Enabling the transition of patients to the right care:
Evolution of the Toronto Central LHIN’s Resource Matching and
Referral (RM&R) Program
e-Health 2013
Presented by:
Shiran Isaacksz, Sr. Director, Regional and Provincial Initiatives
Stephanie Saull-McCaig, Director, Information Management
CFPC CoI Templates: Slide 1
Faculty/Presenter Disclosure
• Nothing to Disclose
Patient – Sally
This is Sally
Home
Care
Profile
Age: 75
Medical
History:
Long
Term Care
Community
Support
Rehab
Acute
• Type 2 Diabetes
• Mild dementia
• Recent hip replacement
• Required Rehab Services,
CCAC In-Home services and
Community Support
Patient – Healthcare Landscape
Sally represents the 1% of the population which account for
34% of healthcare expenditures.
population
healthcare expenditures
Patient Challenges
Sally and her care team are finding
the navigation through the Care
Continuum difficult due to the
inefficient referral processes.
The Problem
Patient and Provider Challenges
•
•
Inefficient paper referral processes,
which require faxing referral
applications between provider
organizations, create unnecessary
delays due to:
• Incomplete information
• Illegible writing
• Inappropriate matching of
patients to programs/services
Unnecessary delays can contribute to
alternate level of care length of stay.
The Solution
Resource Matching & Referral (RM&R)
A patient-centred approach to managing referrals across sectors
•
•
WEB
•
RM&R matches patients to
appropriate programs/services based
on assessed clinical needs, reducing the
number of inappropriate referrals.
RM&R enhances communication and
collaboration between providers, and
increases referral process efficiency by
creating documentation and service
referrals electronically.
RM&R improves health system
reporting and planning by providing a
single source of LHIN-wide referral
data.
RM&R Achievements
28,727
activeService
registered
users
84 Health
Providers
•
6 Acute Hospitals
8 Rehab/CCC Hospitals
Toronto Central CCAC
34 Community Support Services Agencies
37 Long Term Care (LTC) homes
(including 3 Convalescent)
59,239 logins on average per month
•
•
•
•
5,897 LTC beds
Benefits
Challenges
•
•
•
•
Further Refinement to Referral Forms and Processes
Alignment with Other Provincial Systems/Priorities
Ability to Support Growth/Expansion
Streamlined Reporting
Enablers
Strategic
Priorities
Vision
Driving Principles
Enabling the timely transition of patients to the right care
Simplify the Referral
Process
Make the System
Smarter
Governance
Business Engagement
Technology
Drive System
Change through
Information
Vision for RM&R
INTELLIGENT
REFERRALS
‘ONE’ REFERRAL
FOUNDATION SETTING
• Enhancing Referral Processes
• Improving Matching
• Business Intelligence Tool
• Leveraging Information from Source
Systems
• Smart Triage (matching upfront)
• Link to Other Data Sets
• User-Driven Adoption
• Real-time Auto-generated Referral
• Predictive Analytics
Evolution of RM&R
Integrated RM&R
Analogous to the evolution of Consumer Electronics
Standalone RM&R
Pre-RM&R
Provincial Initiatives
Provider Portal
Access
Intelligence
Access
Data
HIAL
HealthClinical
Information
Access Layer
DataPortal
Repository
Provider
Links
applications,
engines
Shared
central repository
that
storesto
Browser-based
toolintegration
to allow
access
and
data repositories
to form
an
documents
and data
discrete
data elements
ConnectingGTA
online
integrated
from health
care
organizations
(e.g.,
Single
pointsystem
of
access
for clinicians
Provides
a setregistries).
of communication
and
repositories,
across
continuum
of care
integration
services to communicate and
Ability
for clinicians
collaborate with one another
Information
•
•
•
•
CDR
Data
Convergence Towards a Common Technical Platform
Provider Portal
Access
HIAL
Information
CDR
Data
The Road Ahead…..
Better Transition of Care
Thanks!
Any questions, please contact us at Shiran.Isaacksz@uhn.ca or
Stephanie.Saull-McCaig@uhn.ca