Consistent with our approach to be very focused on a small number of key priority improvement initiatives, our Year 1 performance improvement opportunities to address the listed measures are directly aligned with our priority population key change activities. This approach has proven successful both within our individual organizations and amongst our partner organizations with respect to making impactful and sustainable improvements to care delivery pathways and processes (e.g. COPD and CHF cQIP).
As the G&A OHT matures, it will target its performance improvement activities at data-informed opportunities for improvement and community need that are identified through its strategic plan (to be developed in Year 1). We will develop a set of indicators, that are collectively balanced around the Quadruple Aim and that are less hospital focused and more indicative of population health. We will select upstream measures including social determinants of health, quality of life and Patient Reported Outcome Measures (PROMs), which are more objective measures of population health than a reliance on acute care utilization data in isolation. Examples of measures include homelessness, % of decedents that accessed their preferred place of death. At our OHT Board engagement session on September 26th, Boards suggested including a ‘Provider Reported Experience Measure’ that would help us to understand to what degree our providers experienced “joy” in their work (which they suggested should be a key priority as the G&A OHT is developed).
We will also use our existing patient & caregiver experience and provider experience surveys to identify areas for priority improvement. We will eagerly anticipate provincial Patient Reported Experience Measures, Provider Reported Experience Measures and Patient Reported Outcome Measures.
Recognizing the challenges with the full data set provided to us (i.e. inclusion of Rural Wellington) we did review the ‘Performance Indicator’ tab and identified 2 key performance improvement activities based on our current performance (as described in the Ministry’s full data set) where we are performing below the provincial average: Avoidable ED visits and 30-day in-patient re-admission rate. Both the Palliative and MH&A key change activities have been designed to, and are expected to reduce ED visits. We expect that development of IPCTs and the integration of care coordination into these teams will have a positive impact on our collective performance related to both avoidable ED visits and 30-day in-patient readmission rate.
The key change activities for our target populations are outlined below.
Change Ideas Target Population #1: Palliative
- Develop processes for serious illness conversations facilitated by trained healthcare team members who have trusted relationships with patients/caregivers as a means to enabling patients to be fully aware of the known trajectory of their illness. These conversations will support meaningful plans of care that are aligned with patient values and wishes.
- Implement mechanisms
for identifying patients with serious life-limiting illness and corresponding mechanisms
to appropriately support patients as soon as they are identified as having a
life limiting illness. Selected mechanisms for flagging patients with serious
illness on any chart or record will be established to enable each care team
member to appropriately support patients based on consistent and up to date
information. Proposed tools for identification and communication across healthcare
providers include:
- HOMR – Guelph General Hospital has applied in partnership with several other acute care sites across the province to implement HOMR (mortality risk assessment tool) as a part of a CIHR grant.
- Palliative EMR Toolbar –This tool not only identifies patients but also provides the clinician with resources to support the patient once serious life limiting illness is identified.
- CHESS score via RAI HC (assessment tool) – CHESS (changes in health, end stage signs and symptoms) score identification process training has begun across Guelph and Area H&CC.
- Easy access to care information and navigation via supported technology. We will address this via implementation of the 24/7 serious illness support line, virtual appointments, shared care plans across providers and patient accessible medical records (e.g.”MyChart”). Increased access to care via technology will help patients to avoid the ED when appropriate and eliminate challenges associated with transport.
- Care coordination integrated with primary care including additional social and emotional support via a hospice trained social engagement volunteer, who would also liaise with the clinical care team.
- Technology will be leveraged to strengthen transitions between care settings.
Change Ideas Target Population #2: Moderate to Complex-Vulnerable MH&A
At maturity, G&A OHT envisions serving our full attributed population based on two key principles:
- primary care as the patient’s home base and
- designing MH&A services, at a system level, based on Dr. Brian Rush’s Tiered Framework (Figure II).
The first prototype will be targeted to serve the Tier 5 and upper Tier 4 population:
- Establish a rapid access health hub IPCT for complex needs. This will include access to primary care, psychiatry, and a continuum of mental health and addictions treatment services.
- Create a single client registry for our year 1 target population and ensuring each client has a primary worker assigned who is integrated into the health hub and responsible for coordinating client care and system navigation.
- Leverage an already existing 24/7 crisis phone navigation and support system through the CMHAWW to empower staff with the most up-to-date care plan so that after hours support calls can be more tailored and effective.
- Pilot the use of e-tools to support timely, secure communication between clients and hub supports and also between staff. For example, virtual visits that would enable outreach workers to support a client in getting urgent access to a psychiatry consult, without having to physically go to a specific location.
The second prototype will be targeted to serve the Tier 3 and lower Tier 4 population and will be embedded within existing primary care practices. Our top change ideas for this population include:
- Providing each IPCT with a broader range of MH&A supports, including a behavioural health consultant role, to expand the capacity of the IPCT by working alongside the primary care team as opposed to requiring a referral.
- Integrate care coordination into prototype team that focuses on primary care-based system navigation and social prescribing.