Post on 14-Jan-2015
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Regional Integrated Complex Patient Care Planning (RICP2)
Helping Those Who Frequently Revisit Multiple ED’s BC Quality Forum 2014
February 27, 2014
Laura Cross, Project Manager, Integrated Primary, Acute & Community Care, Vancouver Coastal Health Roy Ang, Clinical Supervisor, Vancouver Community Older Adult Mental Health & Addiction Services, Vancouver Coastal Health
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What we plan to share today…. RICP2 – background Case study example Successes, Challenges Next Steps Questions & Discussion
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Opportunity Knocks
ED’s working mostly in
isolation with inconsistent care planning process
EDs identifying, partnering with the
patient, primary care, home health, mental
health teams to develop a
sustainable shared care planning
process
Wrap Around Care
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Who are the Familiar Faces?
Starting the PDSA Journey
Secure Point Persons • ED’s (ED PP) • Community (CPP)
Shared Care Plan (SCP) Tool based on IHI • Multidisciplinary for
all Clinicians • My Health for Patient
Coordinated & Initiated
SCP’s • Care
Conferencing • Developed by
Community PP • Registry at ED
Standard Operation Procedures Evaluation & Sustainment Planning
2 Trials of developing SCP’s for FF’s from each Community of
Care/ED site
Familiar Faces at ED With Shared Care
Plan
FF presents
at ED and is
flagged as
having a SCP
SCP is pulled and
put on chart
Medical Staff
use SCP
EDPP partners with
CPP if changes are needed to be made to SCP
SCP is developed & coordinated by Most Responsible
Clinician in Community
7 A CASE STUDY
8 The Hilly and Winding Journey
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Sustaining This Work
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SUCCESSES
Quick Wins
Heart Warming
Culture Shift
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CHALLENGES & BARRIERS
Processes Systems Professionals Patients
Integration Care Coordination Flexible Services Communication
Consistent Messaging
Intensive Resources It’s About Time! Patient Centered
Behaviour Change Required All
Round
Leadership Support
Systems & Processes Clout! Preventative
KEY MESSAGES
Next Steps
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Messaging Out to All Relationship Building Plan for Sustainment Evaluate & Track Refine Processes
Discussion & Questions?
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