Published on March 7, 2014
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Care Conference • Challenges – Multiple databases, outdated info on file – Coordinating multiple teams – Patient stability to participate in conference i.e. chronic inebriation • Improvements – Patients prioritize their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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