Regional Integrated Complex Patient Care Planning: Familiar Faces Helping Those who Frequently...
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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 1
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This presentation was delivered in session A3 of Quality Forum 2014 by: Laura Cross Project Manager, Integrated Primary and Community Care Vancouver Coastal Health Roy Ang Clinical Supervisor, Vancouver Community Older Adult Mental Health Vancouver Coastal Health
Transcript of Regional Integrated Complex Patient Care Planning: Familiar Faces Helping Those who Frequently...
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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3
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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