Integrated Comprehensive
Care – Bundled Care Pilot
Project
Hospital – Home a Vertical
Integration Concept
Patient Value Statement
"Please help me fully understand my health challenges
so that I can make informed choices about my care.”
“I would like timely care when it is necessary, in the most
suitable location.”
“I want to be clear about what will happen next so I can
prepare properly and try to worry less.”
“Help support my recovery at home."
Unique opportunity to demonstrate
an alternate model of care
• The St. Joseph’s Health System (SJHS) includes an Acute Teaching
Hospital, Long-Term Care Facilities and a Home Care provider in the
same city
• Perfect setting to demonstrate and evaluate an alternate model of care.
– Better, Faster, Cheaper
• The SJHS has the governance, management and service delivery
alignment to act as an early adopter of this approach.
• Local Health Integration Network (LHIN) support for this project
Alignment with Provincial
Strategies
Commission on the Reform of Ontario’s Public Services
-2012
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Co-ordination across a continuum of care
Patient-centered care
System centered on patients, not institutions or providers
Hospitals make discharge summaries available electronically to
other care providers
• Improving access to care: remote communities
Key Principles
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•
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Simple for the patient
Patient knows what will happen next
Focus on what adds value to the patient
Improve the patient experience
Accountable Care
Organizations
•Accountable for overall cost and quality
of care
•Strategic integration of care
•Manage the full continuum of the patient’s
care
•Performance measurement
•Holds health systems and providers
accountable for care
Primary Care
• Primary care physicians key stakeholders in this
project
• Integrated delivery of care with hospitals, specialty
services and home care
• Critical role in supporting the patient after
discharge, and collaborating with the broader
healthcare team to keep patients at home, prevent
ER visits
Model: Total Joint Replacement
Patient
Integrated Care Coordinator
Patient Population
Three patient groups with broad applicability in
Ontario
•Total Joint Replacements – 500/year
•Thoracic Surgery, Complex Pleural Space – 450/year
•Chronic Diseases (COPD, CHF) – 120/year
Regional Program: Thoracic Surgery
Hamilton: 35%*
Greater LHIN region: 65%*
*April 1, 2012 – June 30th 2012
3rd Party Program Evaluation –
PATH group at McMaster University
Before
Surgery
Home care
Hospital
60 days
Length of Stay
Diagnosis
Home Care
Outpatient
ER visits
Readmissions
Data
Validation
Patient Satisfaction Questionnaires
Pre-hospital In hospital
Referral
Admission
Homecare
Discharge
60-days
Questionnaire 1
Questionnaire 2
Pre-hospital &
Inpatient Care
Transition Home
& Homecare
Early Results
Elective Hip and Knee Replacement
Acute LOS
SJHH
Jan-Mar 2012
4.2
Rehab referral rate
Ontario
Jan-Mar 2012
4.2
12.2%
12%
SJHH
April-May 2012
3.8
8.5%
Thoracic Surgery
SJHH Average Length of Stay
*Hay Benchmark (Canadian Academic Hospitals): 7.6
Apr-Dec 2011
Mar-July 2012
7.8*
5.1
Project Successes
• More efficient home visits
• Remote electronic access to the patient medical record
• Central contact number for patients: access to the team 24/7
• Integrated Carepaths (hospital to home)
• Standard templates for clinical documentation
• Cross-training/knowledge transfer
• Team integration
• Total Joint Replacement:
• Physiotherapy within 24 hours of discharge
Challenges
• Building confidence and trust within the team
• Consistent messaging to patients regarding discharge
date
• Technology implementation
Patient Experience/Engagement
60 day follow up calls:
overwhelmingly positive feedback
• Easy and timely access to the team 24/7
• Coordination of care and support has been very evident
• Patient concerns are directed to the most appropriate
member of the healthcare team
• Feel supported after discharge, less anxiety
Enablers of success – Team
• Process mapping, review of current state
• Knowledge transfer and cross-training
• The “Expert Team”
• Empowered Team:
• Responsibility with Authority
Enablers of success –
Communication
• Real-time access to patient information
• Remote access on mobile devices
• Email communication
• Pictures
• Skype
2 fundamental questions that
challenged the Team
“How can we provide integrated care if everyone has
their own discrete care plan and documentation?”
“How do we provide the team with real-time patientspecific information before the patient leaves the
hospital?”
IT – Critical success factor for
integration
• The clinical team identified a common integrated health record
as a critical success factor
• If we were going to provide comprehensive care, we needed:
• Common integrated care plan
• Opportunity to communicate with other members of the
team
• Communicate information from the HOSPITAL to COMMUNITY
• Communicate and document all patient information during the
community component of their care
Strategies to support
electronic health record
• We leveraged the St. Joseph’s Home Care information
system, Procura, as the platform to establish the
electronic health record
• Devices used by the care providers in the home to
support real-time, secured access to view and
document in the patient health record
Content of the Health Record
Tracking Form
Contact Info
Team
Interactions
Clinical
Documentation
Procura
Contact
Information
Visit
Workload
Patient Folder
Scanned
Documents
Integration with Hospital and
Family Physicians
• Documents are scanned from the hospital record and
uploaded real-time to the Procura database
• Documents that are uploaded to Procura are also
shared with the Family physicians
• Communication to the team from Family physicians is
uploaded to the Procura database to be accessible to
the entire team
Patient Tracking Tool
• Living document that serves as a dashboard for all ICC clients
• Updated by the Integrated Care Coordinators in real-time
• The tracking form is maintained within the Home Care
database
• All team members, Hospital and Home Care can access the
database from any location on iPads, computers)
• Communicates the following information to the hospital and
home care team, for each patient:
• Clinical stream
• Home care serves required after discharge
• Expected length of stay
• Discharge status
Investment in IT
• Purchased iPads with 3G capability for each hospital and home
care team member ($20,000)
• Monthly data charges for remote access ($500/month)
• Blackberries for specific team members ($2,000)
• IT resource at STJH to configure/develop Procura ($22,000)
Total investment for 1 year: $50,000
Criteria for selecting the device
Cost-effective: approximately 30 team members will require access to the
system
Mobility: patients are located throughout the HNHB LHIN
Training: user friendly tool, limited training time
Battery life: required a device that would not need to charged during the
shift
Picture quality: pictures a routinely uploaded to the patient file to track
progress of wound healing for example
Access: required very quick access to the tool and software (time to turn on
and log on had to be minimal)
Secure access: patient information
Enablers of success –
Access to Medical Care
• Physician champions
• Family physician/Primary Care
• Outpatient clinic
• Direct admit to hospital
Enablers of success –
Adaptability
• Build a carepath for the entire continuum
of care
• Adjust the process with feedback from the
entire team
• Ongoing self-assessment
• Right care – right provider – right time
Collaboration with key
partners
• The HNHB LHIN and HNHB CCAC are members
of the ICC-Bundled Care Steering Committee
• A memorandum of understanding (MOU)
between the HNHB CCAC, SJHH and SJHC
outlines the funding transfer
Our Patients’ Experience
Opportunities for further
spread
St. Joseph’s Healthcare Hamilton
• Esophagectomy/Head and Neck surgery
• Complex pleural space – malignancy
• Hip fractures
• Complex medical patient
• Palliative care: extension of our clinical streams
St. Joseph’s Health System
• St. Mary’s Hospital, Kitchener: COPD/CHF
• St. Joseph’s Villa
Regional Programs
• Thoracic surgery/CCO