Published on March 7, 2014
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
What we plan to share today…. RICP2 – background Case study example Successes, Challenges Next Steps Questions & Discussion 2
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 3
Who are the Familiar Faces? 4
Starting the PDSA Journey Shared Care Plan (SCP) Tool based on IHI Secure Point Persons • ED’s (ED PP) • Community (CPP) Coordinated & Initiated SCP’s • Multidisciplinary for all Clinicians • My Health for Patient • Care Conferencing • Developed by Community PP • Registry at ED 2 Trials of developing SCP’s for FF’s from each Community of Care/ED site Standard Operation Procedures Evaluation & Sustainment Planning
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 SCP is developed & coordinated by Most Responsible Clinician in Community EDPP partners with CPP if changes are needed to be made to SCP
A CASE STUDY 7
The Hilly and Winding Journey 8
Sustaining This Work 9
SUCCESSES Quick Wins Heart Warming Culture Shift 10
CHALLENGES & BARRIERS Processes Systems Professionals Patients 11
Integration Care Coordination Flexible Services Communication Consistent Messaging Intensive Resources It’s About Time! Patient Centered Behaviour Change Required All Round Leadership Support KEY MESSAGES Systems & Processes Clout! Preventative
Next Steps Messaging Out to All Relationship Building Plan for Sustainment Evaluate & Track Refine Processes 13
Discussion & Questions? 14
THANK YOU! Laura.email@example.com Roy.firstname.lastname@example.org 15
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