Access to Care: An Improvement Journey. eenablers, Final Report June 2014

Transcription

1 Access to Care: An Improvement Journey eenablers, Final Report June 2014

2 Overview Access to Care is a transition management philosophy and approach focused on keeping patients specifically seniors and adults with complex needs safe in their homes for as long as possible. The approach to care is dependant on equitable access to well aligned community supports and rehabilitative care. Access to Care aligns three coordinated strategies across the South West: Home First Assisted Living, Supportive Housing and Adult Day Programs (AL/SH/ADP) Complex Continuing Care and Rehabilitation (CCC/Rehab) The following slides will outline the purpose of each electronic enabler (enotification, escreener, ereferral, emedlist summary) for improving patient/client care. Additional information is also provided that reviews electronic enabler implementation challenges, opportunities and timelines.

3 Access to Care eenablers Key Messages Access to Care eenablers are building a virtual cross sector care team for patients. This work is foundational to future sharing of information within the circle of care. Clinical and technical co-design of eenablers is a powerful way to build effective solutions.

4 What is Access to Care? Access to Care is an approach to care focused on supporting people, specifically seniors and adults with complex needs, in their homes for as long as possible, with community supports and rehabilitative care. With an aging population, communities and health care partners are working together to support people: In the Community In the Hospital Accessing Specialized Services 4

5 Why did we embark on Access to Care? Many people were waiting in hospital for long-term care and experiencing cognitive and functional decline during this time Many people had care needs that could have been better met elsewhere: 37% of people in Complex Continuing Care beds 30% of people accessing Assisted Living services 20% of people in Long-Term Care 1,000 more people could have benefitted from Adult Day Programs Services varied by region and provider: program elements, eligibility criteria, funding and client fee models Inequitable geographic distribution of services Ability to provide more intensive care for clients in the community and coordinated access due to legislative and policy changes 5

6 How will Access to Care impact Norm s Life? 6

7 How Access to Care ehealth initiatives will impact clients like Norm? Description Definition Benefit Status/Timeline

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9 escreener Description: Definition: Benefit: Status/Timeline: Home First ehealth Projects Implement a screening tool at the point of a patient being admitted to hospital to identify the highest needs patients who should be referred to the CCAC as early as possible while in the hospital. Electronic screening tool (5 questions) that identifies patients with complex needs and the associated electronic referral from hospital to CCAC for client assessment. Earlier engagement of the CCAC for targeted individuals will enable planning for robust service plans in the community earlier in the hospital stay. The electronic screening tool has gone through validity testing at London Health Sciences Centre and St. Thomas Elgin General Hospital and revisions made. Final esreener has been built in Cerner South, Cerner North and Meditech. Now implemented at London Health Sciences Centre, St. Thomas Elgin General Hospital, Tillsonburg District Memorial Hospital, Woodstock Hospital, the rural hospitals of Grey Bruce Health Services and Alexandria Hospital Ingersoll. Expected to be implemented with Home First spread hospital by hospital: Parkwood, Huron Perth Healthcare Alliance, Middlesex Hospital Alliance, Listowel Wingham Hospitals Alliance, South Huron Hospital Association, Alexandra Marine General Hospital, Hannover District Hospital, and South Bruce Grey Hospital Corporation

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11 enotification Description: Definition: Benefit: Status/Timeline: Home First ehealth Projects Provide hospitals with access to the CHRIS database to confirm the CCAC client status of patients when they present in the ED and will notify CCAC as they are being discharged from the ED. This is an automated query based on personal identifiers. System of care integration between the hospital patient information system (e.g. Cerner south, Cerner North, Meditech) and the CCAC CHRIS (Client Health and Related Information System) to identify mutual patients/clients. enotification will allow the CCAC to cancel scheduled Client in-home appointments based on their presence in hospital, hospital staff may make different care planning decisions knowing the patient has supports already in the community and community caregivers will know that their client has had a change in condition requiring an emergency visit and/or a hospital admission. Built and tested for Cerner South. Live at London Health Science Centre, St Thomas Elgin General Hospital, Alexandra Hospital, Tillsonburg District Memorial Hospital, Listowel Wingham Hospitals Alliance, Woodstock Hospital, Middlesex Hospital Alliance, St. Joseph s Urgent Care Centre. Project plan is in development to expand to Cerner North and Meditech sites in Q2/Q3, 2014/15.

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13 Acute to CCAC ereferral Description: Definition: Benefit: Status/Timeline: Home First ehealth Projects Implement an electronic referral form from acute to CCAC in alignment with the Resource Matching and referral work occurring provincially. Electronic order for specific services entered by any hospital HCP into patient information system (e.g. Cerner) and retrieved by CCAC; to transition into electronic order for generic services entered by any hospital HCP into patient information system (e.g. Cerner) and retrieved by CCAC Earlier and consistent engagement of CCAC for individuals will enable earlier in-home service planning, and adoption of more intensive in-home care plans. Referral has been built within Cerner South and is live at St Thomas Elgin General Hospital. This work was completed before the RM&R form for acute to CCAC was completed provincially. Currently working with the OACCAC and Cerner South to determine resources to move forward using provincial form which has been built in CHRIS.

14 CCAC Referral to CCC/Rehab and AL/SH/ADP Description: Definition Benefit: Status/Timeline: Coordinated Access ehealth Projects With Resource Matching & Referral (RM&R) project stretching out over an extended period, there is an opportunity to leverage the CCAC s expanded role as system navigator to increase standardization of referral information and processes across the South West. This project utilized manual excel spread sheets to standardize and manage client information initially and then transferred those work flows into a fully electronic system CCAC ereferral to CCC/Rehab: Electronic referral from CCAC to hospital for Complex Continuing Care and Rehabilitation beds and enabled exchange of information between the CCAC and the hospitals, via the Health Partner Gateway (HPG), for CCC and Rehab bed Wait List/Bed Management. CCAC ereferral to Community (AL/SH/ADP): Electronic referral from CCAC to Community Support Services Agencies (CSSAs) for Assisted Living/Supportive Housing and Adult Day Programs and enabled exchange of information between the CCAC and the CSSAs, via HPG, for Wait List/Vacancy Management. Improved patient information management, more efficient referral processes, and greater harmonization of referral processes, transparency of centralized wait lists, improved data capture ereferral to CCC/Rehab went live at St Thomas Elgin General Hospital, Alexandria Hospital Ingersoll, Tillsonburg District Memorial Hospital and Woodstock Hospital Rehabilitation Unit in October 2013 and WH CCC in January All CCC/Rehab sites Grey Bruce Health Services, Huron Perth Health Alliance, Listowel Wingham Health Alliance, South Huron Hospital Association, Parkwood will be live by 2014/15 fiscal year end. ereferral to community went live in October 2013 with all of the South West live as of March 2014.

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16 emedication List Description: emedlist is a high priority for improved transitions in care. Initially, evaluation was required to identify any possible local/regional level solutions. A trial of a fax solution in Grey Bruce has been identified. Definition: Benefit: Status/Timeline: Access to Care ehealth Projects Leverage the SPIRE-HRM Project initiative to explore the possibility of CCAC receiving the new Medication List Report (under development). This new report would be generated at the same time a patient is discharged from hospital and provide a list of medications, dosages and instructions to provide information and potentially be used to reconcile pre and post discharge medications. Provide medication information more expediently and accurately to the service providers who are performing the medication reconciliation process in the Clients homes to reduce errors and possible injury due to delays in communication of discharge medications. Work in Progress Trial in Grey Bruce started in January 2014 and we continue to spread the trial across the Owen sound Hospital site.

17 The website was initially developed as a partnership between hospitals, the health unit and the CCAC in London, Ontario, and is now a province-wide resource for both the public and health care professionals to access information. It houses more than 50,000 health service profiles: Assisted Living/Supportive Housing Adult Day Program Complex Continuing Care Rehabilitation Long-Term Care Hospice Ongoing work will continue to enhance 17

18 thehealthline.ca enhancement Description: Definition: Benefit: Access to Care ehealth Projects Detailed service information is made available to the CCAC Care Coordinators and members of the public on the services available in each AL/SH/ADP Program and CCC/Rehab setting. Referrals to community service providers typically requires investigation on whether a service/program has capacity to accept new clients. Website initially developed as a partnership between hospitals, the health unit and the CCAC in London, Ontario, and now being expanded to a provincial resource; houses more than 50,000 health service profiles, including AL/SH and ADP information. Consistent information, including videos, will help match clients with services that best meet their needs Status/Timeline: All ADP and AL programs have completed this work with thehealthline.ca. Clients, families and their care coordinators are regularly using this information to determine the best service for their needs. Work is wrapping up to provide the same detailed, consistent information for CCC/Rehab.

19 ehealth Technologies The following projects have elements that have impacted the ehealth initiatives addressed through the Access to Care project, but were out of scope: HUGO, Health Care Undergoing Optimization, focusses on shifting from paper records to the electronic environment. It continues to be rolled out across the South West and can be leveraged to strengthen inter-partner ehealth technologies. cswo, Connecting Southwestern Ontario is a strategy to connect four South Western Ontario LHINs by leveraging current technologies to benefit patients, (Clinical Connect Regional Clinical Viewer, Provincial Hospital Report Manager (HRM), Regional Clinical Viewer, Ontario Lab Information System Practitioner Query (OLIS)). eshift is a budding technology that started as a tool to support high-needs children and palliative patients. This tool allowed front line staff in the community, to connect with clinicians leveraging mobile smart phone technology. The website was initially developed as a partnership between hospitals, the health unit and the CCAC in London, Ontario, and is now a province-wide resource. More details about how the ATC project has leveraged this product are provided in this report. 19

20 ATC ehealth Next Steps The ehealth implementation work that Access to Care has been leading will require: A robust hand-off for appropriate projects from the Access to Care team to identified partners A clear sustainability plan moving forward Ongoing communication strategies and clarity of accountabilities to ensure alignment with the overall ehealth strategy