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INSPIRED Approaches to COPD: Improving Care & Creating Value Follow-up Webinar: Spreading INSPIRED Approaches to COPD at Scale and at Pace June 26, 2014 12:00-2:00pm ET cfhi-fcass.ca 2

Follow-up Webinar Objectives: Part I: From 12:00-1:00pm ET To discuss INSPIRED COPD Outreach Program TM expansion and how we are working at the edges of our health system To reflect on our INSPIRED journey What have we learned? What s our shared commitment toward a new standard in healthcare 3

Follow-up Webinar Objectives: Part II: From 1:00-2:00pm ET *Optional To learn across teams, with specific attention to staffing mix and interprofessional teams, core COPD care and chronic disease management services and improvement capacity 4

INSPIRED COPD Outreach Program TM - Resources Now available on the CFHI online platform: Overview Flow Chart Referral Form Information Sheet Consent Form Intervention Checklist First Letter Template Demographic Form Assessment Form Contact Information Electronic Progress Note Opioid Information Brochure Health Links Use of Hand Held Fan for SOB Personal Directives Template Transition Letter Template Telephone Checklist 12 Month F/u Phone Checklist Oxygen Alert Card Oxygen Brochure 5

What it s all about Joyce Irene Mason (1938-2012) For if it hadn t been for Dr. Rocker and his team we wouldn t have had Joyce our mother, grandmother, sister and friend with us for as long as we did 6

Patient-reported Input: What worked well action plan prescriptions and prednisone on hand or on order accessible education/information/resources improved clinical outcomes relevant to the patient/family someone to call/support/not feeling so alone to manage symptoms feeling cared for/caring, reliable, knowledgeable staff using good communication 7

Patient-reported Input: Room for improvement continuity & non-abandonment more education with family members initiate program at time of diagnosis/ much earlier in the trajectory more information and emphasis on the effects of smoking for those with COPD and their families 8

INSPIRED Program Expansion cfhi-fcass.ca 9

Spread and Scale up of INSPIRED: 3 Examples 1 Within the health authority, to reach patients sooner when they present at the ED (vs. having been hospitalized) 2 Within the health authority, to other chronic disease management programs (beyond COPD) 3 Across the province, to other healthcare facilities/teams 10

1. Emergency Department Lessons If you want to swim upstream and get patients earlier (MRC <3) need to recruit other than hospital in-patients Emergency department GP offices Allied health professionals Hospital website Response Exploring the feasibility & efficacy of recruiting eligible (MRC3-5) patients in the ED Adding INSPIRED referral form (revised for ED) and Action Plan template to ED clinician toolkit to make appropriate referral easier Adding an electronic flag to identify patients with COPD and AECOPD to prompt attending MDs Exploring relevance and usefulness of assessing learned helplessness as a potential factor in ED revolving door patterns for certain patients 11

2. Chronic Disease Management Lessons MDs have requested support from INSPIRED for patients with interstitial lung disease and pulmonary fibrosis. INSPIRED potentially beneficial in other chronic illness where selfmanagement is the goal and people are limited in their ability to leave home, e.g., o Interstitial Lung Disease o Pulmonary Fibrosis o Chronic Heart Failure o Chronic Renal Failure o Neurodegenerative diseases like Muscular Sclerosis & Amyotrophic Lateral Sclerosis Response Plan to expand support to teams and clinicians working with other chronic conditions Work to develop a chronic disease management centre, where patients and families can access care for complex comorbidities in one stop Collaborate with other chronic disease management teams to improve the patient/family healthcare journey and experience 12

3. Whole-of-system Approach Lessons Nova Scotia Department of Health & Wellness recommended INSPIRED in every district health authority With amalgamation of health districts INSPIRED should be a resource for patients throughout the province o Challenges to expansion o Population distribution in rural areas o Funding resources o Personnel o Finding champions o Resource reallocation Response Identify champions around the province Get on agendas for things like Doctors Nova Scotia, internal medicine conferences, Atlantic Respiratory Conference Encourage Nova Scotia teams to apply to the CFHI collaboration Establish INSPIRED team as a resource for those looking to set up INSPIRED-like initiatives in their districts/regions 13

Discussion & Questions? Please submit your comments/questions electronically using the Chat Box on the bottom right of your webinar screen. 14 14

An INSPIRED shift: What have we learned? cfhi-fcass.ca 15

What matters to you Our Objectives (n=78) Objectives & Number of Responses Not a Priority Low Priority Medium Priority High Priority Learning Objective 1: Appreciate the importance of patient and family engagement processes to the design, delivery, implementation and evaluation of COPD care, throughout the care experience, including at the end of life (n=78) 0 (0%) 1 (1%) 17 (22%) 60 (77%) Learning Objective 2: Consider the viability of adapting and applying appropriate mechanisms, instruments and metrics that may be used to establish baseline as well as monitor and assess results (n=78) 0 (0%) 1 (1%) 23 (30%) 54 (69%) Learning Objective 3: Consider key principles, processes, pathways and practices that comprise the INSPIRED program from early intervention and follow up to COPD education, action planning and self-management, coordination of care from hospital to home, and more (n=77) 0 (0%) 0 (0%) 9 (12%) 68 (88%) Learning Objective 4: Identify strategies for engaging and communicating with healthcare providers, community partners and decision-makers during the program design, delivery, implementation and evaluation phases (n=78) 0 (0%) 2 (3%) 16 (21%) 60 (77%) Other Learning Objectives (please specify) (n=20) 8 0 4 8 16

In what areas are you seasoned/fluent? (n=67) Area Patient and family engagement processes to the design, delivery, implementation and evaluation of COPD care Patient and family engagement processes throughout the care experience, including at end of life Performance measurement to establish a baseline and monitor and assess results Engagement strategies for healthcare providers, community partners and decision-makers Agree / Strongly Agree 91% (61/67) 90% (60/67) 76% (51/67) 77% (51/66) 17

In what areas are you seasoned/fluent? (n=67) Area COPD education, action plans and selfmanagement education (n=60) Agree / Strongly Agree 70% (47/67) Coordination of care from hospital to home (n=59) 59% (39/66) Goals of care planning and advance care planning (n=60) 69% (46/67) 18

Intent to Apply Learning Welcome Webinar 89% Yes (59/66) 11% Maybe (7/66) Webinar 1 78% Yes (35/45) 18% Maybe (8/45) 4% N/A (2/45) Webinar 2 82% Yes (23/28) 18% Maybe (5/28) 19

What you said The INSPIRED model looks great and a tool to really help us better to help patients and families. It is also a model propel integration of services and staff within our academic health care setting. We wonder if your agenda by assisting us is to establish a national network of provider programs to better serve the population. (YES) Very excellent about the potential opportunity to apply an INSPIRED-like QI initiate in my own institution. The proven structure and results of the program provides weight when proposing a program in our institution. (YES) Now that we have more knowledge of the INSPIRED model, although excellent, we realize that this is not a model we are in the position to offer (funding). (N/A) 20

What you said Redundancies/overlap: We already have a program in place and many of your components we are already doing or others do not fit. (MAYBE) Resources constraints: We don't have a respirologist, RTs We have a small population We are struggling politically to work together with community, hospital, home care, long-term care but this is certainly the vision of care we have. (MAYBE) Although we will not be implementing the INSPIRED model (intensive outreach) we most definitely gain knowledge and insight from the information provided on the webinar, especially the contributions from family, front line staff. 21

What are your barriers & facilitators to doing things differently? (n=36) Barriers 1. Funding or Cost of Program (n=11) 2. Organizational Culture and Support (n=11) 3. Time and Resources (n=7) 4. Current Knowledge/Need for Data (n=3) 5. Patient Demographics (n=2) 6. Technology (n=1) 7. Geography (n=1) 8. External Factors (n=1) Facilitators 1. Organizational Culture and Support (n=3) 2. Technology (n=1) Other 1. Too Soon to Tell (n=2) 2. Unclear (n=1) 3. None (n=1) 22

Topics of interest What would you like to learn more about during future sessions? INSPIRED Program (n=7) How to (n=7) Patient Engagement (n=4) Specific Components of COPD Care (n=4) Sustainability (n=2) Buy-in (n=2) Is there anything you would like to know about the INSPIRED COPD Outreach Program that was not covered in today's webinar? Resource requirements of the program Sustaining connections Resource materials Information on others who are implementing 23

Reported Satisfaction Other/N/A Very Dissat. Dissat. Neutral Sat. Very Sat. WW How satisfied 6.2% (4) 0.0% (0) 0.0% (0) 13.8% (9) 58.5% (38) 21.5% (14) W1 were you overall with your webinar 4.4% (2) 0.0% (0) 6.7% (3) 17.8% (8) 53.3% (24) 17.8% (8) W2 experience? 0.0% (0) 0.0% (0) 0.0% (0) 28.6% (8) 39.3% (11) 32.1% (9) WW 6.2% (4) 0.0% (0) 1.5% (1) 7.6% (5) 51.5% (34) 33.3% (22) W1 How satisfied were you with the webinar 4.4% (2) 0.0% (0) 6.7% (3) 8.9% (4) 51.1% (23) 28.9% (13) W2 technology? 0.0% (0) 0.0% (0) 0.0% (0) 14.3% (4) 53.6% (15) 32.1% (9) WW How satisfied *Had not yet been introduced to platform are you with the learning 4.4% (2) 0.0% (0) 0.0% (0) 26.7% (12) 48.9% (22) 20.0% (9) W1 management W2 platform 0.0% (0) 0.0% (0) 0.0% (0) 28.6% (8) 50.0% (14) 21.4% (6) (Desire2Learn)? 24

Discussion & Questions? Please submit your comments/questions electronically using the Chat Box on the bottom right of your webinar screen. 25 25

Thank you Checklist: INSPIRED Approaches to COPD Care Collaborative Applications due June 30, 2014 Complete the last e-survey by July 4, 2014 (1pm ET) We will circulate a 60-day follow up e-survey in early September 2014 Check online for all INSPIRED webinar resources & materials (granted access until end of December 2014) Contact registration@cfhi-fcass.ca for follow-up cfhi-fcass.ca 26

Part II: Learning Across Teams cfhi-fcass.ca 27

Range of Team members Of 8 Organizations 8/8 reported MD &/or NP team members 1/8 reported both 6/8 Pharmacist 5/8 APN (ACP/Palliative Care) 7/8 Social work (SW) 5/8 Mental health 5/8 Respiratory Therapist (RT) 6/8 Physiotherapist (PT) 4/8 RN 4/8 Occupational Therapist (OT) 3/8 Primary care (RN, GP) 4/8 Dietician 1/8 Spiritual care 3/8 Discharge planner or coordinator 4/8 Home care 2/8 Smoking cessation 2/8 Management 5/8 ED or EMS 2/8 chronic disease management Other: Administrative assistant Speech Therapy Spirometry 28

Range of Services Primary care: Spirometry testing Patient care plan education & development COPD education to patients & families Smoking cessation Case manager Acute care: Pulmonary rehab Action plan education Self-management Community referral for outpatient rehab/pt Advance care planning / Personal directives / Palliative care Discharge planning Inpatient care pathway In-Home care: Access to services, e.g., SW, RN, PSW, PT, OT, dietitian and speech Telehealth Routine follow-up Other: Preventative care Links to community (beyond healthcare) Role clarity among service providers Involvement of patients and family carers? Peer support? 29

3 Questions 1. Who makes up your healthcare team providing services to patients living with COPD? 2. What are your COPD care services? (existing services vs. newly planned work) 3. What s one thing you ve learned about the INSPIRED COPD Outreach Program that you can apply to your own context/setting? OR Having learned about INSPIRED, what questions has it raised about your own setting? 30

Case 1. The Ottawa Hospital Rehabilitation Centre Team Roles Advanced Practice Nurse* Respirologist Patients & Families Physiotherapist Registered Nurse Respiratory Therapist *Advanced Care Planning Coordinator and Project Lead 31

Case 1. Partnerships - The Ottawa Hospital Team Allied health Psychology, Mental health services Occupational Therapy (OT)/Physiotherapy (PT), Social Worker Community Care Access Centre (Rapid Response Nurses) Palliative care, Internal Medicine Emergency Health Services (EHS), Advanced Care Paramedics Community Health Centres, Lung Association, Family Health Teams 32

Case 1. Services - The Ottawa Hospital Existing Services Pulmonary rehab Individualized action plan education by a certified respiratory educator Community referral for outpatient rehab/physio New planned work Individualized action plan education by a certified respiratory educator Access to Advance Care Planning and Personal Directive 33

Case 2. Grey Bruce Health Services Team Roles Proposed INSPIRED: Grey Bruce Health Services (GBHS) & Partners (Owen Sound Family Health Team (OSFHT), Community Care Access Services (CCAC), Emergency Medical Services (EMS), Public Health Unit (PHU) Allied Health OT, PT, Dietician, Pharmacist, Ad Hoc Diabetes Services, CHF, Pain Management Services etc. Partnerships* EMS CCAC PHU OSFHT Registered Respiratory Therapist and or Registered Nurse Palliative Care Emotional Support Pastoral Care Ad Hoc Social Work, Mental Health Services Patients & Families Medical Support Respirologist, Internal Medicine, Hospitalists, Family Physician, Nurse Practitioner COPD REACH Team Coordinator TBD Steering Committee* Leadership: GBHS Exec, OSFHT, EMS, CCAC, Core members of REACH, LH MD Admin Assistant * Note: GBHS exe = Grey Bruce Health Services Executive, OSFHT = Owen Sound Family Health Team, PHU = Public Health Unit EMS = Emergency Medical Services, CCAC = Community Care Access Centre, LH MD = Lions Head area Physician 34

Case 2. Services - Grey Bruce Health Services Existing Services COPD REACH Team COPD Readmission Avoidance Project COPD Care Services and Support (Outpatient smoking cessation; lung health program) South West Self-Management Program New Planned Work Teach back methodology; HCP role refinement educational material review; emotional support Proposed EMS Study (EPIC) Smoking Cessation Project (Hospital-based) Discharge Redesign Project 35

Case 3. Health PEI Respiratory Therapist Coordinator Emergency Health Services Primary Care Provider Patients & Families Respirologist Palliative Care Mental Health Smoking Cessation Program Management Spirometry equipment company Pharmacists RT and PT Physician and/or NP Patients & Families Primary Care Nurse Social Work Discharge planner Mental Health worker Home care services Allied Health Home care Provincial management ER Department Health PEI - Carolyn Harbourside Health Center Susan 36

Case 3. Health PEI Current status in Primary Care Patients with COPD (suspected and confirmed) are referred to the Primary Care Nurses (PCN) Follow the Canadian Thoracic Society Guidelines PCN case manage Performs spirometry testing in the family physician s office Provides 1-on-1 education to the patient (and family as needed) Provides group education to patients and family (this is not occurring in all networks yet) 37

Case 3. PHN case management cont. Develops action plan with the patient and collaborating physician Helps co-ordinate community and other services as needed Offers smoking cessation support and referrals to addiction programs Follows up PRN and yearly. Harbourside hospital admissions, LOS in hospital and readmission rates have gone down since this work has started 38

Case 3. Health PEI Lessons Learned/Future Needs Need a provincial coordinator Mainly able to service those patients who s family physician has signed on with the network as collaborating physicians; need to expand this service to all patients within the networks Need better form of communication between RN and physician s who are housed outside of the health center Need for improved coordination of community, primary care, and acute care services Continuation and increased data collection; both quantitative and qualitative 39

Case 3. Services - Health PEI Harbourside Health Center Existing Services Spirometry COPD education to clients and families New Planned Work Case manager to coordinate care for familiar faces within the province. New position recently filled. Health PEI Existing Services COPD Inpatient care pathway has been developed COPD primary care program with standardized processes New Planned Work Hospital-Primary Care transition Role clarity of diversity of service providers to minimize duplication and ensure patients and their families are at the center of action plan development Dedicated support to plan, develop and implement next steps is required. This includes stakeholder engagement, development of materials and resources, communication and training 40

Discussion & Questions? Please submit your comments/questions electronically using the Chat Box on the bottom right of your webinar screen. 41 41