Transition Points Workshop - CentralEastLHIN/media/sites/ce/uploadedfiles/...A CDPM systems approach has the potential to achieve: •Fewer people with chronic diseases •Better clinical

Transition Points Workshop

September 22nd 2008

Objectives

• Review the CDPM model• Provide an overview of longitudinal care• Present a completed process flow diagram (KCC

to ICHD transition point) and identify gaps and potential requirements for improvement

• Document information on 5 identified priority transition points

• Discuss required information/data and the process of information flow that would support continuum of care and seamless transition of patients from one service area to another.

‘Care for the chronically ill needs to bea collaborative, multidisciplinary process

[that supports] coordinated, seamless care across settings and clinicians and over time.

Source: Crossing the Quality Chasm, Page 11.

A CDPM systems approach has the potential to achieve:

• Fewer people with chronic diseases

• Better clinical outcomes, longer more functional life

• Increased efficiency in the system, quality care in the appropriate setting by the appropriate provider at the right time

• Reduced hospitalizations, reduced use of emergency departments and reduced duplication of services

• Increased healthy behaviours MoH-LTC, 2007

INDIVIDUALS AND FAMILIES

Improved clinical, functionaland population health outcomes

HEALTH CAREORGANIZATIONS

Informed,activated

individuals& families

Prepared, proactivepracticeteams

Activated communities &

prepared, proactivecommunity

partners

HealthyPublicPolicy

SupportiveEnvironments

CommunityAction

DeliverySystemDesign

ProviderDecisionSupport

InformationSystems

Productive interactions and relationships

PersonalSkills & Self-Management

Support

Ontario’s CDPM Framework




Informed,activated





partners

HealthyPublicPolicy


CommunityAction


InformationSystems



Support

Delivery SystemDesign


Delivery System DesignFocus on prevention and improve access, continuity

of care and flow through the system:

• Interdisciplinary Teams• Integrated Health Promotion and Disease

Prevention • Planned Interactions, active follow-up• Adjustment, innovations in practice • Information System• Outreach and population need based care

Delivery System DesignKey elements to facilitate seamless care:

• Create networks to providers delivering care to our patients (internal & external)

• Cooperation & Collaboration between providers• Primary care through to tertiary care and back to community• Coordinated care across operating units• Functional Integration• Shared policies & practices of common functions (Consistency)

• Evidence based clinical care guidelines and protocols incorporated into care delivery

• Focus on internal process re-design (across transition points)

• Define roles and responsibilities (role clarity) especially at transition points• Physician involvement• Organized system easy to access by patient• Patient has information to make decisions• Measurement of performance outcomes




Informed,activated





partners

HealthyPublicPolicy


CommunityAction





Support

Information Systems


Information Systems Are essential for enhancing information for providers to provide

quality care; for patients to support them in managing their disease on a day to day basis; and for integrating services across the health

care system:• Electronic Health Records• Case Management Software• Patient Registries to identify patient subpopulations

for proactive care• Web - based support• Information for Patients• Links (internal and external)

– How and how well does information flow.

The RNS Vision

Using the Ontario CDPM framework, implement a comprehensive CDPM program for our patients, thereby preventing and/or delaying onset to dialysis, improving the QOL for renal patients throughout their lifespan and reducing health care costs.

We will achieve this through….

• Increased Self management• Strengthened Coordination• Risk Stratification Process• Enhanced IT system• Collection & Sharing of aggregate data• Increased communication• Increased Quality for patients and staff

Strengthen Coordination

• We need your help

For Today… First step……

• Give you more information about:– Continuum of care and longitudinal care– Things to look for in identifying gaps in the care

delivery process during transitions– Making improvements to existing processes

Then……

Help you to……• Identify 5 key transition points of greatest

importance.• Collect information on these transition points• Identify gaps• Identify possible solutions

Key Deliverables for the Day• Collection of required information to complete

process flow diagram for five major transition points in care with identification of gaps

• Generation and brain storming of possible solution to fill the gaps

• Identification and flow of data/information required at the transition points

• Identification of top two transition points and organization of working groups to complete work on these transition points

Roll up your sleeves. We need your help

Longitudinal CareCoordination

Helping patients through the Perilous Journey of the Healthcare System

Learning Objectives

• Define the “care continuum”.• Explain current challenges working across

the care continuum.• Understand “population” based care.• Promote “systems” thinking.• Discuss coordination of care.

Question

What is your definition of the continuum of care?

“The current health care delivery system is structured and financed to manage acute care episodes,

not to manage and support individuals with progressive

chronic disease”Crossing the Quality Chasm:

A New Health System for the 21st CenturyNational Academy Press 2001

Challenges with Coordinating Care

A study showed that no information was sent to specialists in 49% of referrals. Referring physicians received feedback from the specialist 55% of the time.

In 2005, 33% of adults hospitalized in the previous 2 yrs received information as to whether they should take their pre-hospitalization medications; 48% reported not routinely getting information about the side effects of drugs.

A study showed that 33% of physicians do not consistently notify patients about abnormal results.

28% of primary care physicians and 43% of specialists were dissatisfied with the quality of information they received from each other.

Bodenheimer, 2008

Problems with conflicting recommendations

Chronic Disease Self-Management Confusing medication regimens( high potential for error

and duplication) Lack of follow-up care Inadequate pt and caregiver preparation Poorly executed care transitions leading to greater use of

hospital and emergency services¹ Duplication of diagnostic testing²

1. Coleman et al, 2004 2. Bodenheimer 2008

Fragmented care Reactive: incident driven Patients were told what to do

Coordinated, integrated care Proactive: prevention focus Patient Self Management focus Reduced costs with home based therapies

Partner

Coordination

Mutually Aligned Incentives

Outcome Driven Care Management

HomeGP/Neph. Dialysis

Specialist Ancillary Services

Hospital

HospitalNephrologistDialysis

SpecialistAncillaryServices

Acute Care Chronic Care

Acute to Chronic

Adapted from RMS

WHO The Challenge of Chronic Conditions

Identifies 5 Core Competencies 1. Pt centered care2. Partnering3. Quality Improvement4. Information and Communication Technology5. Public Health Perspective

“Partnering with those who care for the patient across time, in different settings, from different disciplines and for different comorbid health concerns.” WHO 2005

Traditional Role Of The Health Professional

New Role Of The Health Professional

How may I help you ?

WHO The Challenge of Chronic Conditions

Identifies 5 Core Competencies 1. Pt centered care2. Partnering3. Quality Improvement4. Information and Communication Technology5. Public Health Perspective

“A public health perspective emphasizes the entire care continuum, from clinical prevention to palliative care.” WHO 2005

Population Health

Public health defined: “ The science and art of preventing disease, prolonging life, and promoting health through the efforts of society” (Acheson D. Public Health in England. London, HMSO, 1988)

Thinking from a public health perspective moves the workforce from caring for one patient at a time, to planning care for populations of patients.

Population refers to patients associated with a particular provider, clinic or health care system.

A population approach adds another dimension as individuals benefit from the information developed for populations to which they belong.

Source: World Health Organization, 2005

www.health.gov.on.ca/transformation/fht/guides/fht_chronic_disease

1-31 --9/20/2010

Seamless Integration of Patient Care

Pre-Dialysis PD/HHD ICHDIn Patient

Unit

Seamless Transition throughout Renal Lifespan from GP to Nephrologist to CKD to ESRD to Transplant to End of Life

care.

Transplant

Nephrologists

Primary CareProviders

SpecialistsCommunity

Agencies

Pharmacies

Dialysis ProgramUnits

Acute CareHospital

MDT Team

CCAC

Coordination Across the System

Care Coordination

“The deliberate integration of patient care activities between two or more participants involved in a patient’s care to facilitate the

appropriate delivery of health care services”

Bodenheimer 2008 ( from Agency for Health care research and quality 2007)

Fragmented Care

Continuity of Care

5 C’s of Longitudinal Care

Communication Collaboration Co-ordination Community Change

Communication

Is the essential element in successful partnering.

Requires special skills, the ability to:– Negotiate– Share decisions– Identify strengths and weaknesses– Clarify roles and responsibilities– Evaluate progress

WHO 2005

Collaboration

To be competent in collaborating with each other, providers need skills that promote cooperation, communication, and the integration of careMust work interdependently while

demonstrating mutual respect, trust, support and appreciation of each discipline’s unique contribution

WHO 2005

Co-ordination

“Break down the silos”Financial, regulatory, and professional

barriers serve to further reinforce these silos of care such that care coordination across different setting is often lacking.Operating independently with no common

care plan may adversely affect patients.

Coleman et al, 2004

Community

Community partners can be as diverse as employers, academic institutions, civil society groups, media, government, pt advocacy groups and faith-based organizationsPromote development of pt referral

pathways between healthcare and community.

WHO 2005

Change – Emotional Intelligence © HayGroup

Social Skills• Leadership• Developing Others• Influence• Communication• Change Catalyst• Conflict Management• Building Bonds• Teamwork &

Collaboration

SocialAwareness

• Organizational Awareness• Service Orientation• Empathy

Self-Management

• Self-Control• Trustworthiness• Conscientiousness• Adaptability• Achievement Orientation• Initiative

Self Awareness

• Emotional Self-Awareness

• Accurate Self-Assessment

• Self-Confidence

RENAL Continuum of Care

Transplant/End of LifeTransition planning to TransplantCoordination of Palliative Care

COORDINATIONTo assist patients in navigating the health care system,

providing caregiver consistency as they transition through the Renal lifespan. To communicate & collaborate as a patient advocate with the Interdisciplinary team

CKDChronic Kidney Disease (CKD)

Home visits according to risk assessmentInitial assessment for multidisciplinary care planning

Communication of Care Plan with GP's.Promotion of patient self management.

Reinforcement of CKD teachingRigorous monthly data collection

Dialysis Home visits according to Risk Assessment

Facilitate transition from CKDAttend first Dialysis (HD and PD)

Patient visits at all regional hospitalsFocus on Co-morbid management

Discharge planning & follow-upRigorous monthly data collection

Reinforcement of modality education forunplanned starts

Introduce useof systematic tools

and processes.

Proactively managehigh risk caseload.

Function of Coordinating Role

ImprovingCare

Coordination

Provide focusedtraining/education

and follow up monitoring

Extend GP role through collaborative

partnershipswith qualified nurses.

Facilitate appropriate fast track care inCommunity &

hospital.

Monitor Outcomes

Identify highrisk population

Blue = Data interventionGreen = Role re-engineering

Purple = Process re-engineering

ESRD Newly-diagnosed CKD

Acute Starts

GPs, Nephrologist ReferralCKD.

EmergencyPreviously unknown to

the program

PD, HHD, ICHD

1. INTAKE 2. CDM introduction 3. Key Worker identification

Assessment: inc. Risk Screening, PHQ9Baseline Evaluation

Allocate to Key worker

Individualised Care Plan:5 A’s Goal Setting & Evidence Based Pathways

Follow-up: Telephone coaching or individual consults (frequency based on

High, Medium, Low status.)

Individual servicesDental, Physio, OT, Podiatry,

Psychology, CounsellingDiabetes Ed

Community linkagesPhysical Activity, Socialisation support,

Lifestyle management, Psychosocial support, Self-help groups

Group programsStanford course, rehab, Diabetes education,

Falls prevention, Tai-Chi for arthritis, CVD Phase 3, etc.

Psychologist case reviewand treat directly or extra support to key worker

Scheduled Recall and Review & 6-monthly evaluation surveys

GP: Intro & Clinical data for

evaluation

GP: Detail Care Plan

Patient-held record

GP:Revisions to Care

Plan or 6 months

Targ

et G

roup

s &

Ref

erra

l Sou

rces

Review assessmentsalready completed to avoid duplication

CDM Pathway

Mental health

conditionidentified

Evaluating Longitudinal Care

• Demonstrated reduction in subsequent postdischarge hospital use¹– “Half as likely to return to hospital than those without

transition coach”• QOL-

– “Pt’s report high levels of confidence in managing their condition..”¹

• Rehospitalizations, deaths and total costs significantly lower²

1. Coleman et al, 2004 2. Bodenheimer 2008

“Nephrotopia” Chronic Care Model*

Patient

Family

(CDPM)

Primary Care

Providers

Specialist

Referral

Hospital In-Patient Unit

Local CDM Team/CenterPre-Dialysis

Hospital Community Integration

ESRD

Full Family Practices provide ongoing chronic disease prevention and management according to standards with guidelines at point of patient care.Provincial eGFR for early referral.Health Risk Questionnaire – Health Coaches for Diabetes and HPT. DATA

Specialist support the diagnosis and episodic treatment of chronic illness with information following continuum of care.Shared Decision Making for Modality choice –based on patient’s core values & lifestyle.Pre-emptive Transplant. DATA

CC Health Coaches & MDT in shared care model. Home visits – Initial assessment. Patient risk stratification. Proactive Case management for patients with complex co-morbidities. Questionnaire patient activation levels, - Education & self management support. Patient Life PlansNative access in situ before dialysis. DATA

Multidisciplinary Team coordinates care across the continuum acting as a navigator for complex patients. Health Coaches straddle hospital/community/home care. Proactive care based on risk stratification. Telephonic DM. LTC facilities/Home Assist programs.DATA

Support programs.CC &Multidisciplinary Team coordinate care between hospital, community and home.End of Life care.Family supports.Discharge with home visit F/U.DATA

Resources intensify according to patient needs

Prevention & Promotion work through all sectors

*(E-HealthTechnology TBA)

“Nephrotopia”- Goals & Outcomes

Patient

Family

(CDPM)

Primary Care

Providers

Specialist

Referral

Hospital-

In patient unit

Local CDM Team/CenterPre-Dialysis

In – Center

Community Integration

ESRD

Goal: Decrease or halt progression of Diabetes and HPT thereby decreasing progression to renal failure and increasing patient QOL..Diabetics = 65% with Hgb A1C <7HPT = 80% with BP <130/80Decrease need for Nephrologist referral.Decrease % of “parachutes” to renal program.

Goal: Increase patient QOL/Prevent or delay onset to dialysis through co-morbid management.Shared Decision Making for Modality choice –based on patient’s core values & lifestyle.50% Choose Home TherapiesIncrease % of Pre-emptive Transplant.

Goal: Increase QOL/Prevent or delay onset to dialysis through co-morbid management.Modality – 50/50 – Clinical – BP, A1C, Anemia Mgt.Self-Management – 80% of patients have self management goal.Delay of onset, reduced hospital utilizationDialysis Access – Incidence >50% native access

Goal: Increase patient QOL Co-morbid management.QOL/Patient Satisfaction QuestionnairesCVC – < 10% CSN KDOQI AVF>60%Decrease in Hospital Utilization/”Drop Ins”“Parachute” 50/50 re-capture rate.% Reduction in parachute rate.

Goal: Increase QOLReduced ALOS, Reduced hospital visits.Reduced re-admission rates.Reduced Renal occupancy rate.Increased % of home visits within 7 days of discharge.

Program

Targets

Evidence

Based

Guidelines

Continuum of care…..what can you add to this vision?

References1. Coleman, E. et al ( 2004). Preparing Patients and Caregivers to Participate

in Care Delivered Across Settings: The Care Transitions Intervention, JAGS52: 1817-1825.

2. Bodenheimer, T. ( 2008). Coordinating Care- A Perilous Journey through the Health Care System. N Engl J Med, 358; 10.

3. World Health Organization ( 2005). The Challenge of Chronic Conditions; Preparing a Health Care Workforce for the 21st Century. Geneva, World Health Organization.

4. Wagner EH, (1998). Chronic Disease management: what will it take to improve care for chronic illness? Eff Clin Pract. 1998;1:2-4

5. Nielsen, J. (2000). Disease Management Coordinates “Care”- Not “cases”-To Improve ESRD Patient Outcomes. Nephrology News and Issues,Sept. 67-70.

Process Flow DiagramsKCC to ICHD

Process Flow Diagrams

Snap shot of processes carried out within RNS service areas/programs.

Outlines general flow of tasks by service providers.

Identifies: Common processes & data used by service areas Areas of potential efficiencies & improvements Possible explanations of outcomes

Transition Points in care

A point at which there is a service change within the health care system



Ideal Outcomes

Seamless patient transition and continuum of care

Want to prevent…

Patient anxiety Break in coordination of care Loss of patient information Loss of patient confidence Overall risks to patients &

staff

KCC to ICHD transition point

Understand the processes carried out within each service area

Associate tasks to team members ID data collected ID what works well within the existing

process What processes should be consistent

throughout the program ID gaps and potential solutions

Process Flow DiagramKCC to ICHD

Referral to KCC KCC on-going visit KCC post clinic KCC transition to ICHD Transitioned to ICHD

Initial thoughts …

What are your initial thoughts about this process flow?

What works well?

KCC ICHD

Nephrologist

RN

Dietitian

Pharmacist

Social Worker

Vascular Access Nurse

Front Unit Clerk

Back Unit Clerk

External Lab

Volunteer

Nephrologist

RN

Dietitian

Pharmacist

Social Worker

Vascular Access Nurse

Unit Clerks

Resource Nurse

Educator Leader

KCC LeaderICHD Leader

Initial Analysis



Ideal Outcomes

Seamless patient transition and continuum of care

Findings: Gaps and potential solutions

KCC Referral process--Gaps

Referral to KCC not consistent Patient reminder done by volunteer and if no

volunteer patient reminder not done In patients need to be booked when out patients.

Currently manually tracked by unit clerk Patients who do not show up sometimes fall through

the cracks. No follow up MDT must review patient info from chart. Very little

info accessible in Meditech

KCC Referral process—Potential Solutions

Automated referral process set up in Meditech (for pts with Unique number)

Look into increasing automation in Meditech i.e. automating generated letter that reminds patient of KCC initial appointment (date driven), notification of d/c inpatients referred to KCC, flag patients after a certain number of months who have not been seen, etc.

New Meditech screens being designed/redesigned to facilitate data entry and automation of reports and data retrieval

KCC On-Going Visit--Gaps

Not always the same MD who sees/follows patient KCC secretaries multi-tasking, other duties i.e. filing

falls behind. All disciplines must compete with chart to access

patient info Wait times for patients to see disciplines sometimes

long No Patient acuity rating. Difficult to judge who is a

“heavy patient” vs. “light patient” (for operational time management in clinic)

KCC On-Going Visit–Potential Solutions

Explore MD model in clinics to support more consistent care of patients

Explore more even workload model for KCC secretaries

Continue to facilitate data entry into Meditech Explore more efficient operational tactics to minimize

patients’ wait times in clinic

KCC Post Clinic--Gaps

MDT rounds at end of clinic sometimes generates over-time

Tasks required to finish clinic spills over to next day

For Initial Visit patients, MD does not see

KCC Post Clinic—Potential Solutions

Explore more efficient means of enabling patient reviews

Consider alternative model where MD sees new KCC patients

KCC Transition to ICHD—Gaps

Routine orders written in KCC may not be implemented until weeks later in ICHD

Notification of new ICHD starts done manually and is dependent on Resource Nurse

No formal “hand off” from KCC to ICHD

KCC Transition to ICHD—Potential Solutions

Need to build in process to have routine orders verified by MD if > 3 weeks (?) implementation

Automate referral to ICHD Explore incorporating a more formal ‘hand off’

from KCC to ICHD

Patient transitioned to ICHD--Gaps

No formal orientation or information provided to patient

Routine orders needing review/verification may be written by a different MD than the MD who is now on for ICHD

Inconsistent management of first HD treatment by ICHD RNs

Patient transitioned to ICHD—Potential Solutions

Incorporate formal orientation and provision of information to new ICHD patients

Discuss alternative MD model that enables consistency of care

Creation of 1st ICHD treatment curriculum for staff to follow

Accountabilities

Collection of datasets that enable measurement

Performance Indicator development Team commitment and understanding of

needed changes for improvement Desire for improved patient care and

outcomes

Working Groups

• From the 5 identified transition points• Break into working groups

Transition point gap identified

What is the level of risk associated with the gap?

Risk to patient safety or

working out of scope of practice

Increased work load for staff/ unnecessary

delay for patients

A nuisance, easily completed but

should be eliminated through

automation

High priority

This gap significantly increases workload and make patients wait

Effects my workload and delays patients but only for a limited amount of time

Medium priority

Frequently occurs

Rarely occurs

Low priority

Prioritizing identified gaps

Key principles to consider when documenting process flow

Step 1• Identify team members involved in the process• Write down actions/activities of each team member that they carry

out within the process.• Indicate at process points what information is collected and/or

documented (electronic and/or paper).

• Identify any policies or standards that guide practice (if any).

Step 2• Identify what works well in the process (does not need any changes and should

remain part of the process).Step 3 • Identify gaps throughout the process and categorize the gap based on

the following:The gap poses:– Patient risk or causes staff to work out of their scope of practice– Increase workload or makes patients wait– A nuisance, easily completed but should be eliminated through automation

Solutions

Questions are never indiscreet, answers sometimes are.

Oscar Wilde

Flow of Information

Computers are useless. They can only g ive you answers.

Pablo Picasso

Input of data

Data Accuracy Clear definition and understanding of

datasets Simple and efficient process of data

entry Accessible resources that enable data

entry

Meditech Screens enable data input

Other enables of data entry

Accessing the data

Requires datasets to reside in Meditech in order to:

Input

Access

Analysis and reporting of data

“Front end” populated from data that resides in the Meditech repository

Med

itec

h

• Regardless of what Nephrology data management system (software) is purchased, requires access to Meditech data.

Patient clinical datasetsDemographics Clinical History

Patient Name MD Health Card Number DOB Address Phone Number (s) Allergies Family MD Nephrologist (refer)

Lab values Weight Vital Signs Medications Diagnostic Test results Dialysis Modality (if applicable) Dialysis Access (if applicable) Dialysis Prescription (if applicable) Immunization

Medical Social Work Dietitian Pharmacy Nursing

Overview: Current data being collected within RNS

RNS Process Flow DiagramPh

arm

Tec

hSo

cial

Wor

kDi

etPh

arm

Exte

rnal

La

bPa

tient

Secr

etar

yNu

rse

Neph

Phones pt and sets up initial visit.

Refers pt. to clinic

Pt Info

Receives info, pre registers pt and starts chart. Leaves in RN

mailbox

Speaks with MD re: pt

Pt. Edn

Faxes info to KCC clinic

Sends MOX to MDT re: pt

Letter

Calls KCC RN Neph Secretary faxes pt info to KCC

Office sends letter to pt & KF book & video

Letter

Pt receives letter and goes for blood work

Receives MOX

Receives info from MD

Reviews pt’s chart

Receives MOX

Pt Info

Receives MOX and enters appointment into black book & scheduler

Receives MOX

Ref

Sends next steps letter re: blood work

and map to KCC

Pt Info

Pt. agrees to date. Asks questions

Pt. Info

Reviews chart

Receives blood work and adds

to chart

Reviews chart

Reviews chart

Arrives for initial assessment

Point of data entry

Overview: Collection of current datasets

Datasets collected through use of paper forms

Other members of RNS MDT do not have access to paper data unless chart is accessible

Datasets Manually inputted into system

KCC Indicators & Reports

Reported at RNS Program Council

Some datasets tracked manually

Manual data collection and analysis

Lakeridge Health Whitby Kidney Care Clinic

Date of Report:______ ###### Report Period: From _ Third QuartOct 1/07 To Dec 31 2007

Population Demographics Frequency of Report every month

1 Current number of Patients enrolled in ARIC: Number: 5752 Number of new patients referred during report period: Number: 63 As Percentage of Total Patients: 11.00%3 Distribution of new patient referrals according to KDOQI Stage: This is the new referrals that were seen

Stage Number % Quarterly Trends: Q1 Q2 Q3 Q4 Yearly60-89% Stage 2 0 0 Stage 2 % 0 0 0 0 0.00%30-59% Stage 3 9 21.00% Stage 3 % 16.00% 16.60% 21.00%15-29% Stage 4 32 74.40% Stage 4 % 75.00% 69.00% 74.40%<15% Stage 5 2 4.60% Stage 5 % 8.90% 14.30% 4.60%

434 Distribution of total patients enrolled in ARIC according to KDOQI Stage:

Stage Number % Quarterly Trends: Q1 Q2 Q3 Q4 YearlyStage 2 0 0 Stage 2 % 0 0 0 0 0.00%Stage 3 129 24.20% Stage 3 % 25.20% 22.30% 24.20%Stage 4 371 69.60% Stage 4 % 68.10% 71.80% 69.60%Stage 5 33 6.20% Stage 5 % 6.60% 5.90% 6.20%

5335 Distribution of total patients discharged from ARIC by reason:

Reason Number %Start on PD 11 20.00%Start on HHD 1 1.80%Start on ICHD 12 21.80%Transplant 0 0.00%Transfer to Other Program 6 10.90%Transfer back to Nephrologist Office 1 1.80%Expired /never seen 23 41.90%Patient refuse to return to ARIC 1 1.80%

TOTAL 55

Catheter Associated Blood Stream Infection Rate

00.20.40.60.8

11.21.41.6

04/05

- Q1

Q2 Q3 Q4

05/06

Q1 Q2 Q3 Q4

06/07

Q1 Q2 Q3 Q4

07/08

Q1 Q2 Q3 Q4

CABSI/1000 line daysbenchmark/1000 line days

CQI Implementation

Number of Months Between Episodes of Peritonitis

0.010.020.030.040.050.060.070.080.0

Q1 Q2 Q3 Q4 FY Q1 Q2 Q3 Q4 FY Q1 Q2 Q3 Q4 FY Q1 Q2 Q3 Q4

04/'05 04/'05 05/'06 05/'06 06/'07 06/'07 07/'08

Patient Months

CQI Completed

CWPDIG benchmark

Taking things to the next level…

Prioritize data sets and indicators to be collected and reported for KCC.

Establish a more efficient data collection process

Establish reporting of meaningful reports that direct the actions within RNS to move towards improvement and achievement of standards and excellence of care

Increase automation of data management within RNS

Level 3Level 2

Level 1

Foundation

Data is Power!!!

Conclusion

Remember and

spread the word




Informed,activated





partners

HealthyPublicPolicy


CommunityAction



InformationSystems



Support


The Goals of CDPM• Activated Communities are collaborating across sectors and

with health care organization to identify and meet the needs of their populations. Individuals and families are linked to community resources

• Prepared Practice Teams at the time of the visit, they have the consumer information, decision support, people, equipment, and time required to deliver evidence-based clinical management, health promotion/prevention, and self-management support

• Informed Activated Individuals understand the disease process, are part of the care team, and realize his/her role as the daily self manager. Family and caregivers are engaged in the individual’s self-management. The provider is viewed as a guide on the side, not the sage on the stage.

We will achieve this through….

• Increased Self management• Strengthened Coordination• Risk Stratification Process• Enhanced IT system• Collection & Sharing of aggregate data• Increased communication• Increased Quality for patients and staff

The 5 C’s

• Communication• Collaboration• Coordination• Community• Change

Thanks for all your help

Being a contribution• “Naming oneself and others as a contribution

produces a shift away from self concern and engages us is a relationship with others that is an arena for making a difference. Rewards in contribution… are of a deep and enduring kind……”

Ben & Rosamund Zander - page 63

We give you all an “A”

“Giving an A”• “An A can be given to anyone in any walk of life.

When you give an A, you find yourself speaking to people not from a place of measuring how they stack up against your standards, but from a place of respect that gives them room to realize themselves.”

page 26 - “The Art of Possibility” by Ben & Rosamund Zander

You are all leaders

“Leading from Any Chair”• “A leader does not need a podium; she can be

sitting quietly on the edge of any chair, listening passionately, and with commitment, fully prepared to take up the baton”.

page 76 - “The Art of Possibility” by Ben & Rosamund Zander

Final thought to leave you with

“Patience and perseverance have a magical effect before which difficulties disappear and obstacles vanish.”John Quincy Adams

Documents

Transition Points Workshop - CentralEastLHIN/media/sites/ce/uploadedfiles/...A CDPM systems approach has the potential to achieve: •Fewer people with chronic diseases •Better clinical