Integrated Comprehensive Care – Bundled Care Pilot Project

Hospital – Home a Vertical Integration Concept

Patient Value Statement"Please help me fully understand my health challenges so that I can make informed choices about my care.”

“I would like timely care when it is necessary, in the most suitable location.”

“I want to be clear about what will happen next so I can prepare properly and try to worry less.”

“Help support my recovery at home."

Unique opportunity to demonstrate an alternate model of care• The St. Joseph’s Health System (SJHS) includes an Acute Teaching Hospital, Long-Term Care Facilities and a Home Care provider in the same city

• Perfect setting to demonstrate and evaluate an alternate model of care.

– Better, Faster, Cheaper

• The SJHS has the governance, management and service delivery alignment to act as an early adopter of this approach.

• Local Health Integration Network (LHIN) support for this project

Alignment with Provincial StrategiesCommission on the Reform of Ontario’s Public Services -2012

• Co-ordination across a continuum of care• Patient-centered care• System centered on patients, not institutions or providers• Hospitals make discharge summaries available electronically to

other care providers• Improving access to care: remote communities

Key Principles• Simple for the patient• Patient knows what will happen next• Focus on what adds value to the patient• Improve the patient experience

Accountable Care Organizations• Accountable for overall cost and quality of care

• Strategic integration of care

• Manage the full continuum of the patient’s care

• Performance measurement

• Holds health systems and providers accountable for care

Primary Care• Primary care physicians key stakeholders in this

project

• Integrated delivery of care with hospitals, specialty services and home care

• Critical role in supporting the patient after discharge, and collaborating with the broader healthcare team to keep patients at home, prevent ER visits

Model: Total Joint Replacement

Patient

Integrated Care Coordinator

Patient PopulationThree patient groups with broad applicability in Ontario

• Total Joint Replacements – 500/year

• Thoracic Surgery, Complex Pleural Space – 450/year

• Chronic Diseases (COPD, CHF) – 120/year

Regional Program: Thoracic Surgery

Hamilton: 35%*

Greater LHIN region: 65%*

*April 1, 2012 – June 30th 2012

3rd Party Program Evaluation – PATH group at McMaster University

Hospital 60 daysBefore Surgery

Data Validation

Home careHome CareOutpatient

ER visitsReadmissions

Length of StayDiagnosis

Patient Satisfaction Questionnaires

Pre-hospital

Admission

HomecareIn hospital

60-days

Questionnaire 2

Transition Home & Homecare

Discharge

Questionnaire 1

Pre-hospital & Inpatient Care

Referral

Early ResultsElective Hip and Knee Replacement

SJHHJan-Mar 2012

OntarioJan-Mar 2012

SJHHApril-May 2012

Acute LOS 4.2 4.2 3.8

Rehab referral rate 12.2% 12% 8.5%

Thoracic SurgeryApr-Dec 2011 Mar-July 2012

SJHH Average Length of Stay 7.8* 5.1

*Hay Benchmark (Canadian Academic Hospitals): 7.6

Project Successes• More efficient home visits• Remote electronic access to the patient medical record• Central contact number for patients: access to the team 24/7• Integrated Carepaths (hospital to home)• Standard templates for clinical documentation• Cross-training/knowledge transfer• Team integration• Total Joint Replacement:

• Physiotherapy within 24 hours of discharge

Challenges• Building confidence and trust within the team

• Consistent messaging to patients regarding discharge date

• Technology implementation

Patient Experience/Engagement

60 day follow up calls: overwhelmingly positive feedback

• Easy and timely access to the team 24/7

• Coordination of care and support has been very evident

• Patient concerns are directed to the most appropriate member of the healthcare team

• Feel supported after discharge, less anxiety

Enablers of success – Team

• Process mapping, review of current state

• Knowledge transfer and cross-training

• The “Expert Team”

• Empowered Team:

• Responsibility with Authority

Enablers of success – Communication

• Real-time access to patient information

• Remote access on mobile devices

• Email communication

• Pictures

• Skype

2 fundamental questions that

challenged the Team

“How do we provide the team with real-time patient-specific information before the patient leaves the

hospital?”

“How can we provide integrated care if everyone has their own discrete care plan and documentation?”

IT – Critical success factor for integration• The clinical team identified a common integrated health record

as a critical success factor

• If we were going to provide comprehensive care, we needed:• Common integrated care plan• Opportunity to communicate with other members of the

team

• Communicate information from the HOSPITAL to COMMUNITY

• Communicate and document all patient information during the community component of their care

Strategies to support electronic health record • We leveraged the St. Joseph’s Home Care information

system, Procura, as the platform to establish the electronic health record

• Devices used by the care providers in the home to support real-time, secured access to view and document in the patient health record

Content of the Health Record

Procura

Tracking Form

Contact Info

ClinicalDocumentation

VisitWorklo

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Patient Folder

ScannedDocuments

Contact

Information

TeamInteractions

Integration with Hospital and Family Physicians• Documents are scanned from the hospital record and

uploaded real-time to the Procura database

• Documents that are uploaded to Procura are also shared with the Family physicians

• Communication to the team from Family physicians is uploaded to the Procura database to be accessible to the entire team

Patient Tracking Tool• Living document that serves as a dashboard for all ICC clients

• Updated by the Integrated Care Coordinators in real-time

• The tracking form is maintained within the Home Care database

• All team members, Hospital and Home Care can access the database from any location on iPads, computers)

• Communicates the following information to the hospital and home care team, for each patient:• Clinical stream• Home care serves required after discharge• Expected length of stay• Discharge status

Investment in IT• Purchased iPads with 3G capability for each hospital and home

care team member ($20,000)

• Monthly data charges for remote access ($500/month)

• Blackberries for specific team members ($2,000)

• IT resource at STJH to configure/develop Procura ($22,000)

Total investment for 1 year: $50,000

Criteria for selecting the device

Cost-effective: approximately 30 team members will require access to the

system

Mobility: patients are located throughout the HNHB LHIN

Training: user friendly tool, limited training time

Battery life: required a device that would not need to charged during the

shift

Picture quality: pictures a routinely uploaded to the patient file to track

progress of wound healing for example

Access: required very quick access to the tool and software (time to turn on

and log on had to be minimal)

Secure access: patient information

Enablers of success – Access to Medical Care• Physician champions

• Family physician/Primary Care

• Outpatient clinic

• Direct admit to hospital

Enablers of success – Adaptability

• Build a carepath for the entire continuum of care

• Adjust the process with feedback from the entire team

• Ongoing self-assessment• Right care – right provider – right time

Collaboration with key partners• The HNHB LHIN and HNHB CCAC are members

of the ICC-Bundled Care Steering Committee

• A memorandum of understanding (MOU) between the HNHB CCAC, SJHH and SJHC outlines the funding transfer

Our Patients’ Experience

Opportunities for further spreadSt. Joseph’s Healthcare Hamilton

• Esophagectomy/Head and Neck surgery• Complex pleural space – malignancy• Hip fractures• Complex medical patient• Palliative care: extension of our clinical streams

St. Joseph’s Health System• St. Mary’s Hospital, Kitchener: COPD/CHF• St. Joseph’s Villa

Regional Programs• Thoracic surgery/CCO