MP05 - Health Care Integration for Frail Older Adults

ONE CLIENT ‐ ONE TEAM
Advancing an Integrated System of Care
Driving Transformation
Stacey Daub
Chief Executive Officer
Toronto Central Community Care Access Centre
Jodeme Goldhar
Lead, Health System Integration for Complex Population and Primary Care
Toronto Central Community Care Access Centre What have we learned from leading strategy and changing delivery models to ensure integration?
How do we continue to advance an integrated system of care for populations with complex needs? A Debate About Reform and Which Road is Best…
Steadfast Despite Political Context
Structural Reform?
Layered On?
Point of Care – Functional Integration Incremental Build
Maturity Reached Over Time
Flip Our Thinking
Point of Care Integration Our Aim
Supporting populations with complex needs with better care at home in their communities, utilizing existing resources
Our Approach: Creating One Team
For the client/family
• Seamless care
• One team approach
For the providers
• One team approach
• Built around client and family needs
Delivering integrated care requires integrated action within 3 key domains…
1
3
2
At home, in the community
Acute, CCC or Rehab
When necessary, the transition
Framework for Integration
Multiple Integration Initiatives
Aim: One client, One team
Point of Care Integration Virtual Ward Kids with Medical Complexity
Point of Care Integration Palliative Care ICCP Older Adults Point of Care Integration
Integrated Home Based Primary Care
(IHBPC)
IMPACT Plus
Integrated Community Care Team (ICCT)
Hospitals
Allied Health Professionals
Primary
Care
Specialists
CCACs
Community Service Providers
Long Term Care
Stop, Take Stock and Reflect
What Have We Learned?
Deliberately being open
Deliberately responding differently
“I meet with my ICCP care coordinator every two weeks or so… She speaks with my doctor. This is the first time the doctor ever came to my home.” – Client
Client and Family Experience
“The cross‐sector care we now provide is improving the patient experience ‐ as witnessed by shorter lengths of stay and improved patient satisfaction scores within these patient groups.” – Acute Care Partner
“The Coordinator works with other professionals to collect information, so I just have one person to contact. It saves me time.” – Primary Care Physician
Integrated Care Team
“If [Care Coordinator] had not helped arrange a specialist appointment for that patient, it would not have happened. Without her follow‐up, that patient would have gone to the ER.” – Primary Care Physician
Balance Approach to Evaluation
Mixed Methods Research:
• Qualitative Longitudinal Research
• Developmental Research
• Secondary Data Analysis
• Case Flows & Client Trajectories
Qualitative & Quantitative:
• Client and Caregiver surveys
• Stakeholder Interviews
• Retrospective Analysis
• Outcome & Process Metrics
Qualitative:
• Quality Improvement
• 100 Process Changes
• PDSA Cycles
• Small Tests of Change
Process and Outcome Measures
(Quantitative Information: Retrospective Cohort Analysis)
Walk a Mile or Two…
How can we work together differently?
What do I need to do differently?
How can we understand and experience different perspectives?
How can we all work together on what is most important to the client/family?
Opposing Notions/
Tensions
Integrated Solutions
Demonstrating Value Less Talk And More Delivery
Do not wait for complex solutions
There is no script…
Lead
Through Ambiguity
Relationship Will Determine Success Trust Will Determine Success
Safe
Shared Accountability Leadership Leaderful
Greater Emphasis on EMOTIONAL INTELLIGENCE
Lift Up, Look out…
…and Honour the Past
Policy Considerations
• How do we design our system to deliver the best value for clients and their families so that they experience the multiple parts of the system as ‘ONE TEAM’?
• How do we design incentives to ensure:
– capacity to deliver high performing home and community care? – providers work in an integrated model?
• How do we look at accountability models so we move from organizational or sector accountabilities to integrated accountabilities tied to the client/family experience?
For more information, please contact:
Stacey Daub
Chief Executive Officer
stacey.daub@toronto.ccac‐ont.ca
Jodeme Goldhar
Lead, Health System Integration for Complex Population and Primary Care
jodeme.goldhar@toronto.ccac‐ont.ca