Shared Care Planning for Complex Patients

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Information about Shared Care Planning for Complex Patients
Health & Medicine

Published on March 7, 2014

Author: bcpsqc



This presentation was delivered in session A3 of Quality Forum 2014 by:

Venie Dettmers
Leader, Health Services Planning, Primary Health Care
Vancouver Coastal Health

Alida Fernhout
RN, Downtown Community Health Centre
Vancouver Coastal Health

Manda Harmon
Clincial Coordinator, Downtown Community Health Centre
Vancouver Coastal Health

Shared Care Planning for Complex Patients Alida Fernhout, Manda Harmon & Venie Dettmers BC Quality Forum February 27, 2014

Presentation Overview • What We Were Trying to Accomplish • The Target Population • Care Conferencing and Shared Care Planning Experience • Outcomes 2

What we were trying to accomplish – connect/coordinate services VCH Primary Care Clinics in Downtown Eastside St. Paul’s Hospital Emergency Department Other Community Clinicians Community Agencies

The Target Population • High Users of the Emergency Department Project Focus: 89 People who visited St. Paul’s Hospital ED 10+ in 2011/12 year & known to VCH GP or NP in the Downtown Eastside Primary Care Clinic Patients With Care in Cohort Plan Downtown Community Health Centre 39 11 Vancouver Native Health 23 9 Pender Community Health Centre 10 2 Strathcona Mental Health Team 15 3 Primary Outreach Team 2 1 89 26 4

Downtown Community Health Centre Clients - 39 Problems % /(Number of Patients) Substance Use – alcohol, crack or cocaine, non-beverage alcohol use 82% / (32) Mental Health Issues – childhood trauma, depression, post traumatic stress disorder 87% / (34) Physical Health Issues – hepatitis C, cardiac issues, respiratory & COPD 100% / (39) Social Issues – housing concerns/unstable housing, poor support systems 97% / (38) 5

Downtown Community Health Centre Care Conference Process Chart reviews, contact other care providers Discuss health care goals Identify all the players Meet with the patient Care Conference

Care Conference • Challenges – Multiple databases, outdated info on file – Coordinating multiple teams – Patient stability to participate in conference i.e. chronic inebriation • Improvements – Patients prioritize their concerns – “I’ve never been asked before” – Choice for them to attend ~ most chose not to attend – Open communication channels among multiple partners 7

Downtown Community Health Centre Care Planning Process Case conference Care Plan Follow-up Identify and discuss health goals Share action plan with all team members, including SPH ED Nursing coordinator to follow-up at 3 month intervals Place action plan at front of chart Follow-up with patient: change in goals, satisfaction Document action plan and assign roles

Care Planning • Challenges – Difficult to inform all clinic staff – Care plan not shared with staff at buildings & agencies – Multiple databases; no central online location to share careplan • Improvements – Action plan is patient driven – Shared work load – Improved communication 9

Sustaining Best Practice in DCHC • Clinical Coordinator is responsible for overall tracking • Monthly rounds held - to identify new clients and update team on existing clients in the list • Any staff member can request a patient be added to list for care conferencing and planning – central (paper) list located in chart room • Primary care nurse/nurse coordinator is identified for each client future planning and follow-up; ‘Officially’ provide nurse with dedicated time to work on complex patients. • Complex care conferencing is organized and care plan developed following process developed in pilot • Care plan is stored in EMR and emailed to other teams involved • Challenge – time challenge for current nursing staff to fulfill role and maintain follow-up 10

Impact on Use of Services – 26 with care plan 12 Months Before Start of Pilot 12 Months During Pilot % Change Number of ED Visits 576 435 -24% Number of Hospital Admissions 51 39 -24% Average Length of Stay Days 6.3 7.5 +19% Number of GP or NP Visits 608 710 +17% 11

Changes on Clients – Provider Perspective • Prevented patients from going to ED - deeper positive relationship with client; also introduced patient to 811, Seniors Crisis Line and other resources • By bringing the right people together, prevented crisis or adverse events • Not noticed any changes 12

Provider Experience Feedback • Able to be more thorough and have more structured approach • Excited that somebody is doing the coordination/being the orchestra leader • People tend to take more responsibility with face to face conference; there is better communication; • First time we targeted community agencies and ED although we’ve done case conference before • Challenging to getting people to the table; GPs are part-time. • Resources needed to address patient issues––mental health housing; getting into detox right away; outreach support e.g. to get to appointment 13

Thank You 14

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