Patient Engagement: One Health Link’s Perspective Priest-Feb26.pdfBruno Geremia Co-chair,...
Transcript of Patient Engagement: One Health Link’s Perspective Priest-Feb26.pdfBruno Geremia Co-chair,...
Patient Engagement: One Health Link’s Perspective
North East Toronto Health Link
Presented by: Lisa Priest, Director, North East Toronto Health Link (NETHL) Stephanie Greco, Member, Patients’ Advisory Council, NETHL Bruno Geremia Co-chair, Patients’ Advisory Council, NETHL Walter Leahy, Liaison Care Coordinator, TC CCAC, NETHL
Presented at: Longwoods Ways & Means | Health Links Feb 26, 2015
North East Toronto Health Link
Continuum of Engagement Levels of Engagement
Consultation Involvement Partnership and Shared Leadership
Direct Care
Better Care System
(Better Tracking and Triage for Equitable, Reliable Care)
Information Management System - Better Care - that identifies, tracks and notifies Health Links patients in real time
Patients are enrolled and engaged simultaneously
Health Links patients identified in real-time develop the care plan with coordinators/clinicians
Governance
Patients’ Advisory Council
Unmet needs of Health Links patients and their caregivers are brought to Patients’ Advisory Council
Caregiver is co-chair of Patients Advisory Council and sits on NETHL Advisory Council
Questions for program evaluation created by Patients’ Advisory Council; changes made based on results
Policy
“Conscience of Health Links” talks
Recommendations driven by patients
Patient stories highlighting issues and system solutions
Patient and caregiver-driven priorities
Factors influencing engagement: Patient (beliefs about patient role, health literacy, education) Organization(policies and practices, culture) Society(social norms, regulations, policy)
Adapted from: Carman, K., Dardess, P., Maurer, M., Sofaer, S., Adams, K., Bechtel, C., & Sweeney, J. (n.d.). Patient And Family Engagement: A Framework For Understanding The Elements And Developing Interventions And Policies. Health Affairs, 2013, 223-231.
Framework for Patient Engagement
3) Administrative Functions
Update Notification
Settings
1) Identification & Reporting 2) Notifications
Notify NETHL Program/Care Coordinator
Notify Care Team (internal/external)
Identification by Classification Algorithm
Display on System Report(s)
a) Initial Notification
c) Provider Notifications
Direct Care: Health Link Better Care Program Initiation: Emergency Department
BETTER (Better Tracking and Triage for Equitable Reliable) Care System
Future Phases (Community Partners)
Patient is engaged in the ED by the TIP nurse or Sunnybrook staff or CCAC coordinator (if already in their care) that she/he qualifies for additional services as part of a Better Care system and that their primary care physician will be notified and they may opt of that service. We can then communicate risks to patients of opting out and request that family doctor be contacted about care planning without patient. Brochures will be mailed out to patient. NETHL Office is notified of Enrolment status. Should the Patient Opt Out, process ends, but will be revisited at future ED Visits. If patient not contacted while in ER ( time of day, weekend or staff not available) then patient will be contacted at home by one of the above to offer the program.
If patient does not opt out, primary care physician is then notified by TIP nurse or
NETHL office that the patient has been identified and that a Care Coordinator (where
available) may be assigned or additional services may be available through NETHL
partners. Assessment is scheduled through Care
Coordinator/PCP. Assessment determines Care Team Requirements. Care Team augmented through referral request or consultation (via
PCP/TC CCAC Care Coordinator). TC CCAC will contact patient in real-time
NETHL is notified of additions to Care Team.
PATIENT ENGAGEMENT & ENROLMENT
PROCESS/OPERATIONS
Better care
patients
Frailty patients
ICCP patients
ED Care Coordination
Better Care System - Identification of target population - Flagging - Notification
Better Care System
Quality Improvement: Health Quality Ontario
Patient Co-design
Source: Smart Health Messaging NETHL’s Patients’ Advisory Council
Health Links Program Evaluation Answers to questions developed by Patients’ Advisory
Council Patient interviews, Feb.
20th
“There’s somebody that needs the emergency service and it’s not me”
“I thought [the Better Care] program was wonderful. They had asked me questions that hadn’t been asked before”
“My goal really is to get back on track- to have a normal day, I don’t know what it is. It’s been like that for the last 5, 3 months. It’s a long time.”
Stephanie Greco Member, Patients’ Advisory Council,
North East Toronto Health Link Stephanie is a member of the Patients’ Advisory Council of the North East Toronto Health Link. She has been involved in co-designing a coordinated care plan, consulting on a patient workbook and helping guide questions for Health Links patients who are identified and provided care plans in real-time. Most recently, she created an “All About Me” patient card to help providers communicate better with patients. As someone who has interacted in the health care system since birth, she is expert in understanding the gaps that can occur. Through her work, she hopes to make the patient voice heard from the hospital to the community.
• Patient since the day I was born
• Providers talking to family members, not me
• Asked the same question over
• Instead try:
• What should I know about you? • What are your goals? • How can I help?
Life as a Patient with Complex Needs
“All About Me”
Bruno Geremia Co-chair, Patients’ Advisory Council
North East Toronto Health Link Bruno is the co-chair of the Patients Advisory Council. In this capacity, he has led the group to co-design a care plan, enforced governance standards and insisted on transparency of information for patients and caregivers. He comes to this role with significant experience: as the father and a caregiver of a child – now an adult - with complex medical issues, Bruno knows well the gaps that can occur from hospital to community and now, palliative care. Bruno has worked with community and hospital organizations to better integrate the family, patient and caregiver voice to the health care system. He has spent almost two decades in this role, working as a family leader at Holland Bloorview, co-chairing the Family Advisory Committee from 2008 to 2012.
Walter Leahy Liaison Care Coordinator, TC CCAC,
North East Toronto Health Link
Determinants of Health
Patient
Social factors English is not first language Poor social supports
Socially isolated
Economic Factors Limited
finances/income
Physical environment
Lives in Toronto Supportive Housing
Limited Mobility
How We Worked Together with the Patient:
TC CCAC Liaison Care Coordinator (most responsible provider)
Core Care Team(approaches patient in Sunnybrook ED and initiates Care plan)
Patient in the ED
Telemedicine IMPACT PLUS
Nurse
Women’s College Hospital
(Pain Clinic)
SPRINT Supportive
Housing Virtual Ward Meals on
Wheels Family Doctor ---- ----- ----- -----
-----
Appreciation North East Toronto Health Link
Patients’ Advisory Council • Executive Lead: Malcolm Moffat, EVP Programs, Sunnybrook
• Medical Lead: Dr. Jocelyn Charles, Chief, Family & Community Medicine, Sunnybrook
• Administrative Lead: Lisa Priest, Director, NETHL (also leads patient engagement) NETHL Program Office: • Linda Jones-Paul • Kittie Pang • Adwoa Rascanu
Better Care Project Team • Richard Mraz • Navin Goocool • Ashley Silver • Ken Nwosu • Anita Tang • Mark Fu
NETHL Partners • Anne Johnston Health Station • Bellwoods Centres for Community Living • Don Mills Family Health Team • Flemingdon Health Centre • Providence Healthcare • Scarborough Academic Family Health Team • Sunnybrook Academic Family Health Team • Thorncliffe Neighbourhood Office • Toronto Rehab Toronto • Toronto Paramedic Services (EMS) • TC-CCAC • SPRINT Senior Care
• Kurt Rose, Director, Corporate Strategy & Information, Sunnybrook • Jeff Curtis, Chief Privacy Officer, Sunnybrook • Rebecca Morison, Legal Counsel, Sunnybrook Special thanks: Dr. Joshua Tepper