Integrated Care for High Users of the Emergency Department

Venie Dettmers and Misty BathQuality Forum 2013February 28, 2013

Presentation Overview

• Provincial and VCH Context

• Target Population

• Aim and Measures

• Integrated Care Process

• Successes, Challenges and Emerging Themes

• Next steps

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All health authorities in BChave committed to a common goal

“British Columbians have the majority of their health needs met by high-quality community-based health care and support services.”

…to be achieved through the creation of an integrated system of primary care and community care services.

Development of Integrated Primary and Community Care (IPCC) system in all of VCH communities by 2015

Enhance Integration/ Care Coordination Across the Continuum of Care

VCH True North Goals and Integration Strategy

Target Population

General Population:• High incidence of poverty & homelessness• Open air drug trade• Higher morbidity• Higher use of services

IPCC Target Population:• High ED Users - People who visit St. Paul’s Hospital ED 10+ during the year & known to VCH GP or NP

Downtown Eastside

What we are trying to accomplish – integrate/connect/coordinate

services

Downtown Community Health Centre

St. Paul’s Hospital Emergency Department

Strathcona Mental Health

Team

Primary Outreach Services

Vancouver Native Health Clinic

PenderCommunity Health Centre

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How do we know that change is an improvement

July2012

July2013

What We Are Testing - Integrated Care Process

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Registry Summary/Tracking Tool – Integrated Care for High ED Use Clients (DTES IPCC)Last Updated: Jan. 31, 2013

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# of

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Number of ED Visits at SPH by DTES Core Residents Known to VCH GP/NP (Active Clients n=59)FY 2012/13 FY 2011/12 FY 2011/12 Average FY 2012/13 Average

Period 1 2 3 4 5 6 7 8 9 10 11 12 13 TotalFY 2011/12 73 86 76 92 101 93 91 84 126 99 74 58 68 1121FY 2012/13 51 87 71 55 68 63 87 73 33 57 645

July Dec

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Num

ber o

f Adm

issio

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Period

Number of SPH ED Admissions by DTES Core Residents Known to VCH GP/NP (n=59)

FY 2012/13 P1-P10 FY 2011/12 FY 2012 Average FY 2012/13 P1-P10 Average

July Dec

What’s Working/Success

• Multi-level engagement of stakeholders – Steering Committee , Working Group and Site Team Leads

• Buy-in from Directors and Managers

• Clear vision of integrated care

• Development of supporting clinical tools: registry, care plan template, case conferencing guidelines

• Integrated care process start-up and regular updates of registry

Challenges and Mitigating Strategies

Challenges Mitigating Strategies

Competing priorities e.g. accreditation

•Timeline adjusted

Some clients hard to find •Primary Outreach Services made available to help

Slow implementation/Resources needed

•Funding provided for additional RN•Fine-tuning of approach •Ongoing messaging and attention from senior leadership team

Emerging Themes

• Emergence of specific population cohorts with un-met needs

- Clients with excessive alcohol misuse

- Clients attending ED for socialization

- Clients with complex & unstable MH issues

- Clients with combination Addiction/Trauma/Axis II histories

- Aboriginal clients with addictions/trauma

• Lack of clarity i.e. program services, roles and time spent engaging high needs clients

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Next Steps

• Provide team education to dispel cross programs myths and misconceptions i.e. scope, roles etc.

• Examine how project work can transition to everyday clinical work = developing sustainability

• Continue to examine and explore solutions to system wide issues arising from this project work:

- Need for after hours community based service?

- Developing out-patient infusion clinics for soft skin infections?

- Liaising with existing community based outreach resources for wrap around support for complex clients?

Thank YouYour Questions?