Triple Aim in Health Care Strategic Role of CHCs

Lyn Linton, Executive Director Julia Swedak, Director of Quality & Decision Support

Gateway Community Health Centre

Presenter Disclosures

RELATIONSHIPS WITH COMMERICAL INTEREST None

DISCLOSURE OF COMMERCIAL SUPPORT This session has received no commercial support

MITIGATING POTENTIAL BIAS None

ACKNOWLEDGEMENTS

Institute for Healthcare Improvement (IHI) – Triple Aim Framework

Rural Hastings HealthLink (RHHL) South East Local Health Integration Network Association of Community Health Centres (AOHC) ThinkLink Graphics

WHERE YOU LIVE MATTERS

Marginalization Indexes – Rural Hastings HealthLink

Economic Deprivation Index Social Deprivation Index

Combined Deprivation Index

TRIPLE AIM FRAMEWORK

POPULATION HEALTH

PATIENT EXPERIENCE

COST

Population Health

Reduction of Costs

PATIENT

Patient &

Provider Experience

Adapted from: IHI Triple Aim Framework

CHC MODEL OF CARE & WELL BEING A Shared Purpose

Adapted from AOHC Model of Health and Wellbeing

Building the Bridge

Healthcare Sectors

Provincial/ Regional Integrated Healthcare System

Health System Transformation Health Links

PRIMARY CARE

Transitions In Care Integrated Care Systems

System Thinking, Planning, Barriers & Alignment

Focus on 1- 5% Medically & Socially Complex

Population Needs Based Health Equity SDH

Patient Experience Care Coordination Plans

Patient Goals Patient Stories Patient Forums

Accountability Performance / Knowledge Management

Education / Continuous Improvement

System Cost Shifting from Acute Care to Primary Care System

Decreasing ED & Hospital Utilization

Transitions in Care

Primary Care

Social Support Services

CCAC

CSS

A&MH

Specialists

Hospital

RHHL Approach

Population Health

Reduction of Costs

Patient & Provider

Experience

Improved health outcomes Seamless Transitions System Integration

Return on Investment

Integrated Plan of

Care

Medically Complex

Socially Complex

Age Material & Social Deprivation Medical Complexity

Listening and Understanding the Patient Experience Improving Patient Experience through system integration, Care Coordination & Navigation Maximize provider skill and time Improve quality, communications and patient confidence in provider

Knowledge Management ↓ ED Visits ↓ Hospitalization Right Patient, Right Place, Right Time

Adapted from: IHI Triple Aim Framework

Navigating Transitions in Care The Role of System Navigation in Primary Care

A Registered Nurse System Navigator was embedded in each of our four RHHL sites. The role of the System Navigator focuses on:

Identifying complex patients, Collaborating with primary care providers, Acting as a liaison between transition points in care, Follow up with patient’s post-discharge from hospital, Ensuring that medication reconciliation has been completed after transitions in care, Identifying, integrating, and addressing social economic factors impeding the patient’s ability to achieve optimal health outcomes, Facilitating shared-care planning between transition points of care, Monitoring and evaluating the patient’s care coordination plan against expected outcomes, Advocating on behalf of the patient/family/caregiver, and Creating spread across the continuum of care by engaging practitioners and broader health and social sector partners.

Patient Experience – Patient Voice

Care Coordination Plans Patient Story Boards

Listening to Patient Experience – Engagement

Patient Story Board

15

Patient Engagement Forums

15

Conversation Guide

Having the Conversation

KNOWLEDGE MANAGEMENT

Accountable to Communities and Funders

Capture & Measure Work

Develop and Implement Meaningful Indicators

Reporting and Evaluation

E-tools

Data Discipline

and Integrity

CHC

Regionally Integrated Model

Data Management Coordinators in 4 Primary Care Sites

Indicators & Common

Definitions

Data Discipline

& Integrity

Reporting &

Evaluation

RHHL Knowledge Management

Quality and Continuous

Improvement

Information Flow Across

Sectors &

E-Connectivity

Privacy

RHHL Complex Client Criteria

4 or more co-morbidities

3 or more Emergency Department visits in the past year

2 or more hospital admissions in the past year

5 or more prescription medications

Palliative/End of Life

RHHL Patient Population

RHHL Patient Population

23

RHHL Complex Patient – Age Demographics

0

20

40

60

80

0-17 18-59 60-79 80+ Age Group – RHHL Q4 Data , n=151

Number of Patients in each age group

RHHL Complex Patient - Co-Morbidities

0% 10% 20% 30% 40% 50% 60% 70% 80%

RHHL Q4 Data, n=151

% of Patients with Complex Conditions

RHHL Patient Social Complexity - Q4 14/15

26

Patient Experience with System Navigator – Q4 14/15

System Navigator Explanation of Treatments

85% Very Good

System Navigator Listening to Patients

85% Very Good

Time Spent with System Navigator

88% Very Good

System Cost – Hospital Diversion

ED Utilization

652

87

Visits Reduced

by 87%

Pre Care Coordination-Data Collected for each patient in the previous year

Post Care Coordination-April 1, 2014- March 31, 2015

System Cost – Hospital Diversion

197

33

Complex Patient Hospital Admissions Pre and Post RHHL Care Coordination Plans

Admissions Reduced by

83%

Hospital Admissions

Pre Care Coordination-Data Collected for each patient in previous

year

Post Care Coordination-April 1, 2014-March 31, 2015

Return on Investment

Complex Problem – shift mindset to

systems approach

Focus on relationships

between organizations

– Joint approach and agreed actions

Backbone Support –

Infrastructure to support the

initiative (people, skills, structure)

Continue to influence

primary care model for system change

Continuous improvement

and Communication

Lessons Learned…

Shared performance

and knowledge

management

CHAMPIONS HAVE A RESPONSIBILITY IT’S YOUR TIME

Lead from experience Teach how to scale, spread and build capacity

Stewards for Change

Adaptive Leadership

LLINTON@GATEWAYCHC.ORG

JSWEDAK@GATEWAYCHC.ORG