Care Coalition: Integrated Case Management Project ... · Planning and implementing solutions...
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Contact Kelly Walker Tel:02 8717039 Email: [email protected] Acknowledgements Conclusion Lessons learned during the Implementation Phase: Case for change . South West Sydney Local Health District Drug Health Services (SWSLHD DHS) Goal The goal of the Care Coalition project is to reduce client risks in the Opioid Treatment Program Method Clinical Redesign Methodology was used for the Care Coalition Project and the following activities were conducted: Sustaining change • Sponsorship • Staged Implementation • Participation, engagement • Ongoing Monitoring & Evaluation • Grouped solutions being managed by the same working party. Objectives: By December 2016 1. Improve access to the services (increase number of admissions to the service each month) by 5% 2. Increase number of clients successfully transferred to community pharmacy service by 25% 3. Improve client satisfaction &health outcomes by 10% 4. Reduce DNA rate for case management appointments from 80% to 50% 5: 80% of clients have a signed collaborative care plan Planning and implementing solutions Survey monkey used to get feedback from 16 OTP staff & 160 clients Dr to Dr interviews with 8 GP s 30 Patient & Carer Interviews (PaCE) 21 pharmacists input by Survey Monkey 30 file audits Process mapping of client journey 100% (n=8) GPs, 55% (n=21) pharmacists and 93%(n‐19) staff identified need for effective communication. Ineffective communication is also partly responsible for clients DNA rate “I wouldn’t know who my case manager is …But I can come and ask for help…It could help if there was someone to talk to regularly” “I don't feel we get listened a lot here” (OTP client) Clients identified various assistance they need from case managers(CM). Only 17 clients identified needing nothing from CM Care Management Framework encompassing: Service Communication and Liaison including: Centre Operations: Staff Competency Development : • Client Identification Guideline • Risk Assessment • Assessment Pathway • Care Coordination Pathway • Transfer of Care • Clinical Review • Service Liaison • Service Email • After Hours • Social Media • Dosing Hours • Lifestyle & Group Programs • Client Safety at the Clinics • Maintenance of the Facility • Implement ComPurS • Staff Competency • Professional Development • General Manager DHS ‐ Project Sponsor • Redesign Program Manager • Communication with Purpose Strategy (ComPurS) Manager • SWSLHD Executive team • Project Steering Committee members • ACI Centre for Healthcare Redesign 2015 • All Stakeholders • Our consumers • SWSLHD Drug Health Service Admin Staff • Kelly Walker, Angela Fasheun and Ravina Raidu Diagnostics Introduction of an iDose Results Solution owners identified & finalised Risks & issues identified – mitigation strategies in place Implementation Governance Structure established Started implementation of quick wins and stage one solutions Data collection strategy to monitor progress & measure outcomes finalised – data now available Assertive follow up for DNA clients established Introduction of global care plan forms Business process for 3 monthly review established ‐ auditing underway High Risk SPOM assessments underway More communication and discussion of clients Clinical reviews and high risk meetings occuring at daily handover using ISBAR Focus groups with staff Solution validation survey Key Messages: “Communication needs to improve to ensure that the clients issues are understood”(community pharmacist) “at least 50% of the patient need case management but they don’t have a case manager” (GPs) “We need effective follow‐up of patients with complex medical and psychosocial needs”(OTP staff) Mortality and morbidity reviews of Root Cause Analysis’s (RCA) over the past two years, highlighted lack of evidence of co‐ ordinated case management practice and fragmented communication. 750clients are registered currently on OTPs, file audits indicates DNA can be as high as 80% Care Coalition: Integrated Case Management Project Implementation Lack of clear risk assessment tools & framework Limited resources in the service Inconsistent assessment, documentation & communication of information Varied consistency of case management practice Access to & consistency of appropriate & specialist education and training Limited surveillance to ensure client safety at the centre Previous Patient Journey- Process map Anticipated New Patient Journey: Coordinated Care in Coalition with the Client • An understanding of Installation (set it up ready to go) versus implementation of change and evaluation of outcomes • Impact of Implementation climate: Organisational stress on ability to implement solutions • Impact of Organisational readiness: Multiple concurrent changes • Interest was shown by project team from another region and support provided via emails, teleconferencing and telephone • Sponsorship support and key stakeholders engagement to success of the project installation phase and would play a key role in sustaining change • Presentation on Engaging patient experience for improvement at Change Management & Redesign Community of Practice‐ Liverpool Kelly Walker Angela Fasheun Ravina Raidu “(changed hours) allows me to stay away from other clients who are trouble” Client Satisfaction survey – Dosing Hours Pilot Solution Failure to Attend Rate dropped from 80% pre project to 5% in all centres 80% of clients now satisfied with the service hours
Transcript of Care Coalition: Integrated Case Management Project ... · Planning and implementing solutions...
ContactKelly Walker Tel:02 8717039 Email: [email protected]
AcknowledgementsConclusionLessons learned during the Implementation Phase:
Case for change
.
South West Sydney Local Health District Drug Health Services (SWSLHD DHS)
GoalThe goal of the Care Coalition project is to reduce client risks in the Opioid Treatment Program
MethodClinical Redesign Methodology was used for the Care Coalition Project and the following activities were conducted:
Sustaining change
• Sponsorship• Staged Implementation•Participation, engagement•Ongoing Monitoring & Evaluation
•Grouped solutions being managed by the same working party.
Objectives: By December 20161. Improve access to the services (increase number of admissions to the service each month) by 5%2. Increase number of clients successfully transferred to community pharmacy service by 25%3. Improve client satisfaction &health outcomes by 10% 4. Reduce DNA rate for case management appointments from 80% to 50% 5: 80% of clients have a signed collaborative care plan
Planning and implementing solutions
Survey monkey used to get feedback from 16 OTP staff & 160 clients
Dr to Dr interviews with 8 GP s
30 Patient & Carer Interviews (PaCE)
21 pharmacists input by Survey Monkey
30 file audits
Process mapping of client journey
100% (n=8) GPs, 55% (n=21) pharmacists and 93%(n‐19) staff identified need for effective communication. Ineffective communication is also partly responsible for clients DNA rate
“I wouldn’t know who my case manager is …But I can come and ask for help…It could help if there was someone to talk to regularly”
“I don't feel we get listened a lot here” (OTP client)
Clients identified various assistance they need from case managers(CM). Only 17 clients identified needing nothing from CM
Care Management Framework encompassing:
Service Communication and Liaison including:
Centre Operations: Staff Competency Development :
• Client Identification Guideline
• Risk Assessment• Assessment Pathway
• Care Coordination Pathway
• Transfer of Care
• Clinical Review • Service Liaison• Service Email• After Hours• Social Media• Dosing Hours• Lifestyle & Group Programs
• Client Safety at the Clinics
• Maintenance of the Facility
• Implement ComPurS• Staff Competency• Professional Development
• General Manager DHS ‐Project Sponsor
• Redesign Program Manager• Communication with Purpose
Strategy (ComPurS) Manager• SWSLHD Executive team • Project Steering Committee
members
• ACI Centre for Healthcare Redesign 2015
• All Stakeholders• Our consumers • SWSLHD Drug Health
Service Admin Staff• Kelly Walker, Angela
Fasheun and Ravina Raidu
Diagnostics
Introduction of an iDose
Results Solution owners identified & finalised Risks & issues identified – mitigation strategies
in place Implementation Governance Structure
established Started implementation of quick wins and stage
one solutions Data collection strategy to monitor progress &
measure outcomes finalised – data now available
Assertive follow up for DNA clients established Introduction of global care plan forms Business process for 3 monthly review
established ‐ auditing underway High Risk SPOM assessments underway More communication and discussion of clients Clinical reviews and high risk meetings occuring
at daily handover using ISBAR
Focus groups with staff
Solution validation survey
Key Messages:“Communication needs to improve to ensure that the clients issues are understood”(community pharmacist)“at least 50% of the patient need case management but they don’t have a case manager” (GPs) “We need effective follow‐up of patients with complex medical and psychosocial needs”(OTP staff)
Mortality and morbidity reviews of Root Cause Analysis’s (RCA) over the past two years, highlighted lack of evidence of co‐ordinated case management practice and fragmented communication.
750clients are registered currently on OTPs, file audits indicates DNA can be as high as 80%
Care Coalition: Integrated Case Management Project Implementation
Lack of clear risk assessment tools & framework
Limited resources in the service
Inconsistent assessment, documentation & communication of information
Varied consistency of case management practice
Access to & consistency of appropriate & specialist education and training
Limited surveillance to ensure client safety at the centre
Previous Patient Journey- Process map
Anticipated New Patient Journey: Coordinated Care in Coalition with the Client
• An understanding of Installation (set it up ready to go) versus implementation of change and evaluation of outcomes
• Impact of Implementation climate: Organisational stress on ability to implement solutions
• Impact of Organisational readiness: Multiple concurrent changes
• Interest was shown by project team from another region and support provided via emails, teleconferencing and telephone
• Sponsorship support and key stakeholders engagement to success of the project installation phase and would play a key role in sustaining change
• Presentation on Engaging patient experience for improvement at Change Management & Redesign Community of Practice‐ Liverpool
Kelly WalkerAngela FasheunRavina Raidu
“(changed hours) allows me to stay away from other clients who are trouble”
Client Satisfaction survey – Dosing Hours Pilot Solution
Failure to Attend Rate dropped from 80% pre project to 5% in all centres
80% of clients now satisfied with the service hours
