Seamless Transitions

Seamless
Transitions:
Hospital to Home
David Fry
Vice President, Patient Care,
Mississauga Halton CCAC
Patti Cochrane
Senior Vice President, Clinical
Strategy & Chief Innovation
Officer, Trillium Health Partners
Michelle Samm
Joint Senior Project Manager,
Mississauga Halton CCAC/
Trillium Health Partners
OACCAC Conference
June 6, 2016
Seamless Transitions:
Today’s presentation
Agenda
1. Understanding the Issue
2. Establishing a Formal Partnership
3. Board and Operational Oversight
4. The Design Process
5. Evaluating Our Success
6. Opportunities and Next Steps
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Seamless Transitions:
Background – the issue
• Hospital to home transitions can be challenging for patients,
caregivers and health and social service providers
• Mississauga Halton region – one of Ontario’s fastest growing
seniors’ populations, set to triple by 2035
• In 2014/15:
o Trillium Health Partners –
no bed admits
o Mississauga Halton CCAC –
10% more patients from
hospital referrals
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Where It Started:
ESTABLISHING A FORMAL PARTNERSHIP
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Seamless Transitions:
Partnership
Timeline
• 2011: Mississauga Halton CCAC identifies “Managing
Systems Transitions” as a Strategic Plan priority initiative
• 2012/2013: Regional review of factors impacting system
transitions for patients was completed
• January 2014: First meeting of Mississauga Halton CCAC
and THP CEOs and senior leaders
LHIN endorsement
• Initiative supported by early endorsement and ongoing
investment from Mississauga Halton LHIN
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Seamless Transitions:
Myths Busted
Myths in Mississauga
Halton CCAC about THP
•
•
•
•
The hospital does not know
about the complexities of
community care.
It is as easy to deliver care in
the community as it is in the
hospital.
Hospital does not understand
that patients behave and heal
differently at home.
Hospital is not concerned with
making available the necessary
information to take proactive
action.
Myths in THP about the Mississauga
Halton CCAC
•
•
•
•
•
•
CCAC does not understand hospital pressures and
process-driven approach creates inertia.
CCAC puts economy ahead of quality and does not
staff appropriately for surges in the patient load.
The quality of care is not the same in the
community: care is sub-standard and patients are
not as safe in the community; services in the
community are not provided with as much
reliability as in the hospital; CCAC does not have
the skills/knowledge to provide home care.
Acute care can only happen in hospitals
CCAC does not communicate changes adequately.
It is not possible to manage the gap created by
the differences in the way different CCACs
operate.
There is no predictability to the system.
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Seamless Transitions:
Partnership Principles
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Seamless Transitions:
Partnership Mandate
Mandate:
• Go out and be disruptive innovators.
• Strive for transformational change, not incremental change.
“Transformation is a deliberate, planned process that
sets out a high aspiration to make dramatic and
irreversible changes to how care is delivered, what
staff do (and how they behave), and the role of
patients, which results in substantial, measurable
improvement in outcomes, patient and staff
satisfaction and financial sustainability.”
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Seamless Transitions:
Partnership
“Transformation is a deliberate, planned process that
sets out a high aspiration to make dramatic and
irreversible changes to how care is delivered, what
staff do (and how they behave), and the role of
patients, which results in substantial, measurable
improvement in outcomes, patient and staff
satisfaction and financial sustainability.”
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How We Governed:
BOARD AND OPERATIONAL OVERSIGHT
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Seamless Transitions:
Governance - Board
Board-level
• Mississauga Halton CCAC and THP
Boards of Directors approved
initiative work plan before design
process began
• Both governing bodies had to
endorse proposed changes to
organizational structures
o Recognition that processes and
procedures in both needed to
change to improve transitions
from hospital to home
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Seamless Transitions:
Governance – Board
Mississauga Halton CCAC
• Board approves Strategic Plan
• Mississauga Halton CCAC Board of Director’s Patient Care
Quality Committee reviews feedback from organization’s
patient and family advisory forum – Share Care Council
• CEO provided frequent updates back to Board on initiative
status because of system implications of the scope of work
THP
• Interested in exploring regional partnerships
• Discussion at sub-committee
• Monthly updates
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Seamless Transitions:
Governance – Operational
• Joint, CEO-led Steering
Committee (monthly
meetings)
• Cross-organization Working
Group (weekly meetings
during pre-planning and
early test phases; bi-weekly
thereafter)
• Joint Project Manager
(provided updates to
Steering, Working Group,
staff huddles; managed
design process)
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Seamless Transitions:
Governance – Operational
Operational
• Dedicated interdisciplinary design team: physicians,
Mississauga Halton CCAC care coordinators, nurse,
physiotherapist, occupational therapist, social worker,
professional practice lead, performance management
consultant, patient/caregiver advisor, communications specialist
• Led process design and testing; acted as project champions and
change ambassadors
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What We Accomplished:
THE DESIGN PROCESS
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Seamless Transitions:
Define phase
• Interview and observation:
o Design Team
o Patients and caregivers
o Staff, including physicians
o Primary care physicians
o Community providers
• Problem statement: We lack a shared understanding of
patients’ needs to inform and execute a care plan that will
give them confidence to leave hospital.
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Seamless Transitions:
Brainstorm phase
• Patient engagement – Share Care Council
• Staff and physician engagement – five brainstorming sessions
o 154 staff attended
o 1,301 ideas generated
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Seamless Transitions:
Prototype phase
• Objective: to create a consistent, integrated, personcentered approach for hospital to home transitions that
improves patient experiences, while eliminating duplication
in processes and gaps in communication and care.
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Seamless Transitions:
Prototype phase
Current State
Future State
A traditional approach
where hospital care teams
are geographically based
and hospital and
community teams are
siloed.
An integrated approach,
grounded in leading practice,
designed to deliver high
quality, efficient, effective,
integrated care that connects
care providers across the
continuum to improve the
patients’ experience.
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Seamless Transitions:
Prototype phase
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Seamless Transitions:
Prototype phase
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Seamless Transitions:
Prototype phase – Video
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Seamless Transitions:
Test/Refine/Learn phase
• What: Key components of
Seamless approach
• Where: Medicine program
at Trillium Health Partners Credit Valley Hospital (THPCVH)
• When: September 29,
2014 to June 26th, 2015
• Who: Patients on two
physician teams (started
with one physician team,
the test was expanded to
include a second team on
January 21, 2015)
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Seamless Transitions:
Test/Refine/Learn phase
*March 2015
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Seamless Transitions:
Evaluation phase – Patient Profile
*Sept. 29/15 to March 31/16
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Seamless Transitions:
Evaluation phase – Patient Feedback
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Seamless Transitions:
Evaluation phase – Key Findings
• Seamless patients had
significantly lower readmission
rates, compared to other THPCVH Medicine patients.
o 52% decrease in 30-day
readmission rates.
o Estimated that reduced
readmission rate will save 0.9
days (potential conservable
days) and reduce patient
mortality rates.
• Increased utilization of community services.
• No difference in Length of Stay (LOS) or ALC rates
between test and control groups.
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What We Learned:
EVALUATING OUR SUCCESS
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Seamless Transitions:
Lessons learned - Testing
People:
• Build shared cultures to facilitate
work across sectors
• Identify operational leads and
supports early
• Establish expectations for new
attitudes and behaviours to
sustain transformative change
Patient focus
• Utilize partnership
principles to keep work
focused
• Engage stakeholders
continually
Time:
• Need adequate time to build and
strengthen relationships between
partnering organizations and its
people
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Seamless Transitions:
Lessons learned - Governance
Operations:
• Ensure committed and
courageous leadership
• Establish patient-centred,
strategic partnership
principles and mandate
• Engage operational leads
during planning phases to
ensure smooth rollout
during testing
• Provide ongoing and
consistent communications
across organizations
Leadership/Board:
• Organization’s leaders
need to identify strategic
partnership opportunities,
and lead partnership
activities (top-down) –
open to taking honest look
at areas for improvement
• Board – importance of
endorsing projects that
support improvements in
QIP targets
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How We Are Applying Lessons Learned:
OPPORTUNITIES & NEXT STEPS
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Seamless Transitions:
Opportunities & next steps
Care Coordination
Program of Work
• Refined, consistent,
enhanced Care
Coordination
Framework
• Core competencies for
care coordinators
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Seamless Transitions:
Opportunities & next steps
Care Coordination Program
of Work (continued)
• My Story documents –
written, plain language care
plan used for all patients,
patient goals, welcome
letters
Second Partnership
Initiative
• Tested approach with second
regional hospital provider,
Halton Healthcare
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Seamless Transitions:
Opportunities & next steps
Ongoing work with Trillium Health Partners
• Complex implementation process related to Medicine –
THP is determining next steps for full implementation of
Seamless Transitions approach
• Unit-Based Affiliation project
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Seamless Transitions:
For more information
Executive Sponsors:
• David Fry, Vice President, Patient Care, Mississauga
Halton CCAC
o Email: david.fry@mh.ccac-ont.ca
o Phone: 905-855-9090 ext. 5333
• Patti Cochrane, Senior Vice President, SVP Clinical
Strategy & Chief Innovation Officer, Trillium Health Partners
o Email: Patti.Cochrane@trilliumhealthpartners.ca
o Phone: 905-848-7683
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Seamless Transitions:
For more information
Visit the Mississauga Halton CCAC’s website.
(www.healthcareathome.ca/mh)
• Review the Guidebook (provides a summary of the
partnership and design process).
• Refer to the Seamless Transitions “Quick Facts” sheet.
• Watch the video, featuring physicians, a hospital social
worker, and a Mississauga Halton CCAC care
coordinator.
Questions?
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