Integrated Patient Care: Waterloo Wellington Short Stay Model. July 2016
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1 Integrated Patient Care: Waterloo Wellington Short Stay Model July 2016
2 Agenda Guiding Principle for model development Benefits to patients Model development getting there Model at Intake Model at Hospitals Supporting roles Team Assistants Questions 2
3 The Guiding Principle Delivering Better Coordinated And Integrated Care for Our Short Stay Patients: The Waterloo Wellington Local Health Integrated Network New Short Stay Model has: The Short Stay Care Coordinators follow the patient through their entire journey: From point of initial access service provision and discharge. to community Includes and referrals 3
4 The Benefits to the Short Stay Patient Build trusting relationships with patients and care partners Reduce hand-offs between Care Coordinator s Reduce the number of times a patient tells their story Strengthen relationship with Primary Care 4
5 How Did We Get There? Defining a Short Stay Referral and Process Mapping: Data collection: Tracking referral information, types and timing of short stay referrals from both community and hospital Reviewed location of initial referral (hospital/intake) to determine FTE required 5
6 .cont d Defining a Short Stay Referral and Process Map Staff Engagement Sessions: Cross section of Care Coordinators and Team Assistants actively participated in working groups. Consider impact to remainder of the team: Intake streams, hospital work flow 6
7 .cont d Defining a Short Stay Referral and Process Map Streaming of referrals to dedicated caseloads before the model went live to support understanding of the caseload complexity. Defining roles and mapping processes within each team 7
8 .cont d Defining a Short Stay Referral and Process Map Reviewed the patients length of stay Review of Community Management processes: E.g. initial team contact, standards of care, discharge 8
9 Review hospital walk out and develop clear definitions Co-locate Short Stay CCs with their team hospital and community intake Align one manager for Short Stay team Maximization of TA role.cont d Defining a Short Stay Referral and Process Map Staggered Implementation site by site to ensure learnings could be translated between implementation 9
10 Sample Data - Review Average Number of Referrals/Month Short Stay Team Hospitals (5 caseloads) Intake (2 caseloads) Short Stay patients with a LOS > 90 days transferred to the appropriate Community Caseloads unless: ADP funding only Chemotherapy disconnects Wound care only patients Referrals/mth 100/caseload 120/caseload 10
11 Short Stay at Intake Intake has dedicated streams for assessment Two streams are dedicated to short stay Assessments are booked into specific appointment times per our Intake Calendar Short Stay CC assesses 4 referrals/day Three are pre-booked and one remains open for urgent/same day assessments Overflow assessments are managed by the rest of the Intake Team 11
12 Sample Calendar from Intake 12
13 Short Stay in Hospital Dedicated Short Stay Care Coordinator (SSCC) at each hospital site Through referral tracking, engagement and process mapping it was determined each Hospital s pattern was unique. Each site utilizes the short stay coordinator according to their site s needs/specialty e.g. orthopedic carepath surgeries, day surgery 13
14 Common Themes with SSCC in Hospitals:.cont d Short Stay in Hospital Hospital SSCC assess their patients either face to face or over the phone Unlike Intake no specific # of assessments/day as hospital volumes fluctuate and are less predictable than Intake Hospital SSCC still need to ensure time to manage their caseload All SSCC s need to provide coverage for each other for planned and unplanned absences 14
15 Enhancing the role of our Team Assistants 15
16 Supporting Roles Review Team Assistants A review of Team Assistants (TA) role revealed: Short Stay Care Coordinators needed two teams of TAs assisting them 1. Centralized TA s supporting the community caseload 2. The Intake/Hospital TA supports initial assessment 16
17 Team Assistant Role A working group was committed to evaluating the TA role within the short stay model to identify enhanced activities they could do without CC oversight. 1. Phones are answered by the TA first. Redirecting to CC if unable to solve concern. 2. Monitoring reports that come in and then redirecting to CC if urgent. 3. Updated Professional Service Provider Report TA s to automatically process if within established guidelines 4. Wound reports account for the largest percentage of reports which will now be on dedicated wound caseloads only. 17
18 Evaluation Robust Post go live engagement session and 6 month evaluation included: Monitoring of # of assessment completed by SS coordinator Ability to be responsive to community needs (SPO and Patient, RUM reporting) Care Coordinator and TA feedback Impacts to remainder of the teams Process Improvement/PDSA cycles initiated Discharge Process Initial team contact 18
19 19
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