Regional Integrated Complex Patient Care Planning: Familiar Faces Helping Those who Frequently Revisit Multiple Emergency Departments

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Information about Regional Integrated Complex Patient Care Planning: Familiar Faces...
Health & Medicine

Published on March 7, 2014

Author: bcpsqc



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

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


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


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