamless Transitions:Lessons learned - Governance

Operations:• Ensure committed and

courageous leadership• Establish patient-centred,

strategic partnership principles and mandate

• Engage operational leads during planning phases to ensure smooth rollout during testing

• Provide ongoing and consistent communications across organizations

Leadership/Board:• Organization’s leaders

need to identify strategic partnership opportunities, and lead partnership activities (top-down) –open to taking honest look at areas for improvement

• Board – importance of endorsing projects that support improvements in QIP targets

OPPORTUNITIES & NEXT STEPS

How We Are Applying Lessons Learned:

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Seamless Transitions:Opportunities & next steps

Care Coordination Program of Work

• Refined, consistent, enhanced Care Coordination Framework

• Core competencies for care coordinators

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Seamless Transitions:Opportunities & next steps

Care Coordination Program of Work (continued)

• My Story documents –written, plain language care plan used for all patients, patient goals, welcome letters

Second Partnership Initiative

• Tested approach with second regional hospital provider, Halton Healthcare

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Seamless Transitions:Opportunities & next steps

Ongoing work with Trillium Health Partners

• Complex implementation process related to Medicine –THP is determining next steps for full implementation of Seamless Transitions approach

• Unit-Based Affiliation project

Executive Sponsors:

• David Fry, Vice President, Patient Care, Mississauga Halton CCACo Email: david.fry@mh.ccac-ont.cao Phone: 905-855-9090 ext. 5333

• Patti Cochrane, Senior Vice President, SVP Clinical Strategy & Chief Innovation Officer, Trillium Health Partnerso Email: Patti.Cochrane@trilliumhealthpartners.cao Phone: 905-848-7683

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Seamless Transitions:For more information

Visit the Mississauga Halton CCAC’s website.(www.healthcareathome.ca/mh)

• Review the Guidebook (provides a summary of the partnership and design process).

• Refer to the Seamless Transitions “Quick Facts” sheet.

• Watch the video, featuring physicians, a hospital social worker, and a Mississauga Halton CCAC care coordinator.

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Seamless Transitions:For more information

Questions?