Quality Improvement Plan (QIP) for Waterloo Wellington CCAC 01/04/2017

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1 Quality Improvement Plan (QIP) for Waterloo Wellington CCAC 01/04/2017 This document is intended to provide health care organizations in Ontario with guidance as to how they can develop a Quality Improvement Plan. While much effort and care has gone into preparing this document, this document should not be relied on as legal advice and organizations should consult with their legal, governance and other relevant advisors as appropriate in preparing their quality improvement plans. Furthermore, organizations are free to design their own public quality improvement plans using alternative formats and contents, provided that they submit a version of their quality improvement plan to Health Quality Ontario (if required) in the format described herein. 1

2 Overview The leaders and staff of the Waterloo Wellington Community Care Access Centre (WWCCAC) are committed to the vision of Outstanding Care and Service Every Person, Every day. We strive to provide the people of our diverse communities with equitable access, individualized care coordination, seamless transitions, and quality health care. The WWCCAC Board of Directors supports quality and safety through governance practices that put patients first and ensure accountability. Similarly, CCAC senior leaders inspire and empower leaders and staff to find new ways to improve the patient experience and provide excellent care. The Quality Improvement Plan (QIP) initiatives were developed to align with our Strategic Plan for and with the input of our stakeholders like our patients, carers and our system partners. Like the previous QIPs, the initiatives fall under the following priorities: 1. To reduce avoidable hospital admissions among home care clients 2. To reduce the number of unplanned emergency department visits among home care clients 3. To identify patient as meeting Health Links criteria 4. To improve client experience 5. To reduce falls among long-stay home care clients 6. To reduce service wait times QI Achievement From the Past Year Of the many achievements of the last year, we would like to highlight one of our most significant Quality Improvement (QI) achievements of the past year: the implementation of process improvements for our Nursing Clinics. We have established Nursing Clinics in Kitchener, Cambridge, Guelph, Fergus, Palmerston and Waterloo which provide a variety of nursing services such as infusion therapy, wound care, catheter care and injections, and are operated by WWCCAC contracted Nursing service providers. Nursing Clinic utilization was analyzed using Assessment Urgency Algorithm (AUA) reports to determine the percentage of patients receiving nursing service in the home and at Nursing Clinics. From that analysis, we realized there was an underutilization of our clinics and the many benefits of clinic utilization, such as: Scheduled appointments (no waiting at home or Emergency Department); Supporting independence, community engagement and patient mobility; More efficient use of nursing human resources and supplies; builds nursing expertise and optimizes health care funding; Supplies availability at the clinic no risk of supplies not arriving or running out in the home setting; Patients receive greater nursing continuity and consistent approach to care; A platform to build specialized care (e.g., wound care). On January 4, 2016, process improvements that were developed in conjunction with our Service Providers were implemented. Improvements, such as streamlined nursing service authorizations for patients requiring initial visits in home, consistent identification of clinic-appropriate patients through the use of the AUA score, revised nursing policy, clear processes for nursing service providers to use when identifying a patient that is not able to transition to a Nursing Clinic, and a communications letter to physicians and other system partners to support culture of clinic, were developed. The implementation of the process improvements led to a standardized approach to defining patients that should receive nursing services at the clinics and an increased percentage of patients with an AUA of 1-2 attending nursing clinics from 53% to 86.7% and of patients with an AUA of 3-4 attending nursing clinics from 30% to 67%. The overall implementation improved the process of offering nursing service by providing flexibility of service delivery location without duplication of assessments and documentation. Population Health WWCCAC has partnered at a sub-regional level in Guelph, with Guelph General Hospital, the Guelph Family Health Team, and local Emergency Medical Services to implement a pilot for tele-homecare for patients with COPD. By using remote monitoring and technology to assist patient communications with care providers, this pilot aims to reduce unnecessary ER visits and hospital admissions through promotion of self-management of chronic disease in partnership with primary care. 2

3 WWCCAC has partnered at a sub-regional level in Cambridge with Langs Community Heath Centre and Cambridge Memorial Hospital to improve transitions between acute, home, and primary care for patients with CHF. By using remote monitoring, and technology to assist patient communications with care providers, this pilot aims to reduce unnecessary ER visits and hospital admissions through promotion of self-management of chronic disease in partnership with primary care. Equity In 2017/18 WWCCAC will be assuming responsibility for coordinated bed access for hospice beds across the region. As it has done previously with long-term care (LTC) and post-acute care, coordinated bed access improves the flow of patients out of acute care, and improves the equity of placement into hospice beds by using a single regional point of access with a common waitlist for all hospice beds, and clear guidelines around eligibility. Integration and Continuity of Care WWCCAC is committed to establishing "Effective Partnerships & Relationships" (Strategic Plan Success Factor #3) within the local healthcare system. WWCCAC recognizes the inter-dependence of its quality initiatives with the right partners to best meet the needs of patients and carers. In 2017/18, WWCCAC is partnering at a sub-regional level in Wellington to align home and community care services with primary care as part of the Wellington Integration Roadmap (the Rural Wellington Health Alliance (RWHA) - a Collaborative QIP). As the second phase in a geographic and functional realignment of care coordination services, all primary care practitioners will be aligned with care coordinators and care coordinator neighbourhood teams to promote a single point of access into home and community care for primary care. This will provide improved and more consistent communication between CCAC and primary care, as well as provide coordination of care and an improved patient experience. Access to the Right Level of Care Addressing ALC Issues Many of the initiatives that WWCCAC will be implementing in 2017/18 (and has implemented over the last number of years) are aimed at improving patient flow through the system and/or avoiding unnecessary ER visits and hospital admissions. For example, the tele-homecare pilots in Guelph and Cambridge are designed in part to preempt ER visits, and to reduce length of stay (LOS) by providing care to patients in their homes, as opposed to in hospital. One of the foundations of the primary care alignment initiative is to reduce the need to access acute care services by preventing acute events/incidents and by decreasing LOS for patients in hospital where possible. Engagement of Clinicians, Leadership & Staff In 2017/18, WWCCAC is embarking on an ambitious project to align care coordination with primary care. By aligning each primary care practitioner with a specific care coordinator and his/her neighbourhood team, we will improve relationships between primary care and coordinators, provide more consistent service to both patients and primary care, and improve communication across sectors. This project aims at creating an environment - Where coordinators can easily connect with a physician s office, and vice versa, to share information in a timely manner where they aren t spending excessive amounts of time chasing paperwork and, as a result, they can quickly address patient needs; Where physicians have easy access to a patient s care plan, they understand their patient s goals, and know what services their patients are receiving in the home or in the community to support these goals. As a result, less time is spent managing re-referrals; Where a physician has a better understanding of what care coordinators do, what services CCAC provides and helps to set the patient s expectations from the very start - so less time is spent re-setting expectations - and directs the focus on delivering the care. Resident, Patient, Client Engagement In 2017/18, WWCCAC will establish a Patient/Carer Advisory Committee for the first time, to provide an explicit avenue for input from patients and families to continue the integration of the principles of patient and family centered care across the organization. 3

4 Staff Safety & Workplace Violence Wherever they are carrying out the work of WWCCAC, employees have the right to a safe workplace, free of violence. WWCCAC recognizes that in serving the public employees may come into contact with situations and environments which may be hazardous to the employee s personal safety. WWCCAC makes every effort to identify all potential sources of violence and risks to personal safety in order to eliminate or minimize these risks. Staff safety and workplace violence is an ongoing focus within the organization and is addressed through a multitude of activities and policies and procedures. These support the identification of unsafe situations within the patient care environment and ensuring staff safety and reducing workplace violence is important to us. 4

5 Sign-off I have reviewed and approved our organization s Quality Improvement Plan: 5

6 2017/2018 Quality Improvement Plan for CCAC 6