CCAC ehomecare: Supporting Patients with the right care at home. OACCAC Conference June 2016

Transcription

1 1 CCAC ehomecare: Supporting Patients with the right care at home OACCAC Conference June 2016

2 2 CCAC ehomecare: Using technologies to enhance delivery of home care services CCACs have a mandate to support people to maintain or regain their ability to live independently in their communities after an illness, a hospital stay or as a person ages.

3 3 CCAC ehomecare ehomecare is not a program or a technology; rather an over arching strategy to leverage existing and emerging technologies, individually and in combination to support people to live in their own homes with the best possible quality of health and life.?? ehomecare eshift? eclinic Tele-Consult Tele-Home Care????

4 Expanding use of Technologies Technology enabled consultative models: Eliminating the need for a clinician and patient to be in the same location for the purposes of assessment and diagnosing Technology enabled remote monitoring Supporting self management Technology enabled intervention models Supporting different ways to deliver hands-on care in the community Robotic surgery/eshift & eclinic 4

5 5 eshift An Intervention Model To date: 5 CCACs: Complex Pediatrics, End-of-Life, Pre/Post- Acute Chronic UK: End-of-Life US: Post-Acute Chronic France: Oncology Multi-national academic collaboration 5000 distinct patients supported Over 1,000,000 hours of care Visual Effectiveness caseload measures

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7 7 Clinical Record - Dashboard Secure web/mobile based Designed and accessible to Physicians, Accessible to the full care team Population or disease specific Provides a longitudinal view of patient and caregiver experience

8 eshift eclinic 4 + Patients 8-12 hours Patient Visits Utilization Options: 10 pts 3X daily or 30 pts 1X daily 1 hour

9 9 eshift An Intervention Model SW CCAC Palliative Experience Readmission in last 30 days of life: Traditional Shift Nurse: 50% readmitted eshift model: 1.9% readmitted (sustained) Represents a 96% reduction in hospital use Is a technician better than a nurse?? Knowledge Transfer = informed care team Informed team = ability to anticipate care needs Anticipation = ability to pre-empt crisis Pre-empting = better patient experience & lower cost

10 10 Responding or Pre-empting Health System structured to respond First Responders Emergency On-call Trigger? Patient Crisis (real or perceived) Responsive approach is appropriate for unexpected care needs But when care needs are not if, but when..

11 11 1. Remote Care eshift Model: Multi-Value Add Improved capacity (1 nurse: 6 patients vs 1:1) Improved access: To specialized clinical skill set Geography no longer a barrier

12 12 eshift Model: Multi-Value Add 2. In-home clinical record/dashboard Traditional EMR: documentation of what happened eshift: demonstrates what s happening now circle of care and see into patient home Anticipating enables pre-empting crises 96% reduction in readmission Improved effectiveness of care Improved quality of care

13 Patients First: Action Plan for Health Care Improve access providing faster access to the right care. Connect services delivering better coordinated and integrated care in the community, closer to home. Support people and patients providing the education, information and transparency they need to make the right decisions about their health. Protect our universal public health care system making evidence based decisions on value and quality, to sustain the system for generations to come.

14 The Case for Change

15 The Case for Change receive care from 5 or more physicians fill prescriptions from 3 or more pharmacies

16 16 The Case for Change High Rising Risk Patients Low Risk Patients 5% 30% 65% Source: Edington, D. Lost Productivity the High Cost of Doing Nothing, University of Michigan

17 The Case for Change 1-2 well managed chronic diseases Rising Risk Patients 30% Co-occurring psycho-social risk factors Symptoms are not severe, so ignorable until Source: Edington, D. Lost Productivity the High Cost of Doing Nothing (University of Michigan) 17

18 18 The Case for Change High Rising Risk Patients 18% Escalate Annually Source: Edington, D. Lost Productivity the High Cost of Doing Nothing (University of Michigan), Population Level Commissioning for the Future, Kent Whole Population Database, Interim Report

19 19 WHY? The Case for Change One Care Miss: Patient experiences SOB Cannot access Primary Care Attends ED ED cannot access chart/medications ED physician prescribes new Rx Patient fills Rx at closest pharmacy, pharmacist has no access to chart Medication conflicts with preexisting medication, patient faints 911 call, ED admission Patient/family confidence to selfmanage decreases 18% Escalate Annually Source: Edington, D. Lost Productivity the High Cost of Doing Nothing (University of Michigan), Population Level Commissioning for the Future, Kent Whole Population Database, Interim Report

20 20 Supporting Chronic Disease PREVENTION MANAGEMENT RESPONDING TO CRISIS

21 The Case for Change receive care from 5 or more physicians fill prescriptions from 3 or more pharmacies

22 22 Supporting Chronic Disease PREVENTION MANAGEMENT ANTICIPATING & PREEMPTING CRISIS EXACERBATION RESPONDING TO CRISIS

23 A New System Approach The right care for patients with chronic disease is dependent on specialized clinical skills at the right time. Specialized care has traditionally required patients travel to the specialized provider: Effective use of specialized clinician resources, but not patient centric. Home is increasingly the right place to receive the right care Generalist model supports home can be anywhere in Ontario. Generalist skill set no longer enough: PCP or homecare provider.

24 A New System Approach Solution no longer either location based specialized or community generalist; Must be both to: Deliver better outcomes Avoid unnecessary use of emergency and hospital services. Leverage technology to virtually integrate full care team Transform practice from reacting after the exacerbation to anticipating and Pre-empting the crisis.

25 SW Post Acute Moderate COPD (IFM) Acute Home Care Intervention Self Management Hospital LOS: 5 Days Step-Down Technology Enabled Intervention eshift eclinic Supported Self Management Care Coordination TeleHomecare Up to 3 days Up to 60 days

26 26 Hospital Team Daily review of dashboard Scheduled video conferences w/patoient in the home Initiate alternate action Virtual Integration of the Care Team Primary Care enabled to monitor and engage as appropriate. Real-time Dashboard on demand CMR monitored by DRN.

27 Improved Outcomes Hospital LOS Baseline: 8.1 days Preliminary Results Preliminary result: 5.8 days (28.4% reduction) Readmissions within 30 days of leaving in-patient Baseline: 22.3% Preliminary: 9.6% (56.9% reduction) Improved Experience Evidence Underway: Education adoption pre/post Patient Voice

28 Where to now? Chronic disease not reversible Not a question of if decline will happen, but when Vast majority have primary care provider, many also have CCAC services But the ED visit is the trigger to alert care team to decline 28

29 HNHB Upstream Chronic (COPD) On CCAC COPD Dx Complex Palliative Care Plan services eshift Location chosen to die: Home Education & baseline Monitoring inform care plan Specialist Primary Care Palliative Physician Location chosen to die: Hospice Residential Hospice

30 Chronic Disease rarely a single condition Multiple Chronic Disease COPD CHF Diabetes Rheumatoid Arthritis Cardiologist Endocrinologist Patient & Primary Care need specialized clinical support Respirologist Primary Care Patient Rheumatologist How do we enable broader consolation?

31 31 Common Patient Record: Enabling Broader Collaboration Dashboards eshift Consult CHRIS Patient Health Record eshift Patient Clinical Record eshift Collaborate Caregiver Portal MyeShift Patient Portal

32 32 eshift Dashboards: Disease State View Dashboards COPD CHRIS Patient Health Record eshift Patient Clinical Record CHF Diabetes Palliative

33 Patient Dashboard Patients with multiple diseases have diseasespecific dashboards View patient data through multiple disease-specific dashboards

34 Patient Dashboard Crucial Clinical data is available real-time Disease-specific dashboards display relevant metrics

35 35 Common Patient Record: Enabling Broader Collaboration eshift Consult CHRIS Patient Health Record eshift Patient Clinical Record

36 Enables direct point of care consultations with the greater care team Emma Johnson, DRN Consult Supports shared patient record collaboration

37 Dennis Hawthorn, MD Consult Emma Johnson, DRN Live chat provides realtime support

38 38 Common Patient Record: Enabling Broader Collaboration CHRIS Patient Health Record eshift Patient Clinical Record eshift Collaborate

39 Supports Multi- Disciplinary clinical rounds Patient review selection based on dynamic filters Collaborate Engages remote and inperson clinical members

40 Specialized CMO/CNO meeting audit tools Collaborate Clinical notes and Instructions are shared in real-time

41 41 Common Patient Record: Enabling Broader Collaboration CHRIS Patient Health Record eshift Patient Clinical Record Caregiver Portal

42 Caregiver Supportive collaboration tools for the extended circle of care View of Patient record from e-shift data repository Caregiver Portal Tools to support supplemental hands on care

43 Patient Specifies level of access for each member of the extended circle of care Security and Privacy by Design Caregiver Portal Patient or designate can modify access of any member at any time

44 44 Common Patient Record: Enabling Broader Collaboration CHRIS Patient Health Record eshift Patient Clinical Record MyeShift Patient Portal

45 Supports advanced direction models, DRN to caregiver Enables self care and participation from active caregiver MyEshift Care plan and record entries are linked to eshift data repository DRN Directed Care Plans

46 Supports a variety of devices Basic selfassessments MyEshift Easy to follow care plan Supports directed and delegated tasks Integrates with the Ontario Coordinated Care Plan (CCP)

47 Provincial Structure Provincial Governance: Steering Committee Reporting to M. Miles (CEO Council and PCSC) International academic research Sub-Committee Operations, Clinical Standards manuals, Training Data/Business Intelligence Provincial Resources & Training SharePoint Site Cultural Clinical Operational Technical 47

48 Questions 48