Partners For Better Health

Transcription

1 Partners For Better Health

2 Presentation Outline History IHI Triple AIM Methodology Collaborative Case Management Complex clients Case Management & PBH Lesson learned Next steps 2

3 History IHI Triple Aim initiative started in Edmonton zone (focus on homeless population) 2015: Calgary initiative focused on complex clients in Calgary East Health Service area: a collaboration between Peter Lougheed Centre, East Calgary Family Care Clinic (ECFCC), Mosaic Primary Care Network March 2016: Home Care Sunridge Medical Gallery (SMG) and Addictions & Mental Health joined the initiative 3

4 What is the IHI Triple AIM methodology? Simultaneously: Improve the health status of a population Reduce per capita health care cost (or reduce the rate of cost increase) Improve individual s experience of care 4

5 How does IHI Triple AIM approach the challenge? Collaboratively learn the methodology 1. Identify a particular high-risk population that will be the focus of the work 2. Assess the assets and needs of this population by learning from patient experiences 3. Co-create and execute new care designs to test for impact and cost savings 4. Increase the scale and reach of successful care designs in fivefold to tenfold jumps Act with the individual, learn for the population. 5

6 Collaborative Case Management Home Care has a well established case management model Other community practice areas are adopting a case management approach Collaborative Case Management has a positive impact on health outcomes, experience of care, and reduction in per capita costs (Triple Aim outcomes) Collaboration between programs occurring at a leadership level & clinician level (Community of Practice) Cross ministry collaboration (Service Alberta now a partner) 6

7 Who are the complex? A small proportion of Albertans use significant healthcare resources 100% 75% 50% 25% Alberta Population Healthcare Resources 5% use 66% : Inpatient Emergency & Urgent care Family Physician & Specialty care 0% 7

8 PBH Focus Population Complex Older Adults Frail Elderly 4000 individuals with complex needs live within the Calgary Zone East Health Services Area, 70% are Frail Elderly and Complex Older Adults Barriers to access related to social determinants of health High rates of chronic conditions High Needs Youth High Needs Children Complex Infants Toddlers Reproductive Health 8

9 Client Identification Utilization cut-off values: 6 or more ED visits in preceding year 3 or more Inpatient admissions in preceding year 2 Inpatient admission and 4 or 5 ED visits *meets any one Clinical judgement: Person would benefit from intensive case management 9

10 We need to understand what are the barriers to achieving best health Act with the individual, learn for the population. 10

11 Case Management & PBH Case Managers assess whether client would benefit from PBH Meet with client to understand drivers for utilization & learn patient story Complete Patient Survey (EQ5D, Experience of Care, & Desired Outcomes) every six months Community of practice Build community networks, SharePoint resources 11

12 Engaging Providers Community of Practice Developing Networks Sharing Resources Escalating Issues Collective Problem Solving 12

13 Lessons Learned 13

14 Approach Approach is key Formal: health change methodology Informal: personal characteristics such as openness to meet patients where they are at figuratively and literally Engagement is key Relational continuity Some people take more time Frequent contact 14

15 We re Learning From Clients Expectations of the system and providers: Reliability/trust Listen to my full story and seek to understand it Take medical concerns seriously and address Integration between health and social services Barriers: Housing issues Healthcare worker bias Low health literacy System Silos Client s Vision for Future: Meaning in life, contributing to society, be treated without judgement Maintain functioning 15

16 We re Exploring System Issues Ways to Address Expectations: Work the care plans & role clarity on the team Use groups for skills/connection Trauma informed education for clinicians Addressing Barriers: Consistent care providers Stability of affordable housing Facilitate social connection Supporting Client s Vision of Future: One case manager, regular/longer appointments, meaningful connections 16

17 Next Steps Establish care pathways Consolidate practices Scale & Spread 17

18 Partners for Better Health Working Group Calgary Zone 18