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AcrossSys03_LondonHealth

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3M Health Care Quality Team Awards – Nomination Form Submitted by: London Health Sciences Centre Connecting Care to Home: Optimizing Care for COPD and CHF Patients in London Middlesex (CC2H)

Contact information for administrative purposes Please indicate the category that you are applying for.

Quality improvement initiative(s) within an organization Quality improvement initiative(s) across a health system

Prefix: Name: Laurie Gould Title: Chief Clinical & Transformation Officer Organization: London Health Sciences Centre Address: 800 Commissioners Road East, London, Ontario N6A 5W9 Phone: 519-685-8500; x58111 Fax: 519-685-8127 Email: Laurie.Gould@lhsc.on.ca Project title: Connecting Care to Home (CC2H) Start date of the project: February, 2015

This program was initiated within the past three years and has sustained itself for at least 18 months.

Contact information for publication This will appear in the 3M Health Care Quality Team Awards booklet. If you do not wish to have contact information published, please indicate “n/a” in the applicable fields.

Please use the contact information provided in the nomination form.

Project title: Prefix: Name: Laurie Gould Title: : Chief Clinical & Transformation Officer Organization: London Health Sciences Centre Address: 800 Commissioners Road East, London, Ontario N6A 5W9 Phone: 519-685-8500; x58111 Fax: 519-685-8127 Email: Laurie.Gould@lhsc.on.ca

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Please list project team members, with job titles, including anyone seconded or invited onto the

team from other departments/groups. Include a separate page if necessary.

Name Job Title Role as it relates to the project

1. Laurie Gould Chief Clinical & Transformation Officer, London Health Sciences Centre

Executive Sponsor

2. Sandra Coleman CEO, South West Community Care Access Centre

Executive Sponsor

3. Donna Ladouceur Vice President, Patient Care, South West Community Care Access Centre

Sponsor

4. Judy Kojlak Director, Clinical Redesign, London Health Sciences Centre

Business Lead

5. Sherri McRobert Program Lead , South West Community Care Access Centre

Clinical Lead

6. Nasser Khalil Project Consultant, Clinical Redesign, London Health Sciences Centre

Project Lead

7. Gordon Milak Lead, eHomecare, South West Community Care Access Centre

Lead, eHomecare

8. Dr. Jim Lewis Respirologist, London Health Sciences Centre & St. joseph’s Health Care London

Physician Lead, COPD

9. Dr. Stuart Smith Cardiologist, London Health Sciences Centre & St. joseph’s Health Care London

Physician Lead, CHF

10. Dominic Langley Director, Decision Support, London Health Sciences Centre

Decision Support to Project

11. Hilary Anderson VP Corporate Services and CFO, South West Community Care Access Centre

Decision Support and Finance to Project

12. Caitlin Schultz COPD Navigator, London Health Sciences Centre

COPD Navigator

13. Jennifer Beal CHF Navigator, London Health Sciences Centre

CHF Navigator

14. Margaret Callaghan Clinical Care Coordinator, South West Community Care Access Centre

Clinical Care Coordinator

15. Carole McLean Clinical Care Coordinator, South West Community Care Access Centre

Clinical Care Coordinator

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3M Health Care Quality Team Awards – Nomination Template

Executive Summary (Limit: 250 words)

Connecting Care to Home (CC2H) is an integrated, multi-disciplinary team approach across care settings (hospital, community and primary care), developed to support patients with chronic diseases. It was selected by MOH-LTC to better integrate care for specific cohorts that experience higher rates of ED/readmission following a hospital stay. CC2H focuses on patients admitted to hospital where the patient experience could be improved, the disease trajectory could be positively affected and care returned to the lowest cost setting: patient self-management. Literature shows that integrated multi-disciplinary team-based care improves patient experience, clinical outcomes and lowers overall health care costs. CC2H has delivered all these outcomes by successfully integrating key success factors including patient involvement and education, leading practice care pathways, Physician leadership and participation, integrated care teams across care settings, clinical patient data, executive leadership, a 24/7 live support line and supported self-care initiatives. The project receives strong executive leadership from LHSC and South West CCAC where CEOs/VPs are active participants. Strategic objectives are well articulated and owned by all team members, as is a broad understanding of leading quality improvement methodology. The result is a highly integrated cross-organizational team empowered to develop, test and refine effective, sustainable patient solutions. The program is in the third iteration with key results as follows: Hospital length-of-stay has declined 59.3%, 30 day readmission has declined 41.7% and the total cost per patient to the healthcare system has declined 47.9%. A. Issue Statement: Quality improvement initiative(s) across a health system (5 POINTS)

Chronic diseases are among the most preventable, however once developed are costly and rarely curable. Ontario spends approximately 66% of its health budget to support just 5% of the population.1 This ‘high-risk’ population is largely comprised of seniors coping with multiple chronic diseases, at least one of which is advanced or severe. Data shows 75% of complex patients receive care from 6 or more physicians, 2 are frequent users of emergency department (ED) and receive prescriptions from 3 or more pharmacies. Although the number of Coordinated Care Plans developed through Health Links is growing, few if any of these

1 ‘A 3-year study of high-cost users of health care’, Walter P. Wodchis, PhD⇑, Peter C. Austin, PhD, David A. Henry, MBChB 2 Michael Robertson, Director , Capacity Planning and Priorities Branch, MOHLTC, Presentation to the Canadian Institute for Health Information January 27, 2016

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providers have access to patient clinical data beyond their own organization. This suggests the high cost is as much about a disjointed approach to care, as the disease acuity. A further 15%-35% of the population have developed one or more chronic diseases, are well managed but because symptoms are not severe, are considered ignorable3. Although this ‘rising risk’ population are not currently heavy users of health services, the disease progression is inevitable. Given the number of Ontario seniors aged 65 and over is projected to more than double from 2.2 million in 2015 to over 4.5 million by 2041,4 the high risk population will grow well beyond 5%. Without a strategy to effectively manage both high and rising risk populations, the demand on the system will far exceed available resources.

Ontario has invested in initiatives such as Health Links to better support high-risk patients once they become complex. However there is little focus on the rising risk population. Building upon other project successes, CC2H would enable:

An integrated multi-disciplinary care team that shares accountability as the patient transitioned from hospital to community, to self-management.

Shifting the approach from responding to exacerbations after they occur, to pre-empting them.

Beginning with moderate chronic obstructive pulmonary disease (COPD) as proof of concept, CC2H is expanding to congestive heart failure (CHF) and then to other co-morbidities. Specific objectives Include:

Improved Patient Outcomes

Improved Patient Experience/Confidence to self-manage

Reduced Hospital Length of Stay

Reduced avoidable Emergency Department/readmissions

Reduced overall system Cost B. Innovation in Healthcare Delivery & System Innovation (15 POINTS) The literature demonstrates that integrated multi-disciplinary team-based care improves patient experience, clinical outcomes and lowers overall health care costs5. CC2H is unique in bringing together team members from across multiple organizations to best support the patient

3 Edington, D “Lost Productivity – the High Cost of Doing Nothing” www.Umich.ed/~hmrc/research/pdf/printableresearchslides.pdf;

4 Ontario Ministry of Finance Ontario Population Projections Update, 2015–2041

5 Nancy E. Epstein, Multidisciplinary in-hospital teams improve patient outcomes: A review, 2014, Team-Based Care Optimizes Outcomes

By Mary Frances Thaler, PT, MHA; Jon Kole, MBA, LNHA; and Mojdeh Rutigliano, MSN, RN, RAC-CT, C-NE, Today's Geriatric Medicine, Patients Charting the Course, Citizen Engagement and the Learning Health System, Workshop Summary, Institute of Medicine (US); Editors and Rapporteurs: LeighAnne Olsen, Robert S Saunders, and J Michael McGinnis.

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in the right setting. The result is a single team that knows each other and partner with the patient to collaborate and deliver care. The following comprise the key success factors of CC2H:

Executive Leadership

Patient Experience o Patient Advisors on the steering committee o Experience Based Design6 patient and caregiver interviews and formal survey by

Health System Performance Research Network (HSPRN)

Integrated Leading Practice Care Path o Evidence based care path (QBP, literature review) from inpatient to community o Physician leadership, consensus building and adoption o Measurement Tools: Risk Stratification, CAT2, MMRP, Standford self-

management, etc.

Physician Leadership & Participation o Hospital physician (specialist) remains Most Responsible Physician (MRP) for 7

days post hospital discharge Daily rounds include patients at home using real-time dashboard (See

Appendix A)

Identifies trends proactively and adjusts care plan to pre-empt exacerbation

Available to support unexpected issues 24/7 o Warm Hand off to Primary Care on Day 8:

Video conference from the patient home connects patient/caregiver, hospital & primary care physicians, homecare providers, informal caregivers

o Primary care access to in-home patient clinical record (CHRIS/eShift) and dashboard

Supports patient/homecare team as required

Integrated Care Team across care settings o Hospital Navigator o CCAC Clinical Care Coordinator o Single Service Provider – eHomecare model

Remote Directing RN (COPD) o Integrated, joint provider education

Integrated Patient Clinical Data o Hospital system (Cerner) eReferral to CCAC / subsequent eReferral to homecare

provider (VON)

6 www.institute.nhs.uk/.../experienced_based_design.

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o Common, shared community record (by CCAC, VON) accessible to hospital and primary care

Client Health & Related Information System (CHRIS)

CCAC’s province-wide Health Record/Case Management eShift

Real-time in-home Clinical Record w/dashboard

Coordinated Patient Education o Inpatient and community consistently use standard leading practice education to

teach, support and reinforce

24/7 LIVE answered telephone o On-demand telephone service answered 24/7 by the Directing RN

Unlike other telehealth models that use a queue and clinical algorithms, the Directing RN is the patient’s primary nurse

The Directing RN has immediate access to the real-time patient record, eliminating collection of information, accelerate focused support.

Supported self-management o Building self-management capacity embedded throughout care path through

repeated support and reinforcement o Completion of care path support in self-management continues through:

Clinical Care Coordinator Access to the 24/7 Line The Telehomecare program Ambulatory clinics

C. Implementation (15 POINTS) CC2H is one of 6 projects selected by the MoH-LTC as an Integrated Funding Models (IFM), to better integrate care for specific cohorts that experienced higher rates of ED/readmission following a hospital stay. Partners developed an integrated project team, including project management, quality improvement coaches, and dedicated leads from each organization for clinical, operations, data analysis, reporting, and patient engagement. To ensure effectiveness key members were cross appointed to more than one of the project structure:

CC2H Steering Committee

A working group

Front line project teams.

The project preparation phase included:

Current state analysis (pre-CC2H): o Multiple organizations, provider versus patient centric approach – confusing for

families o Lack of integration within and between services, sectors and providers -

historic silos

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o Hospital and home care not tailored to patient needs o Lack of standards with variations in care, quality and responsiveness o Home care general skills provider model with limited consistency of provider o Lack of trust by hospital physicians in homecare ability o Inadequate flow of information between providers, sectors and patient and

family

Current state process mapping: o LHSC ED, in-patient o CCAC assessment, referral and case management o Homecare provider admission, care delivery, documentation, communication

staffing & on-call o Data Systems, Data Sharing-Privacy & information flow

LHSC: Cerner CCAC: CHRIS eShift record Provider legacy systems

Data analysis of patient volumes, service utilization, cost and patient feedback in patient and homecare using multiple data sources

The project plan development phase included:

Quality Improvement methodology to identify project objectives, outcomes, measures and enabling an integrated team regardless of who employed the team members:

o Significant emphasis was placed creating a shared understanding of the patient experience as they crossed care settings.

o Where functions were duplicated in different organizations, participants were supported to consolidate to where it best supported the patient.

Physician Engagement: design and leadership

Patient Profile o Baseline patient ‘Norman’, profile developed including medical, functional,

psycho-social determinants.

Leading practice review o Ontario, Canadian and international bodies of knowledge

Future State Mapping of ‘patient journey’ o All stakeholders participated using ‘lean’ methodology

Work plan o Plan-Do-Study-Act (PDSA) approach o Care Paths versions (Norman 1.0, etc.)

Each evaluated (data, patient feedback, etc) prior to revision o Patient Engagement, Change Management plans o Risk Management Plan o Communication Plan o Spread and Sustainability

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Project Action Phase:

Early phases of the front line project team met daily to identify barriers and solutions. Working group advised, leveraged to problem solve.

o Pathway flexibility enabled team to modify

Care path versions were evaluated and revised using o PDSA learning o Patient, physician and staff feedback o Manually tracked data o Data pulls from LHSC and CCAC data bases (Cerner, CHRIS, eShift)

D. Team Leadership (10 POINTS) Executive leadership The project receives strong executive support, particularly from the funding partners (LHSC and CCAC) where CEOs/VPs are active and frequent participants. Strategic objectives are well articulated and owned by all team members, as is a broad understanding of leading quality improvement methodology. The result is a highly integrated cross-organizations team empowered to develop, test and refine effective, sustainable patient solutions.

Project Management Office (LHSC) o Project manager collaborates with all organizational leads o Quality Improvement Coaches: Facilitation of current state/future state

mapping, root cause analysis, etc.

Physicians Leadership (LHSC) o Hospital

Building consensus, adoption and spread Remaining MRP after discharge Coaching to conduct virtual rounds, use of dashboard, etc. Engaging Primary Care to advocate for their participation Designed as a transition from hospital to home where physicians share

accountability and stay connected to partner with the patient ensuring care is seamless.

o Primary care Commitment to support patient/homecare team (including after hours) Warm hand-off/video conference Continued engagement with the Clinical Care Coordinator

Hospital Navigator (LHSC): o Assigned at ED, assess severity, directs appropriate care path, part of care team

throughout pre and post hospital stay o Assess education needs & initiates o Primary liaison for the in-patient portion of the care path, linking

patient/caregiver, physicians, specialized resources and assist in discharge to community

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Clinical Care Coordinator (CCAC): o Combines coordination with clinical, follows patient from hospital to home and

supports self-management o Primary liaison for community portion of care path, linking patient/caregiver,

hospital, homecare and primary care o In Hospital (collaboration with Navigator):

Consent, pathway baselines, develops COPD Action and Coordinated Care Plan

Pre-discharge planning teleconference with providers/partners, primary care and patient

o Day of discharge Meets the patient in their home Clinical assessment, Medication Reconciliation completed Pathway initiated, COPD Action Plan and education reviewed Introduction to equipment in home MRP/Physician Update provided to referring physician ,navigator and

Primary Care Physician Advanced Care Planning & Coordinated Care Plan Updated Establishes the in-home clinical record for the homecare providers

o Ongoing Monitor & support progress to self-management

o Clinical Pathway Completion Coordinated transition to self-management: medications, referral to

community resources Update to Primary Care (Action Plans/Coordinated care Plan/Self-

Management strategies/Use of dashboard)

eHomecare Model/Provider (See Appendix B) o Directing RN

RNs training in COPD, team coverage 24/7 Delivers remote in-home care using eHomecare model/technology

Directing RN uses eShift technology with homecare technician at patient bedside (supports multiple patient simultaneously).

Directs the technician to collect and enter data into real-time record; RN assesses, monitors, directs intervention or consults others (MRP) All interaction is documented within the eShift record for the full circle of care to access

Staff the 24/7 LIVE answer line

On-demand support, access to patient record supports/reinforces self-management strategies

Options to dispatch a nurse, consult MRP, etc. o Homecare Technician

Collects and enters data as directed into eShift record

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o Allied Health Fulfills care path activities as planned, documents within CHRIS/eShift

IT/Data Systems, Privacy & Security, Communications & Patient Engagement, Reporting & Finance (all)

o Sub-groups were convened with members for all organizations (some ad hoc) o Review current state, identify barriers and potential solutions o Approved solutions resulted in specific work plans, which included:

Single Shared Community Patient Record

CHRIS is a provincial electronic patient health record, contracted homecare providers maintain their own clinical records, timely access impossible

CCAC and VON agreed to make CHRIS/eShift the single, exclusive community patient record, (also accessible to hospital and primary care).

Patient Consent

PHIPA requires each organization to obtain consent to collect and share information, providers must obtain consent to treat. Current state mapping identified that with multiple community

E. Patients & Family Engagement (15 POINTS) Patient Engagement

Patient Advisors are sitting members of the London-Middlesex Steering Committee and

provided feedback into the original project design.

Admission to CC2H in-patient, as well as transition home, involve every patient and

caregiver. Although a standardized care path is utilized, socio-economic and preference

factors are considered. Individual needs are accommodated through a co-creation of the

in-home care plan. Individualized education and support plans are developed and

feedback is solicited by all team members.

Supporting caregivers is critical to avoiding unnecessary use of hospital. The in-home

portion of the pathway considers the caregivers need for support and privacy.

Caregivers are asked to identify their level of stress. This is tracked in the clinical record

and depicted on the dashboard for the entire circle of care to see and consider. (See

Appendix C)

The 24/7 LIVE answer line represents significant security for the patient and caregivers.

More than 40% of calls received are from caregivers (See Appendix D)

The MoH-LTC IFM project includes formal evaluation by the Health System Performance

Research Network (HSPRN), Walter Wodchis, is principle investigator. The evaluation

includes patient surveys (See Appendix E)

Local patient feedback was conducted using the Experience Based Design approach; an

interview format. Feedback is incorporated into pathway revisions. A video was

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developed to capture “Hugh’s” experience as a communication feedback process for

hospital team members who don’t see patient after they leave hospital (See Appendix

F)

Supported and satisfied patients is only possible when providers are engaged. Although

not formalized, physician feedback has been collected (See Appendix G)

F. Data and Metrics (10 POINTS) The project objectives align with Ontario’s Patient’s First Strategy and the IFM projects sponsored by the MoH-LTC. However these objectives are high priorities for both LHSC and CCAC:

Improved Patient Outcomes

Improved Patient Experience/Confidence to self-manage

Reduced Hospital Length of Stay

Reduced avoidable Emergency Department/readmissions

Reduced overall system Cost The project was built first around the patient/caregiver journey, and then around the providers (regardless of their employer) supporting that journey. Data collection, analysis and reporting were structured to reflect and enable this approach. Senior Executives from LHSC and CCAC shared a vision and co-lead this work. The objective was to ensure hard and soft data told the story of the patient journey across the care settings. A commitment to transparency of the data was a foundational principle for each organization. Significant effort was initially required because organizations have different data standards, definitions and reporting formats. A quality improvement approach was used to ensure data/finance participants first had a shared understanding of the clinician’s needs and wants. Secondly a clear understanding of each other’s data environment to enable translation of information that was meaningful to all stakeholders. As data was collated, operational and clinical participants were leveraged for the analysis of each pathway version. With each new version data quality, clarity and understanding improved.

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The following chart illustrates the quantitative metrics to date:

Metric Norman 3.1

Target % variance to baseline

Actual % variance to baseline

Hospital LOS -38% -59.3 %

30 day Readmission -20% -41.7%

ED Use CTAS 1 (within 30 days of discharge)

No Target established

-100%

ED Use CTAS 2 (within 30 days of discharge)

No Target established

-92%

ED Use CTAS 3 (within 30 days of discharge)

-100% -100%

ED Use CTAS 4 (within 30 days of discharge)

-100% -100%

ED Use CTAS 5 (within 30 days of discharge)

-100% -100%

Hospital Cost (in patient + readmissions + ED) Estimate -20% to 30%

-57.9%

Homecare (CCAC) Care Path Cost Estimate +20% to 30%

-11.4%

TOTAL COST -47.9%

Formal evaluation is being conducted by Walter Wodchis (HSPRN) and is forthcoming, but interim patient survey results are included in Appendix E. The data above reflects the latest care pathway version (Norman 3.1) however solid improvement was demonstrated with each version. Two initial assumptions have been shown to be incorrect (at least for moderate COPD):

1. It was believed that ED presentation for CTAS 1 and 2 were appropriate and as such there was no expectation the model would affect that use, the result was initially surprising.

o The intended shift to pre-empt exacerbations (rather than responding afterward) was enabled as hospital physicians’ continued to review patient status (dashboard) for 7 days after they went home. This in combination with 24/7

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access is enabling pre-emptive intervention, preventing the escalation of severity and use of ED.

2. An earlier IFM project conducted at St. Joseph’s Hamilton found that early discharge reduced hospital costs, but increased homecare costs. The result was initially surprising.

o The homecare portion of the initial pathway intentionally over serviced patients to build confidence. Evaluation of patient feedback and clinical data (pace of improvement) for each version revised volume, frequency and duration. Review found joint provider training improved homecare effectiveness, and continual reinforcement of standardized self-management education empowered patients in achieving their goals.

G. Analysis (30 POINTS) Preventing and managing Chronic Disease: Ontario’s Framework (May 2007)7 effectively describes the reasons the current episodic, disjointed approach results in higher costs, less than optimal outcomes and poor patient experience. It also outlines an evidenced based approach to significant improvement. By engaging patients/caregivers and supporting providers to work as a team regardless of who employs them, their legacy systems, or the physical location of the patient, CC2H has achieved the outcomes promised by the framework. Clinical leading practice is proved and well established. Moving providers from personal episodic application of practice to a shared, continuous team-based approach remains the challenge. Each element in leading practice is interconnected and mutually dependent – across care settings, organizations and individual providers. System structures, funding models, experience and culture unintentionally reinforce silos. The degree of integration within CC2H is substantial. Organizational readiness is critical and achieved through the following critical success factors: Executive Leadership The leaders of all organizations involved in CC2H have created an environment for change and innovation through:

Meaningful personal participation on a frequent basis

Committing dedicated resources

Enabling and empowering staff o Transparency of information, data o Opening and directly facing challenging issues - no ‘sacred cows’

7 www.health.gov.on.ca/en/pro/programs/cdpm/pdf/framework_full.pdf

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Physician Leadership Physician engagement is a perennial challenge, however the leadership involved with CC2H were exemplary:

Engaging the physician team within the unit (and residents) to participate o To adopt clinical leading practice consistently, forgoing personal opinion and

variation o Accepting responsibility for the patient for 7 days after they leave hospital

Hospital physicians are responsible for patients until discharge. Upon discharge it is assumed primary care becomes MRP, but this isn’t formalized or guaranteed. Early discharge patients often require support before a scheduled appointment with primary care (ex: medication change). If the issue exceeds the scope of practice of the homecare nursing and primary care is not available, ED has been the only option.

Remote care by physicians for patients post-discharge is NOT compensable through OHIP billing codes. The physician lead convinced the team to forgo compensation to enable this project to proceed

o Supporting the homecare team 24/7 if required during those 7 days o Adopting new technology, user logins, etc to monitor the patient at home:

CHRIS/eShift record and dashboard for daily rounds o Shifting focus to predictive/preventative intervention

Monitoring, predicting and enabling homecare providers with what they need to support patient regardless of time or day

In past models physicians (primary or specialist) were hesitant to answer calls from homecare nurses unless they knew them. For the physician to support remotely they need confidence in the reliability of the clinical information being provided. If the nurse is unknown it poses too great a risk, calls are not taken and ED becomes the alternative. By accessing the in home patient record (dashboard) the physician has a trended history at a glance to inform care decisions.

o Engaging their colleagues A criteria for entry into CC2H is that primary care will take the hand-off

on day and provide the support. During the first few months only 46% of patients who were clinically appropriate could be brought on. The remaining 54% either did not have a primary care provider or their provider would not participate. As the hospital physicians saw the effect of the model including patient feedback and drop in ED/readmission, they became champions. As of December primary care participation is now over 90% due to respirologist calling primary care to advocate.

The respirology team has further supported learning with their cardiology colleagues. (CHF launched in January 2017).

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Patient Engagement

Meaningful participation by patients/caregivers in design, evaluation and revisions has resulted

in:

Improved quality of life (See Appendix F)

Confidence and capacity to regain/maintain independence

o One patient has started recruiting family members he knows would benefit

Improved provider experience; when patients are effectively cared for provider buy-in

increases as does work life satisfaction

Coordination

Effective coordination is a recognized value for complex patients. However the variables

involved from presentation at ED through to return to self-management are immense. CC2H’s

combining of a hospital navigator with clinical skills partnering with a community care

coordinator (also with clinical skills) creates a significant level of continuity. The breadth and

duration of the patient journey means turnover in team members is inevitable. The

combination of these ‘co-quarterback’ and access to consolidated data ensures:

No gaps in knowledge transfer

Maintains team cohesiveness – across employers

Is the ‘go-to’ person(s) for everyone, particularly the patient/caregiver

Data Sharing

Preventing and managing Chronic Disease: Ontario’s Framework (May 2007) identifies the

need for sharing data across providers and names registries, provider/client portals and EMRs.

CC2H has met and exceeded these objectives by:

Connected providers to existing databases rather than duplicate data in multiple

locations

Enabling providers to directly access and/or document in the appropriate database,

even if not employed by the organization that owns it

Using real-time data + narrative reports available on-demand

Patient Support

Patients live with chronic disease and its symptoms indefinitely, requiring them to be active partners in managing their condition, rather than passive recipients. Effective partnerships are rarely 50-50, rather they evolve to leverage strengths when they are needed. The ratio of partnering by providers and patients has to date been somewhat unbalanced. Excellent resources exist, but are largely accessible during normal office hours. This may be sufficient in the early stages, however when symptoms present outside of office hours, patients ate left on their own. CC2H has developed a continuum of supports to foster self-management and ensure on-demand support is there if needed:

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Attached to the Clinical Care Coordinator even after pathway completion

Access to 24/7 LIVE answer

Coordinated Care Plan, dashboard updates to Primary Care

While these have proved to be successful as part of an acute admission, a similar set of

supports is needed upstream, added as the disease progresses. Although out of scope for this

project, stakeholders are cognizant of the need to expand the continuum. Findings have been

shared multiple times with groups across Ontario.

Sustainability & Spread

Financial

o The result shows the significant savings for hospital and homecare on a per

patient basis. However 40% of patients were not previously referred to CCAC.

Result is a slight increase in total CCAC cost, but significant net system saving.

Monitoring is in place for expansion.

o Other hospitals in the South West LHIN are exploring

Operational & Cultural

o CC2H project incorporated factors to spread and sustain. Factors apply to all

partner organizations:

Proportionate joint governance operational structure

Dedicated leadership/transition to operations

Communication

Orientation, training

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How to submit your nomination: The nomination should include all of the items listed below. The nomination is to be submitted to jbruyere@cchl-ccls.ca as one PDF file, including any appendices. Electronic signatures are acceptable. Please include the following in your nomination package:

the completed nomination form; and the completed nomination template, not exceeding the 4,000 word limit,

including the executive summary and report. Nominations that do not use the template will not be accepted.

Relevant appendices (limit of 3 pages)

Should you have any questions, please contact: Julie Bruyère, Coordinator, Corporate Partnerships and Events Canadian College of Health Leaders 292 Somerset Street West Ottawa, ON K2P 0J6 Tel: (613) 235-7218 ext. 236 Toll free: 1-800-363-9056 Fax: (613) 235-7218 jbruyere@cchl-ccls.ca Nomination deadline: February 1, 2017

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APPENDIXES

APPENDIX A: Real-time Patient Dashboard

APPENDIX B: eHomecare Model

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APPENDIX C: Caregiver Stress (Self-Reported)

APPENDIX D: 24/7 LIVE answer Line

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APPENDIX E: HSPRN Patient Survey

APPENDIX F: Patient Experience

Hugh was brought onto the CC2H Program October 2015

https://youtu.be/nlNOefa1AzQ

APPENDIX G: Provider Experience “It’s great because it really gives the patient that wrap around care. These are typically high

needs patients and CC2H helps fill the gaps and makes everyone involved feel supported.”

LHSC Resident

“Its great being able to see the patient at home. Usually we’re cut off once they’re discharged,

but now I can actually see that they’re doing well at home.” LHSC Resident

Hear a Physician share her experience: https://youtu.be/AADgG9fbXT4