TOOLKIT COORDINATED CARE PLANNING. London Middlesex Health Link

Transcription

1 TOOLKIT COORDINATED CARE PLANNING The toolkit is for any individual/organization who will be participating in the Health Link approach to coordinated care planning September 2016 London Middlesex Health Link

2 London Middlesex Health Link Toolkit Coordinated Care Planning Contents LONDON MIDDLESEX HEALTH LINK TOOLKIT... 1 BACKGROUND... 3 WHO SHOULD USE THIS TOOLKIT?... 3 WHAT IS THE PURPOSE OF THE TOOLKIT?... 3 WHAT IS THE HEALTH LINK APPROACH TO COORDINATED CARE PLANNING?... 3 TARGET POPULATION GUIDELINES... 4 MINISTRY OF HEALTH AND LONG-TERM CARE LIST OF HIGH COST CONDITIONS... 4 WHY IMPLEMENT THE HEALTH LINK APPROACH?... 5 ONTARIO HEALTH LINKS INDICATORS... 5 WHAT HEALTH LINKS WILL ACHIEVE... 6 FOR PATIENTS/CAREGIVERS... 6 FOR HEALTH CARE PROVIDERS... 6 SOUTH WEST HEALTH LINKS... 6 HEALTH LINKS... 6 COORDINATED CARE PLANNING PROCESS AND PRACTICE... 7 INTRODUCTION... 7 COORDINATED CARE PLAN... 7 COMPONENTS OF THE COORDINATED CARE PLAN... 7 CARE COORDINATION PROCESS MAP - OVERVIEW... 7 CARE COORDINATION PROCESS MAP - DETAIL... 8 IDENTIFICATION... 9 ROLES AND RESPONSIBILITIES... 9 PATIENT/CAREGIVER... 9 LEAD CARE COORDINATOR... 9 CARE TEAM PARTICIPANTS OBTAINING CONSENT EDUCATION INTERVIEW

3 DETERMINING CARE TEAM PARTICIPANTS SOUTH WEST SELF MANAGEMENT PROGRAM SUPPORT FOR INDIVIDUALS WITH ONGOING (CHRONIC) CONDITIONS SUPPORT FOR HEALTH CARE PROVIDERS COORDINATED CARE PLANNING CONFERENCE COORDINATED CARE CONFERENCE OBJECTIVES ORGANIZING / COMMUNICATING A COORDINATED CARE CONFERENCE EVALUATION COORDINATED CARE PLANNING CONFERENCE PATIENT/CAREGIVER EVALUATION PATIENT EXPERIENCE CARE TEAM TOOLS AND RESOURCES LONDON MIDDLESEX LONDON MIDDLESEX HEALTH LINK PROVINCIAL USEFUL WEBSITES

4 BACKGROUND Who should use this Toolkit? The London Middlesex Health Links Toolkit is for any individual/organization who will be participating in the Health Link approach to coordinated care planning. Coordinated care planning refers to the process of engaging all participants in a patient s Care Team (patient/caregiver, physicians, community support, etc.) outlining the patients short and long term goals and identifying who is responsible for each part of the plan. What is the purpose of the Toolkit? The London Middlesex Health Link Toolkit will describe the Coordinated Care Planning Framework and provide front line staff with the tools and resources available to support the creation and maintenance of Coordinated Care Plans with an inter-disciplinary care team which includes the patient/caregiver as equal partners in the patient s care. What is the Health Link Approach to Coordinated Care Planning? The Health Link approach is a local health network consisting of patients, caregivers, Health Care Providers, and Community Support Service agencies that are committed to working together to improve the health outcomes for patients with complex health care needs. The collaboration in care will result in Care Plans that are patientcentred, ensuring that the patient s goals are effectively met and that they have smooth transitions between care providers. Canada s aging population generates growing demands on the health care system. Complex health issues, financial strain, and systems of care silos can create challenges for those receiving the care, their caregivers, and health and social service providers. The Health Links approach to coordinated care planning seeks to improve the quality of care and the patient experience through the health care system, while reducing waste at the system level to create a collaborative network of care. 3

5 Target Population Guidelines The Health Links target population focuses on the top 5% of Ontario s complex patients. To identify people in our community with high care needs, we will consider people living with four or more chronic/high cost conditions with an emphasis on Vulnerable populations (mental health and addictions conditions, palliative patients, and the frail elderly) Economic characteristics (low income, unemployment, job security) Social determinants (housing, living alone, language, social safety net) In addition, patients can be identified as complex and appropriate for Coordinated Care Planning based on clinical judgement. Ministry of Health and Long-Term Care List of High Cost Conditions 4

6 Why Implement the Health Link Approach? Ontario s top 5% percent of complex patients account for 66% of the Ontario health care expenditures: Top 5% of Population with High Care Needs Remainder of the Population Ontario Health Links Indicators Health Links are measured by indicators put forth by the Ministry of Health and Long- Term Care currently focusing on the following 1. Increase proportion of individuals with high care needs that have a coordinated care plan 2. Increase proportion of individuals with high care needs that have access to primary care 3. Reduce readmission rates within 30 days 4. Reduce rate of emergency visits best managed elsewhere 5. Reduce the time from referral to home care visit 5

7 What Health Links Will Achieve For Patients/Caregivers Brings a Care Team together to create an individual care plan and ensures Care Team understands what is important to the patient Care Team will work together with this shared information; everyone has the right information at the right time Improvement to the patient s journey and experience through the health care system Reduced visits to the emergency department and unnecessary hospital admissions For Health Care Providers Collaborative care that effectively meets patient goals Increased access to up-to-date information about the patient Improved ability to communicate and problem solve with an inter-disciplinary, multi-organizational team The opportunity to work together to create one, comprehensive Coordinated Care Plan by providing the infrastructure needed for successful coordination of care (e.g. tools, processes, established accountabilities, electronic information system). South West Health Links The South West Local Health Integration Network (SW LHIN) has organized the South West region into six individual Health Link geographies. This allows for local development of leadership, governance and organization representation. The six Health Links geographies in the South West LHIN were defined based on existing health service utilization patterns. Health Links Huron Perth London Middlesex North Grey Bruce South Grey Bruce Oxford Elgin 6

8 COORDINATED CARE PLANNING PROCESS AND PRACTICE Introduction Coordinated care planning refers to the process of engaging all participants in a patient s Care Team, including the patient and caregivers, to ensure a holistic, patient-driven approach to care. Coordinated care planning includes: conducting Care Conference(s) creating an individualized Care Plan based on the patient s expressed goals and needs continuous updating and follow-up as required and as pre-determined by the patient and their Care Team The result of this process will be the Coordinated Care Plan that accompanies the patient throughout their health care journey. Coordinated Care Plan The Coordinated Care Plan is a paper or electronic plan that outlines the patient s short and long-term needs, goals and care coordination requirements and identifies who is responsible for each part of the Care Plan. The Coordinated Care Plan is a standardized form that was created by a cross-sector, inter-disciplinary focus group with provincewide representation in conjunction with the Ministry of Health and Long-Term Care (MOHLTC). Components of the Coordinated Care Plan My Identifiers My Care Team My Health Issues My Known, Current Allergies and Medications My Plan to Achieve My Goals for Care My Situation and Lifestyle My Recent Health Assessments My Most Recent Hospital Visit My Other Treatments My Current Supports and Services My Appointments and Referrals 7

9 Care Coordination Process Map - Overview The Coordinated Care Planning process aims to provide a standardized approach which can be adapted by each Provider. The process is ongoing as the patient s goals and needs change. A number of tools and resources (optional) exist to support each step of the process. Identify People who would benefit from CCP Engage with individual to see if s/he would like to partipate and gain consent Interview individual to understand what is important to him/her Facilitate a Care Conference to collaboratively develop a care plan Implement the Care Plan and continually Follow-up and Monitor the individual's progress 7

10 Care Coordination Process Map - Detail No Update Documents Patient Identified Obtains Consent Yes Informs LCC potential client LCC identified CCP prepopulated LCC conducts interview Draft Care Plan Developed Care Conference Organized Pre Care Conference Conduct Care Conference Declining LCC facilitates action items LCC conducts follow-up Evaluate Client Goals Client Status Deceased Death CCP Coordinated Care Plan LCC Lead Care Coordinator Modified Care Stable or improving 8

11 IDENTIFICATION Patients will primarily be identified by providers, but it is hoped that processes be strengthened to support patients who self-identify for a Coordinated Care Plan. On August 12, 2015, the Ministry of Health and Long-Term Care provided a standardized Health Links target population. The target population will continue to focus on the top 5% of Ontario s complex and high need patients. (Target Population Guidelines) Roles and Responsibilities Please note that these lists are not all-inclusive. The Lead Care Coordinator may change throughout a patient s healthcare journey. The Lead Care Coordinator may also be a shared role. Care Team participants can include formal and informal care providers Patient/Caregiver Consent to a Coordinated Care Plan if in agreement Identify who is currently involved in their care Share their health care and lived experience Engage in exploring their goals and needs Participate in Coordinated Care Conference(s) Work towards achieving their goals and needs as per the Coordinated Care Plan Adhere to the communication and follow-up strategy as determined during the Coordinated Care Conference Inform providers that they have a Coordinated Care Plan Lead Care Coordinator Obtain consent (if necessary) from the patient to proceed with a Coordinated Care Plan Work with the patient to identify their Care Team Conduct patient interview Begin to complete the Coordinated Care Plan Support the patient in defining their goals and articulating their needs 9

12 Organize and facilitate the Coordinated Care Conference, which will include inviting Care Team participants to be involved in the patient s Coordinated Care Plan Store the most current copy of the consent and Coordinated Care Plan and share copies with the Care Team Collect and share pertinent updates from the Care Team Adhere to the communication and follow-up strategy as determined during the Coordinated Care Conference Work collaboratively with the patient and the Care Team to assist the patient in achieving their goals identified in the Coordinated Care Plan Care Team Participants Participate in the Coordinated Care Conference Adhere to the communication and follow-up strategy as determined during the Coordinated Care Conference Work collaboratively with the patient and the Care Team to assist the patient in achieving the goals identified in the Coordinated Care Plan Obtaining Consent The consent form must be signed by the patient or their Substitute Decision Maker (SDM) before proceeding with the coordinated care planning process IF members of the care team participants do not have existing data sharing agreements between organizations. Successful coordinated care planning requires communication and information sharing between all members of a Care Team including the patient and caregivers. London Middlesex Health Link has an existing consent form if required. Consent can be refused or withdrawn at any time by contacting the Lead Care Coordinator. Furthermore, patients can add/remove individuals/organizations at any time. The Lead Care Coordinator will be responsible for sharing the most current version of the consent with all participants of the Care Team. 10

13 Education Coordinated care planning may be a new concept for patients/caregivers. Resources for patients and their caregivers have been created to explain Health Links, coordinated care planning and how patients may benefit from having a Coordinated Care Plan. INTERVIEW The patient interview is intended to capture a complete understanding of the patient and support them in identifying goals and articulating their needs. The provider guides the patient through discussions about their experiences in order to understand the current situation and needs. This discussion helps to pre-populate the patient s Coordinated Care Plan. Health Care Providers may use their existing methods and tools to conduct the patient interview or conduct the interview as part of their existing assessment. Determining Care Team Participants Once the patient/caregiver has agreed to participate, the Lead Care Coordinator will support the patient in deciding who will be a part of their Care Team. Ideally, the Care Team will involve the patient and their caregiver as well as all Health Care Providers (including primary care) and Community Support Service agencies involved in the patient s care. At this point of the care coordination journey, the Care Team participants should be documented in the Coordinated Care Plan. South West Self Management Program The South West Self Management Program is offered by the South West CCAC in partnership with the South West LHIN. The goal of the program is to have a coordinated approach to support clients, caregivers and health care providers with self-management. Support for Individuals with ongoing (chronic) conditions The South West Self-Management Program offers free programs for people with chronic conditions. These workshops provide participants with the skills, tools and confidence to better manage their conditions such as diabetes, arthritis, chronic pain, heart disease and other ongoing conditions. 11

14 Support for Health Care Providers The South West Self Management Program offers programs for health service providers to assist with the integration and implementation of self-management best practices. This is achieved through communication skills workshops, education and skills training in self-management support, tools, resources and consultation on how to best integrate principles into clinical programs. COORDINATED CARE PLANNING CONFERENCE The purpose of the Coordinated Care Conference brings together the Care Team to share information and to collaboratively create an action plan for meeting the patient s expressed goals and needs. The Coordinated Care Plan will be finalized at the Coordinated Care Conference and will be shared with the Care Team. Coordinated Care Conference Objectives Introduce all participants Review and confirm patient goals Align the health care goals of the providers with the patient s goals Create the Care Plan with particular attention to My Goals for Care, My Plan for Future Situations and My Assessed Health Needs Record action items: referrals, investigations, treatment, etc. Identify who will be responsible and negotiate how and when clinical updates will be shared determine the communication and follow up strategy Organizing / Communicating a Coordinated Care Conference When scheduling a Coordinated Care Conference, it may be helpful to offer different options to accommodate Care Team participants (e.g. in-person or by teleconference/videoconference). Care Team participants not in attendance still receive a copy of the Coordinated Care Plan. Upon completion of the Coordinated Care Conference, the Lead Care Coordinator is responsible for storing/updating the most current copy of the Coordinated Care Plan, and for sharing copies of the Coordinated Care Plan with all Care Team members including the patient. For a Coordinated Care Plan to be effective, the Care Team, including the patient, must have an established follow-up and communication strategy. The Coordinated 12

15 Care Plan will be successful only when it is continuously used by the interdisciplinary team (the Care Team) to provide care for the patient and to work collaboratively with the patient in meeting the patient s goals. Updating the Coordinated Care Plan and communication with Care Team participants will be unique for each patient, as their needs and goals will differ and their Care Team will have various organizations involved. Care Team members who are not in attendance at the Coordinated Care Planning Conference should be made aware of the strategies for follow-up and communication when they receive their copy of the Coordinated Care Plan. EVALUATION Coordinated Care Planning Conference Patient/Caregiver Evaluation In an effort to continuously improve health care processes and ensure that the patient remains in the centre of the coordinated care planning process, the London Middlesex Health Link has developed a patient evaluation to be completed by the patient/caregiver after the Coordinated Care Conference. Patient Experience For a greater in-depth evaluation of the patient experience once the patient has had a completed Care Plan for three to six months, determine if appropriate for an hour long interview detailing the experience. This interview could also be a key element in experience based design for the Coordinated Care Planning process. Care Team In addition to evaluating the process for the patient, it is also important to evaluate the experience of the members of the Care Team so that any process improvements can be identified and integrated into the Coordinated Care Planning Process. 13

16 TOOLS and RESOURCES LONDON MIDDLESEX LONDON MIDDLESEX HEALTH LINK PROVINCIAL Ministry of Health and Long Term Care (MOHLTC) Health Quality Ontario (HQO) Coordinated Care Plan Templates and Guides Care Coordination Tool Summary Coordinated Care Plan Template Detailed Coordinated Care Plan Template Coordinated Care Plan User Guide Care Coordination Tool Proof of Concept Update (Feb-2016) USEFUL WEBSITES South West Local Health Integration Network (SW LHIN) South West Coordinated Care Access Centre (CCAC) South West Health Line 14