Shared Care Planning for Complex Patients

Alida Fernhout, Manda Harmon & Venie Dettmers BC Quality Forum February 27, 2014

Presentation Overview

• What We Were Trying to Accomplish

• The Target Population

• Care Conferencing and Shared Care Planning Experience

• Outcomes

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What we were trying to accomplish – connect/coordinate services

VCH Primary Care Clinics in Downtown Eastside

St. Paul’s Hospital Emergency Department

Other Community Clinicians

Community Agencies

The Target Population • High Users of the Emergency Department -

Project Focus: 89 People who visited St. Paul’s Hospital ED 10+ in 2011/12 year & known to VCH GP or NP in the Downtown Eastside

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Primary Care Clinic Patients in Cohort

With Care Plan

Downtown Community Health Centre 39 11

Vancouver Native Health 23 9

Pender Community Health Centre 10 2

Strathcona Mental Health Team 15 3

Primary Outreach Team 2 1

89 26

Downtown Community Health Centre Clients - 39

Problems % /(Number of Patients)

Substance Use – alcohol, crack or cocaine, non-beverage alcohol use

82% / (32)

Mental Health Issues – childhood trauma, depression, post traumatic stress disorder

87% / (34)

Physical Health Issues – hepatitis C, cardiac issues, respiratory & COPD

100% / (39)

Social Issues – housing concerns/unstable housing, poor support systems

97% / (38)

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Chart reviews, contact other care

providers

Identify all the players

Discuss health care goals

Meet with the patient

Care Conference

Downtown Community Health Centre Care Conference Process

Care Conference • Challenges

– Multiple databases, outdated info on file

– Coordinating multiple teams

– Patient stability to participate in conference i.e. chronic inebriation

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• Improvements – Patients prioritize their concerns

– “I’ve never been asked before”

– Choice for them to attend ~ most chose not to attend

– Open communication channels among multiple partners

Downtown Community Health Centre Care Planning Process

Case conference

Identify and discuss health

goals

Document action plan and assign

roles

Care Plan Share action plan with all

team members, including SPH

ED

Place action plan at front of chart

Follow-up

Nursing coordinator to follow-up at 3

month intervals

Follow-up with patient: change

in goals, satisfaction

Care Planning

• Challenges – Difficult to inform all clinic staff

– Care plan not shared with staff at buildings & agencies

– Multiple databases; no central online location to share careplan

• Improvements – Action plan is patient driven

– Shared work load

– Improved communication

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Sustaining Best Practice in DCHC • Clinical Coordinator is responsible for overall tracking

• Monthly rounds held - to identify new clients and update team on existing clients in the list

• Any staff member can request a patient be added to list for care conferencing and planning – central (paper) list located in chart room

• Primary care nurse/nurse coordinator is identified for each client - future planning and follow-up; ‘Officially’ provide nurse with dedicated time to work on complex patients.

• Complex care conferencing is organized and care plan developed following process developed in pilot

• Care plan is stored in EMR and emailed to other teams involved

• Challenge – time challenge for current nursing staff to fulfill role and maintain follow-up

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Impact on Use of Services – 26 with care plan

12 Months Before Start of Pilot

12 Months During Pilot

% Change

Number of ED Visits

576 435 -24%

Number of Hospital Admissions

51 39 -24%

Average Length of Stay Days

6.3 7.5 +19%

Number of GP or NP Visits

608 710 +17%

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Changes on Clients – Provider Perspective

• Prevented patients from going to ED - deeper positive relationship with client; also introduced patient to 811, Seniors Crisis Line and other resources

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• By bringing the right people together, prevented crisis or adverse events

• Not noticed any changes

Provider Experience Feedback • Able to be more thorough and have more structured approach

• Excited that somebody is doing the coordination/being the orchestra leader

• People tend to take more responsibility with face to face conference; there is better communication;

• First time we targeted community agencies and ED although we’ve done case conference before

• Challenging to getting people to the table; GPs are part-time.

• Resources needed to address patient issues––mental health housing; getting into detox right away; outreach support e.g. to get to appointment

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Thank You

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