Who will you focus on in Year 1?

In our Expression of Interest (EOI), we identified two Year 1 priority populations – Mental Health and Addictions (MH&A) and Palliative.   As we envisioned the role of the G&A OHT in the delivery of care coordination, system navigation and supported transitions throughout the course of the development of this ‘Full Submission’, it became clear that the most ideal approach, from both a change management perspective and to optimize the health of our population, was to add a third priority – In Year 1 we will also integrate the function of care coordination into existing primary care teams towards the development of mature ‘Integrated Primary Care Teams’. (Appendix A). 

1. Palliative

550 people will be included in our Year 1 palliative priority population including those on the palliative home and community care (H&CC) caseload, all patients with a CHESS (Changes in Health, End-stage disease and Symptoms and Sign) score 4+ on H&CC caseload and Guelph Health Links members who have a life limiting diagnosis.   Currently 91% of patients receiving H&CC who have a CHESS score of 4+ have diagnosis of cerebrovascular disease, dementia, CHF, COPD, neurological disease, organ failure OR cancer.  In 2017-18, 82% (451) palliative patients in Guelph-Puslinch visited the Emergency Department (ED) in the last year of life and 70% (385) had inpatient hospital stays (OPCN). As per CIHI (2009) ED cost per patient in Ontario is $148 per visit. The average hospital length of stay for palliative patients in Ontario is 8.8 days with an average cost of $8,318 (CIHI, 2018).  The average cost of an ambulance is $240 per trip. Using the above figures to estimate acute care costs for our target population the totals are $66,748 in ED visits, $3,202, 430 in hospital admissions, and $108,240 in ambulance costs in one year. The H&CC costs associated with patients with a CHESS score of 4+ in the 2018-2019 fiscal year in Guelph-Puslinch was approximately $758,058.

2. Mental Health and Addictions

A recurrent theme from several community visioning and engagement sessions held to identify the MH&A target population was the need to transform care for individuals with moderate to complex MH&A needs. We heard:

  • concerns about patients being unable to access needed care where and when they needed it
  • service providers and physicians struggle to navigate and understand the MH&A system
  • patients frequently ‘fell through the cracks’, ended up going to the hospital because they didn’t know where else to go or were waiting for care.  Those same patients would often return to hospital several times after their care plans weren’t fulfilled.

This experience is confirmed through data that shows that 19.6% of patients who visit the ED for a mental health issue and 27.1% of patients who visit the ED for addictions issues re-visit the ED within 30 days (WWLHIN Performance Dashboard). To address this, care for individuals experiencing moderate (Tier 3) and severe/complex (Tier 5) MH&A issues was prioritized to improve both patient and caregiver experiences, divert unnecessary ED visits, reduce length of stay in the ED and also avoid costly repeat ED visits and EMS calls.

Based on Dr. Brian Rush’s population need estimates, there are approximately 9,760 individuals experiencing Tier 3 levels of MH&A and 320 individuals experiencing Tier 5 levels of MH&A acuity within the G&A OHT (Development of a Needs-Based Planning Model to Estimate Required Capacity of a Substance Use Treatment System, 2019). Instability relating to income, housing, and/or food security and high-cost healthcare consumption are positively associated with increasing levels of MH&A (HQO, 2017). In addition to experiencing greater comorbidity and social determinants of health (SDoH) challenges, we also know that approximately 66% of homeless individuals in our OHT fall within the ‘high acuity’ range (2017-2018 Annual Report: Guelph-Wellington 20,000 Homes, 2019).  Delivering integrated care and supporting transitions and system navigation for this population requires flexible and coordinated community-based support.

3. Integration of Care Coordination in Primary Care Teams

We’ve elected to add this population as a Year 1 priority as it became clear through our stakeholder engagements that if left unaddressed, it had the potential to negatively impact our achievement of the Quadruple Aim – patients and caregivers as well as clinicians & other front line providers described significant opportunity to improve their experiences by fully integrating the functions of care coordination within primary care. Additionally, integrating care coordination functions that are currently dispersed, uncoordinated and sometimes duplicated will transform the patient and provider experience and result in significantly better outcomes at lower costs.  We have designed an “Integrated Primary Care Team” (IPCT) model that integrates the functions of care coordination into the patient’s primary care team.  See Appendix A for a description of IPCTs.  Similar to what was reported through the NHS’s National Voices initiative, our patients and care partners described “people being unaware of whom to approach when they have a problem, and nobody having a generalist’s ‘bird’s eye’ view” of their total care and support needs”. Our IPCT model will transform care coordination and the patient experience – “My care is planned with people who work together to understand me and my carer(s), put me in control, coordinate and deliver services to achieve my best outcomes” (https://www.england.nhs.uk/ourwork/clinical-policy/ltc/house-of-care/).

The primary care attachment rate in Guelph and Area is 97% and 100% of primary care providers have access to inter-disciplinary teams (FHT and CHC models).  This means that in Year 1, the full population of our OHT will begin to experience the benefits of integrated care coordination.

Using the Guelph-Puslinch sub-region as a proxy, in 2018-19 (WWLHIN Decision Support August 2019),

  • Approximately 1,000 home care patients served daily
  • At any given time, approx. 3,000 patients on the H&CC caseload
  • Monthly referral rate between 350–450 new referrals a month,
  • Approximately 6,500 patients served per year
  • Patients referred from: Hospital: 55%, Primary Care: 22%, Community: 18%, Other: 5%
  • The top three diagnosis groups in 2018-19 were:
    • MSK 15.3%
    • Mental Health 14.7%
    • Cancer 13.6%

In 2018-19 there were 99 unique Francophone H&CC clients with a total of 142 unique referrals.

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