Template #1: Maternal Newborn: Strengths and Challenges within the Current System in Addressing Population Needs. Whither the continuum?

Transcription

1 Template #1: Maternal Newborn: Strengths and Challenges within the Current System in Addressing Population Needs Strengths Challenges Full spectrum of (hospital?) care within maternal newborn care continuum Whither the continuum? No standard agreement on a) level of care (1, 2, and 3) definitions, b) level of care expected and available by site and c) standards and accountabilities by level of care by site for system wide confidence: Good support from the tertiary centre; there for the asking Good quality care knowledge and practice informed by evidence this impacts on referral patterns, staffing patterns (gap between unit funding level and unit functional level), timing of return to home hospital from tertiary centre, and accountability to performance expectations in Hospital Accountability Agreement Few services for women with drug problems (at Six Nations: approximately 50% of pregnant women have drug and alcohol problems) Little intentional approach to teen health and continuum of care and support Poor links with mental health and access to care, AND high rates of post partum depression Lack of OR time for gynecological procedures Transportation, both for clients to services (community and hospital, and elective patient transport Women are everywhere and nowhere. High ambiguity as to whether maternal newborn health sits within or apart from women s health. Lumping women and children indiscriminately undermines a comprehensive women s health culture (gender inequity) and results in under resourced continuum of services and supports in and beyond hospitals. Difficult for referring physicians to get information about patient in tertiary care Lack of organized communication system among functional centers in maternal newborn care that can bridge silos and respective intelligence, and build/sustain relationships across the spectrum. Providers need to know who to contact, when, and how to support patients and each other with respect to timely transfer, access to specialist care, and follow up. High C rates in the HNHB LHIN 1

2 Support for regional program perspective e.g. long standing relationships among nurses and their roles, which have promoted LHIN wide education for standardized care People work hard at relationships in the face of lean health human resources The hospital system is tight: Access to Level 3: Is the number of tertiary beds right? Training for neonatal care is stretched and diluted High level of testing in the hospital LOS is related to testing and breast feeding practice/confidence A strength of Team is lost to the system All hospitals have access to, and input data to NIDAY for improved tracking, planning, CQI Information and data challenges: Lack of central data base for cervical dysplasia Quantifying STD rates (especially in selected populations) Drug and alcohol prevalence in birthing age women In Niagara: positive collaboration generally between Public Health and Hospital and specifically with respect to lactation support Public health unit boundaries not aligned with LHIN boundaries; variation among PHU s and interpretation/implementation of mandate leads to role confusion Introduced Midwives for low risk births Is there too much choice in the Ontario system? New Zealand and Ontario regulated midwives at the same time; midwives are the provider for normal births in New Zealand. (CONFIRM) Development of a comprehensive Children s Hospital 2

3 Template 2 for Maternal Newborn: Factors Most Likely to Increase or Decrease the Future Demand for Health Care by 2013 Health System Transformation (right care, right time, right place) in Ontario will likely Increase demand for and expectations of improved linkages among primary health care, public health services and ambulatory care (both generally and among hospitals for a continuum of women s health) Increase the number of informed consumers and resultant expectations e.g. of diagnostic services and continuous testing Raise awareness and prevalence of ethical dilemmas Challenge the future belief systems among residents/consumers and providers given better information, evolving expectations and limited resources Enhance focus on patient and provider safety with subsequent additional costs e.g. infection control, knowledge transfer, e-health. The aging population will likely increase demand for gynecology services a full spectrum of women s health services. fertility treatments with higher incidence of multiple births and high risk births Changing lifestyle practices will likely result in increased prevalence of some risk factors due to for instance, medical and recreational drug use co-morbidities in women e.g. nutrition, diabetes Population diversity will likely increase demand for appropriately responsive services due to, for instance, range of health seeking behaviors, expectations of maternal newborn services, and provider preference e.g midwives, gender preferences) The changing economic climate will likely Shift demand for care as populations shift/people move, seeking security Increase women s risk factors Advances in surgical technology will likely Reduce length of stay (LOS) Increase expenditures Increase demand for and expectations of skills development and training both for those now working in the system and new students, with implications for curriculae Requirements of health human resources for health system sustainability will likely Continue to surface and heighten friction among health care organizations with respect to competitive recruitment and retention Continue to surface and heighten friction among the intergenerational work force with respect to work life balance, compensation, and aspirations for career development.. The current work environment is relentless and cannot be sustained. Young health professionals are wary of what future practice holds for them Expose variable expectations of practitioners in urban communities and less urban communities, and raise level of debate on models of care and care close to home. L:\C. Initiatives (Operations)\P - I (IHSP)\Clinical Services Plan\PAGs\PAGs - Summary Reports from meetings 1-2-3\MAT- GYN-NB\Meeting 1\Meeting 1 Demand Summary.doc 3

4 Building Template #3: Maternal Newborn: Components of an Ideal Service Delivery Model The notes reflect discussion to date. Before the Facilitator completes the Handbook Template #3, please review the proposed model features on the left hand side. Then, add your comments on the right, thinking about the continuum associated services, interdependencies and community linkages. If you have comments about who, how, and other enablers.. please add. Maternal Newborn Care Model Components Foundational to Model of Care Getting there from here: Your comments on Associated Services, Interdependencies & Community Linkages Model reflects shared responsibility for health and health outcomes What can the model/system offer you? What can you do for yourself? Note: Normalize health, pregnancy, motherhood and family health in schools Maternal Newborn health sits within Women s Health Respect the choice of women and mothers Systemize roles, roles, practice and practice protocols e.g. role clarity, awareness of roles, optimal scope of practice for public health practitioners, midwives, physicians, nursing e.g. best practice guidelines for breast feeding Culturally appropriate care Funding model that facilitates strong primary care role Shared care requirements interdisciplinary teams, offloads, integrated ICT environment of trust, confidence, working together NB integrated platform in Australia 4

5 Linked Services: Public Health Public Health brings care close to home and in the home Public Health s credibility and role lend visibility and improved access to maternal newborn health and wellness Every Mom should get a visit from Public Health Linked Services: Pre hospital What gynecological services can be done in offices, not hospitals? Does every baby need to be born in the hospital? Establish criteria for safe birthing in the home: e.g. consumer knowledge, risk informed, and professionally attended NB: Six Nations home/hospital split 40/60 (CHECK) requires risk mitigation strategy Linked Services: Primary Care Level 1 care is an extension of primary care Enhanced primary care support pre and post delivery Good knowledge base among family physicians Family physician access to/presence in hospitals for continuity of care Note: can be hard for family physician to step in among other physicians Linked Services: The Hospital Experience Client/Family centered care Private rooms for patient and significant others Secure environment Optimal scope of practice for all carers Appropriate assessment, level of care, carer Access to mat child, surgery, pediatric, DI, anesthesia Capacity to respond to emergency people and equipment Alternate levels of care available for mom and newborn Some moms monitored at home (CHECK: public health or primary care?) 5

6 Other Queries/Observations for discussion Merits of women s health centres? Relationship: model of care and geography and impact of rurality 6

7 Template #3: Components of an Ideal Service Delivery Model Part 2 PAG Name. Maternity Gyne Newborn Component of service delivery model System Values: Services associated with this component of the model PAG Facilitator: Marion Emo Clinical and non-clinical interdependencies (e.g., DI, lab, other programs/services, other PAGs) Linkages to community services One System: Right care, right time, right place Equitable access to well being and health care (e.g. enhanced access to appropriate level of care at sub LHIN level otherwise tertiary centre is default) Culturally competent care and support Shared care Communication, Communication, Communication Walk the talk : intentional and real: conversations; collaborative planning; shared decision; inclusion; client and family focus System Requirements: Consistency over time Evidence based practice Quality outcomes Role clarity: people, programs, levels of care, units/buildings Optimal scope of practice for strong inter-professional teams within program, site, across sectors Standard definitions Integrated linked system of services across the LHIN: Enablers: One system Incentives for optimal scope of practice for all practitioners e-health for data sharing, right care, CQI Leverage opportunities LHIHN wide e.g. cultural interpreters services LHIN wide compliance with protocols e.g. level 2 transfers For broader Clinical Service Plan Discussion: How does consumer and provider choice drive organization of services? Do primary care models e.g. FHTs work against family physicians present in the hospital? Component Health Promotion Disease Prevention Associated Services Interdependencies Linkages to Community Services Access to Positive lifestyle Education, Healthy Babies Programs learning and practice Recreation. across age continuum Primary Care Consistent Maternal and Newborn Assessment Tool (PHUnits, Primary Care, Hospital Discharge) Enhanced primary care pre and post birthing Improved outcomes: Role and practice consistency: Role of the CCAC (recognizing context of ED/ALC mat newborn is also about patient flow): 7

8 24/7 access best practice guided by checklist and resources the B check outside the hospital Public Health Consistent Maternal and Newborn Assessment Tool (PH, PCare, Hospital Discharge) Every Mom receives a visit or call Access to portable scales in the community to support in follow up Under insured lab services should be provided in the hospital. Other Access to dieticians: Family Health Teams (FHTs) Community Health Centres (CHCs) Public Health Canadian Pre-Natal and Nutrition Program Pre-hospital Care Acute Hospital Care Level of care in a tertiary setting needs to balance low risk and high risk services/specialist role and community hospital role for provider sustainability LOS e.g. 24 hour discharge or less related to community capacity Post-Hospital Care Communitybased Acute Care Communitybased Non- Acute Care Consistent Maternal and Newborn Assessment Tool (PH, PCare, Hospital Discharge) Connect with primary care within hours in home teaching complementary to what primary care provides the public health role values the mother s home/own environment post partum assessment Optimize practice scope of mid wifery Increase number of midwives Standardized level 2 function, resourcing Criteria for safe birthing at home Midwives to be granted privileges at hospitals Under insured lab services should be provided in the hospital. What are the options for monitoring care at home? Is post partum assessment a call or a visist? 8

9 (LHIN wide): Innovation and research Quality assurance HNHB LHIN wide research agendae and innovation uptake Standardize approaches to patient surveys Transparant accreditation outcomes Aligning performance outcomes 9

10 Template #4. Assess and Describe the PAG service delivery model using the HNHB LHIN Criteria PAG Name: Maternal Gyne Newborn Domain Criteria Assessment Description Strategic Fit Alignment with LHIN priorities for health improvement A LHIN wide model of maternal gyne newborn care is consistent with the LHIN s IHSP Phase 1 wherein obstetrics was identified as an emerging priority. Equitable access, improved outcomes and linked services are consistent with the LHIN s mandate for health improvement. Population Health Alignment with trends in health care needs and system transformation Health status (clinical outcomes & QOL) Prevalence A LHIN wide mat gyne newborn health improvement model is a quality improvement response to shifts in HHR availability, practice scope, changing demographics (e.g aging and birth rates), client preferences, and, respects equity of access to health and well being. Healthy lifestyle practices, linked services, optimal scope of practice, best practice and team practice should result in healthier outcomes, sustained skills, recruitment and retention and system effectiveness. System Values System Performance Health promotion & disease prevention Client-focus Partnerships Community Engagement Innovation Equity Efficiency (operational) Access A renewed comprehensive model responds to lifestyle factors, aging, awareness of healthy child development enablers, and shifts in practice e.g. fertility treatments The ascribed components of a mat-gyne-newborn model are predicated on women s, child and family health. Linked services across the continuum of mat-gyne- newborn care is the means to health improvement in the HNHB LHIN The model calls for standardized approaches to understanding patient satisfaction and preferences, transparent and open planning and decision making. Model components and requisites are likely less about innovation and more about walking the talk : revisiting practice and professional barriers for client focused linked services. The model is committed to equity of access to care through standardized practice, protocols and distribution of services. Role clarity, optimal practice scope, team practice, and improved communication for ease of client movement along the continuum of care should result in system efficiencies. Role clarity and linkages among levels 1, 2 and 3, primary care and public health units will enhance timely access and, provider and resident confidence in access. 10

11 PAG Name: Maternal Gyne Newborn Domain Criteria Assessment Description Quality Sustainability From Group Discussion: Sizing and siting e.g. how many beds and where is relatively easy (not to short change politics and decision making, and, feasibility - $$) Collaboration, co-operation and decision making is hard yet essential for sustainability. Integration The model is guided by shared decision making for linked/integrated services. Meeting 3: model and template 4 criteria 11

12 Template #5: Description of Pre-requisites, Enablers and Challenges to Implementation: Category Pre-requisites Enablers Challenges Policy/legislation Evidence based provincial allocation of resources e.g. FHTs, nurse led clinics to optimize equity Provincial Government platform for women s and maternal newborn health Standardized level 1, 2, 3 functional roles and requirements Optimal use of envelope ($$) in an environment of scarce resources, enhanced accountability and expected health improvement Report card for maternal newborn health shared among all contributing stakeholders Outcomes of Provincial Council for Maternal Child Health deliberations Funding incentives that reduce competition, support right care in right place and are aligned with hospital core functions and family health Ontario priority Resources (e.g., human, fiscal, capital, etc.) Community readiness Optimal scope of practice LHIN wide HHR plan for women s health continuum LHIN wide plan for priority building improvements or new builds Understand relationship between health outcomes and services roles and distribution Appreciation of diverse practitioner roles and competencies for improved confidence LHIN wide shared vision for maternal newborn health HNHB LHIN Women s Health Program Academic role re training, re-skilling, research agenda and knowledge transfer a LHIN wide resource with linkages explicit accountabilities Shared vision Provider/practitioner respect for respective roles Multi stakeholder inclusion in planning and/or marketing and or implementation Policy, funding and program silos with little accountability to shared responsibility and accountability for shared clients and patients Independence of Faculty of Health Sciences HHR plans within silos with little or no connectedness to other sectors planning Low to moderate appreciation of health care stakeholders for other local decision makers (e.g. mayors) and the variable expectations of urban and less urban communities. 12

13 Services Right care, right place right time Clarity of role scope Public Health and Primary Care Standardized functional roles and expectations of Level 1,2, 3 Equity of access to appropriate level of care as close to home as possible. ehealth for care decision making, best continuum of care, CQI Partnerships/linkages for Sustainability Mandate/role clarity among providers along the continuum of matnewborn health A LHIN wide Maternal Newborn Regional Program with a shared governance model (See Champlain model)+++ Confer with PCare practitioners re mat newborn care capacity options A LHIN wide maternal newborn program inclusive of all stakeholders Accountability requirements in LHIN H/M/LSAAs for shared planning and decision making Consistent performance metrics for all stakeholders for shared clients +++ Shared governance is a collaborative goal setting, problem solving and decision making process built on trust and communication. All stakeholders share a defined level of responsibility to improve maternal and newborn health services and the delivery of those services within the Region. Organizations with shared governance models in health care are involved with activities that support the delivery of health care. This includes information sharing, research, knowledge exchange, advice, monitoring, public education, and any other activities which support a quality program in a continuous improvement environment. (A Blueprint for Health Mothers and Healthy Babies Healthy Future Version. Interim Report April 2009, Version 3. Champlain LHIN) Meeting 3/implementation and template 5 13

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