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Winnipeg Regional Health Authority(WRHA)
About the WRHA:• One of the largest health
regions in Canada• Providing care to ~ 650,000
people• Specialty services for ~
500,000 Manitobans outside its boundaries
• Annual operating budget of nearly $2.4 billion CAD
• Approximately 28,000 employees
• 3 pre-existing care models for Hospital Home Teams (HHTs)
1
Purpose and Goal
Across Winnipeg, each community area has patients with complex, medical and mental health needs. These patients are often high users of Emergency Medical Services (EMS), Emergency Departments (EDs), and acute care inpatient beds. These patients also often experience challenges with care coordination as well as navigating access to health care and social services.
Our purpose for participation in the IHI-BHLC initiative is to:
1. Identify persons with complex medical, social and mental health needs who
are most likely to benefit from access to community-based interprofessional
outreach teams;
2. Identify appropriate interventions and available existing resources that will
improve the patient experience and lower overall system cost;
3. Develop a sustainable service with embedded evaluation and monitoring.
Our goal is to:
To achieve a standardized care model for the Hospital Home Teams (HHTs) based on IHI’s learning system.
2
Population
3
Total Triple
Aim Population
Size BHLC Population Full
Scale
Scale
Feb-2016
Scale
Mar-2016
Scale
June-2016
Three targeted
community areas
in the City of
Winnipeg
(population
approximately
700,000)
13,576a Must meet at least one of the following criteria:1) ED visits ≥ 6 (last
12mths)2) Hosp. Admits ≥ 33) Bed Days ≥ 304) Complex
Biopsychosocial needs score ≥ 21b
300 140
(46%)
240
(80%)
300
(100%)
Notes:a Cui, Y., Metge, C., Forget, E., Oppenheimer, L., & Moffat, M. Development and validation of a prediction model for all-cause hospital readmissions. J Hlth Serv Policy Res, April 2015: v20(2). Cui, Y., Metge, C., Forget, E., Oppenheimer, L., & Moffat, M. Geographical variation analysis of all-cause hospital readmission cases in Winnipeg, Canada. BMC Health Service Research (2015) in press
b Humboldt County IPA and Care Oregon adaptation of the INTERMED scale: De Jonge P, Huyse FJ, Stiefel FC, Slaets JP, Gans RO. INTERMED--a clinical instrument for biopsychosocial assessment. Psychosomatics. 2001 Mar-Apr;42(2):106-9. PubMed PMID: 11239122.
Data-driven referral process to be launched Feb. 2016 - will automate referral of high system users.
Collaborative care planning and goal setting – patients, family and care givers are integral to care planning and delivery
Patients identified by cross-sector health care professionals and data
Intensive case management with interdisciplinary team-based care, care coordination and communication with existing partners*
Patients are transitioned to appropriate community resources which may include primary care upon achievement of goals
*Partners (internal and external to the WRHA): Those involved in the care of HHT patients per regular roles, collaborates with HHT core team member, and acts as consultants for challenges with care planning and equipment needs
Patient-centred integrated collaborative care service, including home care, allied health and primary care
Hospital Home Team (HHT) Model
4
ServicesPatient Issue/Need Services Required Partners Required
No primary care provider (PCP) Attach client to PCPLocal primary care clinics; Family Doctor Finder; My Health Teams
Cannot perform ADLS or IADLs In-home PT and OTCommunity Therapy Services; WRHA Home Care
Insufficient in-home support to manage health condition(s)
Timely, reliable, and creative in-home support (i.e., PCP home visits)
WRHA Home Care; Geriatric Program Assessment Team
Need for Med Rec In-home consult with pharmacist Community pharmacies
Need for mental health care; Sometimes psychological trauma
Referral (and warm handoff) to mental health services
WRHA Mental Health (GPAT, GMHT, & others); Community counseling service (Klinic); CMHA
Substance abuseReferral (and warm handoff) to addictions services
Addictions Foundation of Manitoba
Difficulty with trustRapport-building; reliable, regular contact with client
WRHA Mental Health (GPAT, GMHT, & others); Community counseling service (Klinic); CMHA
Resistance/refusal of careAssessment; particularly if there is a possibility of cognitive impairment
Public Trustee; Geriatric Program Assessment Team
Limited social support; sometimes social isolation
Reliable, regular contact with client; support with day-to-day decision-making
Client’s caregiver or family members (if applicable); Public Trustee; Community groups; WRHA housing experts
Inadequate/unsafe housingHelp client find and arrange housing-related solutions
Manitoba Housing; Residential Tenancies Branch; Community Wellness Initiative (CMHA)
Food insecurity Donation of food; Income assistanceFood banks; Food delivery and special diet services; Community groups
Inadequate transportationHelp client find and arrange transportation options
Handi-transit; Taxi services; community groups
Poverty, low-incomeHelp client with applications for income assistance, Cdn Pension Plan, Income Tax etc.
Employment and Income Assistance Services; Non-insured health benefits; Public Trustee; Community Income Tax Services
Bio
logi
cal
Psy
cho
logi
cal
Soci
al
StartDate
Intervention Step in Framework*
1. 12/15 Completed inter-reliability testing for HHT Triage Form Identification
2. 01/16 Implemented two-tiered scoring (i.e., pre and post consultation scores) for Risk Prediction Assessment on HHT Triage Form
IdentificationRecruitment/ Engagement
3. 11/15 Conducted in-person site visits (Measurement Lead) for data quality control
IdentificationCare ModelRecruitment/Engagement
4. 10/15 Identified data generated referral process at three community hospitals
IdentificationPartnering
5. 12/15 Networked with many existing service providers and programs to communicate about HHT services and for care delivery
Partnering
Five Interventions Tested since October
6
Strategies to Increase Institutional Support
Engage Winnipeg Regional Health Authority (WRHA)’s IT systems support
Increase visibility of Hospital Home Teams (HHTs) via internal (intranet) postings and updates
Communicate with Community Program’s Team Managers to increase understanding of appropriate referrals for HHT service
Increase awareness and understanding of HHTs in the community, hospitals, and long term care, and engage in more collaboration and partnerships among programs and services
Increase visibility of HHTs via presentations to WRHA Program Operations meetings (Home Care, Public Health, Primary Care, and Emergency) andother site operations tables
Collect data and evaluate impact of HHT services on population outcomes, patient experiences, and costs
7
Strategies to Engage Payers (Manitoba Health)
• Encourage representation from the payer (MB Health) across the layers of HHT’s governance (learn as we learn)
• Scale up effectively with inclusion of clearly articulated deliverables from MB Health and demonstrate benefit in target areas
• Promote open, transparent sharing of data collection and evaluation
Provider Adoption Strategies (Engagement)
• Promote and support communication within the WRHA and Primary Care clinics (i.e., community Primary Care Physicians) to improve the understanding of the HHT referral process and client population for HHT’s service
• Collaborate with physicians, managers, and staff from My Health Teams to increase awareness and facilitate referrals
• Develop and educate stakeholders through effective communication about HHTs
• Use utilization data to initiate referrals from primary care providers
• and support communication within the WRHA and Primary Care clinics
(understanding of the HHT referral process and client population for HHT’s service
8
Strategies to Engage Individuals in HHTs’ Service(Patients and Teams)
Include the client/family/support system in goal setting and regularly revisit and revise the goals with their input to ensure they are relevant and being actively worked on
Support patients’ navigation and build trust and relationships
Assist with patients’ attachment to existing resources such as: Employment and Income Assistance, Primary Care Providers, WRHA community programs & partners(community-based and citizen-organized community programs such as schools, churches, senior centres, and support groups)
Be creative in accessing financial support for low income individuals and families
Educate patients about available services such as First Nations coverage and application procedures
Ensure that HHT team members work together to achieve client goals via regular communication, weekly to biweekly team rounds, and daily team huddles
Incorporate team building and bonding ‘fun’ activities to build team relationships and morale
9
Scale-up Grid BHLC Collaborative: Scale Up Nuts and Bolts Worksheet
Consider IT, Human Resources, Facilities
Key Change Area Individuals 5 25 125 625
(anticipated)
Patient Identification
- Highest users of 1 Community Area in Winnipeg - Patients identified by community hospital in that community area
- Referrals from Home Care Program, and Hospital using Referral Form developed by HHT teams
- Referral Forms received from Home Care, Primary Care, Community MDs, Hospitals - Triage Form developed, looking specifically at eligibility criteria (ER visits, Hospital bed days, and number of Hospital admissions) and risk Referral Form and Triage Form developed with learning through IHI BHLC process
-Integrated data systems for real time patient identification - Appropriate patients are identified from all stakeholders
Care Model Care coordinators (2 at 3 sites) Current caseload:: Varies from 10 to 26
Predicted: 50
-Virtual Ward (VW) Pilot (2011-2012) -8-10 patients -MD, RN & SW Case Coordinator
-MB Health (Gov’t) funding for 2 geographic teams in Winnipeg (2013) -funded positions: 1 Case Coordinator and 1 Admin full time per team -Additional position of .7 EFT OT to one team
- Team composition varies between sites and being studied based on target pop and needs identified - Co-location of HHT staff key in building shared vision of goals
- Consistency achieved among HHTs - Model can be replicated by additional HHTs and sites - Well integrated with services for complex patients
Community Partnerships
-Community Therapy Services (OT) -Church Groups -Salvation Army -Age and Opportunity
-Community Therapy Services -Community Mental Health
-Community Mental Health -Age and Opportunity -Seniors Resource Councils
- Partnerships become more refined - Agencies and community groups become more familiar with HHTs and its service
10
Scale-up Grid BHLC Collaborative: Scale Up Nuts and Bolts Worksheet
Consider IT, Human Resources, Facilities
Key
Change
Area
Individuals 5 25 125 625
(anticipated)
Financing -MD, RN and SW worked a few hours per week in addition to their full time employment
-MB Health funding for 2 geographic teams to work with 50 patients per team
-Goal with current funding is for teams to manage 100 patients per team
- Target recruitment is achieved and funding for HHTs continues
Data -Manual data collection -tracked ER visits and hospital bed days in Excel for pre VW involvement and during VW intervention -EDIS (Emergency Data Information System): real time alerts when HHT patients present to any ER in Winnipeg
- Gained more access to resources and existing data for evaluation and IT -EDIS (Emergency Data Information System): real time alerts when HHT patients present to any ER in Winnipeg
- Currently developing a secure HHT Access data base that can interface with ED, Hospital and EMS data -EDIS (Emergency Data Information System): real time alerts when HHT patients present to any ER in Winnipeg
-Ongoing measurement of outcomes and evaluation - Continued focus on PDSA’s to learn by testing - Ongoing development of an integrated database that supports HHTs and other groups serving complex patients and patient flow Data: *Arrival of evidence-based data
Oversight -3 person team -access to historical data on small patient group
-pilot project team and WRHA made funding request to MB Health -data from pilot project supported funding request -program renamed Hospital Home Team - Formation of HHT Steering Committee with key stakeholders in WRHA -Operational Team formed with team members from each
- Ongoing improvements to structure of HHTs -BHLC Collaborative (IHI) process begins June 2014 -Core Team is formed with members of 3 HHTs and operational support
- Core Team members are champions in ongoing HHT service provision - HHT Steering Committee supports and evaluates HHTs
11
Our Learning About Scaling Up
#1 Consider: Rollout of processes for identification and recruitment of patients - Scale up can be slower when there are system changes with adoption of
new processes
#2 Consider: Staffing complement- Staffing challenges (vacations, staff turnover, sick leave)
- Need to match levels of care with the appropriate resources
#3 Consider: Understanding the population is ongoing- Having sufficient data to analyze requires time
- Monitoring data collection needs to be ongoing
- Partnering with appropriate resources requires knowing the population you are serving
12
Dimension Proposed Measure Data Source Data plotted (Y/N)
Population Health1) Self-reported health:“Would you say in general your health is…?” Excellent, Very Good, Good, Fair, Poor2) Self-reported mental health:
“In general, would you say you mental health is…?” Excellent, Very Good, Good, Fair, Poor3) Functional Status:
Karnofsky Performance Status Scale allows patients to be classified according to their functional impairment 1-100
1) Intake, 3-month, 6-month and/or discharge
2) Intake, 3-month, 6-month and/or discharge
3) Intake, 3-month, 6-month and/or discharge
Yes
Yes
No
Experience of Care
1) Global experience/National Research Corporation Canada (NRC) Picker: Overall impression of care:• While you were a part of the hospital home
team, were you able to get all the services you needed? Yes, completely; Somewhat; No
• Overall, how would you rate the care you received while with the hospital home team? Excellent, Very Good, Good, Fair, Poor
2) Readmission to hospital or the ED within 30 days3) Focus on effectiveness as a measure of quality of care. Goals of care (medical & patient-centred) are being met? Yes/No
1) Regional survey sent out monthly for
the next year by NRC Picker
2) EDIS/DAD3) From EMR macro documenting patient contact (at least monthly)
No
No
No
Per Capita Cost1) Utilization rates (EMS/ED/Hosp)Possible to measure use and assign costs (based on proxy):• ED utilization per 1000 user population• Hospital bed days per 1000 person years by
month• EMS (ambulance) use
1) Admin data Yes
Population Measures Worksheet
13
Hospital Home Teams (HHTs): WRHA
Linking process to data collection
Patient Identification (2 sources)
Referral from Acute care,
Community services
(HC/CMH/FFS Drs)
Centrally-collected data
<high utilizers>
Referral
FormTeam
Review
Triage
form
Intake Criteria≥ 6 ED visits
≥ 30 Bed days
≥ 3 Hosp Admits
Risk prediction:
Intermed ≥ 35?
INTAKE
Yes/No
Provide
Needed
CARE
Process &
Outcomes
Analysis
Data Source/Flow
Referral data + regional source for ED visits, hospitalizations, etc.
MS Access (secure) databaseDTAT: Data tracking & Analysis Tool
Triage Process: “meets criteria for admission to an HHT”
EMR
Capture outcome measures: MDS/RAI (HC)(e.g. MAPLeS Score), SF-1&2, ZBI
Discharge
Processes
These criteria “populated” from regional systems
into DTAT
e.g.,#/type patient contacts
-Home visit-MDS/RAI HC administered-Goals of care determined
May involve a home visit or other preliminary intervention(s)
14
Cumulative Number of Clients Served
15
Self-Rated Physical & Mental Health (N=91)
32%
58% 57%70%
68%
42% 43%30%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Self-RatedPhysical Health
Baseline
Self-RatedPhysical Health
3-month
Self-RatedMental Health
Baseline
Self-RatedMental Health
3-month
Poor/Fair
Good/V.Good/Excellent
|------p = .000-----| |------p = .027-----|
16
ED Visits and Hospitalizations
0.00
0.10
0.20
0.30
0.40
0.50
0.60
0.70
0.80
0.90
1.00
-12 -11 -10 -9 -8 -7 -6 -5 -4 -3 -2 -1 1 2 3 4 5 6 7 8 9 10 11 12
ED Visits (N=163)
Hospitalizations (N=147)
12 months before service start
12 months after service start
service start
17
Ave
rage
Nu
mb
er p
er c
lien
t
Hospital Bed Days (N=147)
0
200
400
600
800
1000
1200
1400
-12 -11 -10 -9 -8 -7 -6 -5 -4 -3 -2 -1 1 2 3 4 5 6 7 8 9 10 11 12
service start
18
Tota
l Nu
mb
er o
f B
ed D
ays
(N=1
47
)
12 months before service start
12 months after service start
Key Accomplishments
19
Using enabling factors like IHI processes to help identify target populations and delivery of services
Improving patient flow with targeted intervention for persons with complex health and social needs
Using data to uncover insight and motivate change. Data is available for use by other services in the region
True demonstration of cross sector interprofessional collaboration among health and social service teams and community groups working specifically with complex patient populations
Continued work and dedication towards demonstration of effectiveness of the service via ongoing data collection and initial analysis of pre and post outcomes (i.e., ED visits, self-rated health, bed days)
Our MilestonesAchieve target recruitment of patients for HHT Service (scaling up) • Flagging processes for referrals are implemented• Achieve consistency with referral processes by HHTs• PDSA’s to achieve consistent application of the HHT Triage Form among all three HHT sites, appropriate risk
criteria, and administration of Stanford Domains Assessment tool (to minimize regression to the mean)
Improve work processes to support effective delivery of enhanced care to the target population• Begin exploration of Levels of complexity including workload, frequency of involvement of disciplines, and
type of contact are identified to achieve role clarity• Ongoing networking with key partners as HHT patient population is further segmented
Continue to refine our learning systems with participation in the Scale Up and Sustainability Track (Year 2)• Ongoing engagement of the Core Team to complete the work of the BHLC-IHI Year 2 Collaborative
Continue to collect data in the newly developed HHT Data Analysis and Tracking Tool • Promptly respond to challenges and incorporate corrective measures
Analysis of data to assess impact and effectiveness of HHT on Triple Aim outcomes including economic net benefit analysis • Comparison with a matched control group for examining effectiveness of HHT service
Form a HHT working group to explore opportunities for publication
20
We wish to acknowledge the following organizations for their support:
21