Transcript Health Link Gather Information and Initiate Coordinated Care Plan

South Simcoe and Northern York Region
Let’s Make Healthy Change Happen
Coordinated Care Plan Process
Training
Workshop
Developed by: SSNYR Health Link
October 19th, 2016
Version 1.4
Agenda
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Health Links Workshop Purpose
CCT Background
Health Links Target Population
Health Links Value Streams
High Level Health Links Process Model
• 1.0 Health Link Client/Patient Identification
• 2.0 Invite and Engage Clients/Patients
• 3.0 Gather Information & Initiate Coordinated Care Plan
• 4.0 Share Information & Conduct Case Conference
• 5.0 Update & Action Care Plan
• 6.0 Re-Assess Client/Patients
• 7.0 Client/Patient Transitions
Page 2
Workshop Purpose
 To provide a review of the Health Links Processes associated with the
Coordinated Care Plan implementation.
 To review the major roles involved in Coordinated Care Planning
 To gather feedback from participants
Page 3
Health Care Inter-Professional Teams
 Well-functioning teams have the patient at the centre,
communicate easily and frequently, have shared objectives
and clear roles and responsibilities, and make decisions
together.
 The Principles and Framework for Inter-Professional Care are:
• focus on patient needs
• ensure health services are relevant, based on
demographics and community needs
• provide quality care
• facilitate access to the right service, at the right time, in
the right place, by the right people respect
• learn from one another and share decision-making
• consult and communicate
Page 4
Coordinated Care Tool (CCT) Background
 In December 2012, Ministry of Health and Long-Term Care (the Ministry)
announced the formation of Health Links.
 Health Links bring together Health Service Providers (HSPs) across the
health care system (primary, community, and acute) to better coordinate
care for high-needs clients / patients.
 Health Links are a “virtual group” who represent a diverse cross-section of
champions with participation of coordinators from a variety of
organizations such as family health teams to community care access
centres. Health Links are tasked with organizing timely, effective,
coordinated care around the patient.
 One of the primary objectives for each Health Link is to establish a
coordinated care plan (CCP) for all patients with complex needs.
 The Health Links Process Model was developed by the SSNYR HL HSPs with
input from the Health Link Leads from the Central LHIN and Health Quality
Ontario.
 Health Links is evolving and improvements are happening all of the time.
Health Links is a learning organization.
Page 5
Health Link Target Population
The Ministry of Long-Term Care has defined the advanced target population
as:
 Patients with four or more chronic/high cost conditions, including a focus on
mental health and addictions conditions, palliative patients, and the frail
elderly and/or
 Income, government transfers as a proportion of income, unemployment
and/or
 Social determinants (housing, living alone, language, immigration, community
and socials services etc.)
Health Link
Total / Overall 4 + Conditions
Of Overall Total: High Cost User
North York Central
20,650
9,375
South Simcoe Northern York Region
13,030
5,775
South West York Region
9,170
7,720
South East York Region
12,390
5,215
North West York Region
14,245
8,190
Central LHIN Total
79,485
36,275
Page 6
High Level Coordinated Care Process Model
1.0
CLIENT/PATIENT
IDENTIFICATION
Check back
with client/
patient
periodically
2.0
INVITE &
ENGAGE CLIENT/
PATIENT
8.0
CLIENT/PATIENT
DECLINES
3.0
GATHER
INFORMATION
&
INITIATE CARE
PLAN
4.0
SHARE
INFORMATION
&
CONDUCT CASE
CONFERENCE
5.0
UPDATE &
ACTION CARE
PLAN
6.0
RE-ASSESS
CLIENT/PATIENT
7.0
CLIENT/PATIENT
TRANSITIONS
Page 7
Health Links Value Streams
CLIENT / CAREGIVER ENGAGEMENT
HEALTH LINKS INTEGRATED TEAM ENGAGEMENT
HEALTH LINKS QUALITY IMPROVEMENT
HEALTH LINKS RESOURCE SUPPORTS
HEALTH LINKS INTEGRATED SYSTEMS
Page 8
1.0
Health Link Client/Patient Identification
The following Health Link Identification Processes will
help Health Service Providers to enroll clients in the
Health Links Model:
•
•
•
•
Retrospective Identification
Real time/New Client Identification
Self-Identification
Common Intake/Referral (TBD)
Page 9
1.1 Retrospective Identification
1.1 Health Links - Retrospective Identification
Health Links Patient/Client Identification
HSP Partner
Health Links
Client
Identification
Guide
HSP Partner
Reviews
existing Client
Roster
HSP Partner
Checks the CCT
to see if Client
already
enrolled
Client is already
identified with
Care Plan
YES
HSP updates
existing CCP
with HSP
participation
details
HL Client / Care Giver
NO
HSP Partner
Creates List of
Potential
Health Links
Clients
HL Brochure /
HL Website
HSP starts
Client Invite &
Engage Process
with HL Client
YES
HSP Partner
engages Client
to discuss
possible HL
Enrollment
HSP does not
create shared
CCP
NO
Client wants
Health Links
Designation
Page 10
1.2 Real-Time/New Client Identification
1.2 Health Links - Real Time
HSP Partner
Health Links Patient/Client Identification
HSP updates
existing CCP
with HSP
participation
details
Health Links
Client
Identification
Guide
HSP starts
Client Invite &
Engage Process
with HL Client
HL Client / Care Giver
YES
HSP meets with
potential
Health Links
Clients
HSP Partner
Engages Client
to discuss
possible HL
Enrollment
NO
Client is already
identified with
CCP
Health Links
Client Brochure
Page 11
1.3 Self-Identification
1.3
Health Links Client Self Identification
Health Links Patient/Client Identification
HSP Partner
Health Links
Client
Identification
Guide
HSP determines
best fit for Lead
Care Coordinator
HSP
Health Links
Training
Guide
(Roles)
Client is best fit
for HSP Lead
Care Coordinator
HSP starts Client
Invite & Engage
Process
YES
YES
NO
Client Qualifies
for Health Links
enrollment
NO
Client is enrolled
with HSP without
HL designation,
no shared CCP
HSP Refers to
other
Community
Partner
Referral Form
with HL
Checked
or Phone Call
YES
NO
HSP contacts HL
Coordinator
HSP Receives/
Acknowledges
Referral
NO
HL Client / Care Giver
HL Lead
Client Qualifies
for HL
enrollment
Client Self –
Identifies and
contacts a
participating
HL HSP
YES
HL Lead
determines best
fit for Lead Care
Coordinator HSP
HL Lead refers
Client to best fit
for Lead Care
Coordinator HSP
Referral Form
with HL
Checked
Client Self –
Identifies and
contacts HL Lead
HL Broch ure /
HL Website
Page 12
2.0 Invite and Engage Clients/Patients
 Inviting and Engaging Clients/Patients is the first
major step for clients on their Health Links Journey.
 A key Health Links principle and aim is to actively
involve the person in their care and to improve the
patient experience.
Page 13
2.0 Invite and Engage Clients/Patients
 The following Health Link Client Invite & Engage
Client/Patient Processes will help Health Service
Providers to activate clients in the Health Links
Model:
Page 14
2.1 Invite and Setup Home Visit
2.1 Health Links Invite & Setup Initial Home Visit
HSP Partner
Health Links – Invite & Setup Home Visit
HSP Lead Care
Coordinator receives
Referral
HSP Lead Care
Coordinator contacts
client to set up home
visit and explains
Health Links if
appropriate (use
judgement)
HSP Lead Care
Coordinator
Schedules Home Visit
HSP Lead Care
Coordinator starts
Gather Information &
Initiate Care Plan
HL Client / Care Giver
YES
Client provides
VERBAL CONSENT to
get health history
from resources
(Hospital, PCP, other
HSPs)
NO, proceed
without
collecting info
Client provides verbal
consent to get health
history
Page 15
3.0
Gather Information & Initiate Coordinated
Care Plan
 The Coordinated Care Plan is completed from the
perspective of the Health Link client but includes the
inputs from the Circle of Care.
 The Care Team members work together to fill in
sections filled out and updated regularly, however, it
isn’t always possible to have all sections completed
during the first case conference with the client.
 As such, the Coordinated Care Plan should be shared
as soon as possible, even if all of the sections have
not been filled out.
Page 16
3.0
Gather Information & Initiate Coordinated
Care Plan
The following Health Link Gather Information and Initiate Coordinated Care Plan
Processes will help Health Service Providers to activate clients in the Health Links
Model:
 Gather Information from other Health
Service Providers
 Conduct Initial Home Visit and Complete
Assessments
 Medication Review (TBD)
 Obtain Consent
 Initiate Coordinated Care Plan
Page 17
3.1
Gather Information from Other Health Service
Providers
3.1 Health Links – Gather Information
With consent
HSP Lead Care
Coordinator
requests
information from
other HSPs (if
available)
Cumulative
Patient
Profile
Eg. Discharge
Notes
HSP Lead Care
Coordinator uses
Information for
Assessment and to
Initiate Care Plan
HSP Lead Care
Coordinator
Conducts Home
Visit
HL Client / Care
Giver
HSP Partner
Health Links – Gather Information and Initiate Care Plan
Page 18
3.2
3.2
Conduct Initial Home Visit and Complete
Assessments
Health Links Conduct Home Visit and Complete Assessments
HSP Partner
Health Links – Gather Information and Initiate Care Plan
HSP Lead Care
Coordinator
conducts Home
Visit at Client’s
preferred location
HSP Lead Care
Coordinator
reviews history,
medications,
providers, etc with
Client
Separate RAI
consent
required
HSP Lead Care
Coordinator
creates
NO Assessments and
uploads to IAR
platform if
required
HSP Lead Care
Coordinator starts
Gather
Information
Eg. RAI
YES
HSP Lead Care
Coordinator
obtains separate
RAI consent if
required
HL Client / Care Giver
Eg. OCAN
Eg. Geriatric
Assessment
Client provides
additional
information to
Lead Care
Coordinator
Page 19
3.3 Obtain Expressed Consent
3.3
Health Links Client Consent
HL Client / Care Giver
HSP Partner
Health Links – Invite and Engage Patient/Client
During Home Visit
HSP Lead Care
Coordinator explains
HL Informed Consent
to Client
HL Consent
Form
HSP scans and files
Consent
authorization on
local HSP server
Client signs
Expressed Consent
Form or provides
Expressed Verbal
Consent
YES
NO
HSP Updates CCP
with Consent
confirmation when
initial CCP is
started
HSP starts the
Gather Information
& Initiate Care Plan
Process
Client Signs HL
Consent Form or
provides Verbal
Consent
Client does not
receive a shared
CCP / Client
enrolled in regular
HSP service
Page 20
3.4 Initiate Coordinated Care Plan
3.4 Health Links - Create Initial Care Plan
Health Links Gather Information and Initiate Care Plan
HSP Partner
Lead Care
Coordinator Creates
Initial Care Plan
Lead Care
Coordinator shares
CCP with all Health
Care Team
Members
Lead Care
Coordinator invites
Care Team
members to add
HSP client
information if
available
HL Client / Care Giver
HL CCP
Training
Guide
Page 21
3.4 The Coordinated Care Plan- Sections
Consent Directives
My Identifiers
My Care Team
My Health Issues
My known, current allergies and medications
My plan to achieve my goals for care
My situation and lifestyle
My recent health assessments
My most recent hospital visit (auto entry)
My other treatments
My current supports and services
My appointments and referrals
Page 22
4.0
Share Information & Conduct Case Conference
 Sharing information is the corner stone of Health
Links Care. The electronic version of the Coordinated
Care Plan makes this much easier.
 Additionally, proactive notification of issues can
easily be shared with team members using the
secure email services within the tool.
Page 23
4.0
Share Information & Conduct Case Conference
The following Health Link Share Information and
Conduct Case Conference Processes will help Health
Service Providers to activate clients in the Health Links
Model:
 Engage Primary Care Provider
 Build Initial HL Integrated Care Team
 Host Initial Case Conference
Page 24
4.1 Engage Primary Care Provider
Page 25
4.2
4.2
Build Initial Health Links Integrated Care Team
Health Links - Build the Health Links Team
Health Links – Share Information & Conduct Care Conference
HSP Partner
HL Service
Provider
Guide
HSP Lead Care
Coordinator
completes initial
assessment to
determine the
required services
HSP Lead Care
Coordinator uses
HL Provider
Service Guide to
Match Clients
HSP Receives
Referral
HSP Confirms
Participation
YES
Lead Care
Coordinator adds
Care Team
members to CCP
Lead Care
Coordinator signs
starts Case
Conference
Process
NO
HL Client / Care Giver
HL Referral /
or phone call
Lead Care
Coordinator
contacts Health
Link Coordinator
for Assistance
Lead Care
Coordinator
Introduces Care
Team at Initial
Case Conference,
if not already on
Client’s Care Team
Page 26
4.3 Host Initial Client Case Conferences
4.3 Health Links - Host Initial Case Conference
HL Client / Care Giver
HSP Partner
Health Links – Share Information & Conduct Care Conference
HSP Lead Care
Coordinator
invites Care
Team Members to
Pre Conference if
required
HSP Lead Care
Coordinator
invites all Care
Team Members to
Case Conference
HSP Lead Care
Coordinator
reviews roles of all
Care Team
Members
HSP Lead Care
Coordinator
reviews plan with
Care Team
Members
Client/Care Giver
Attends Case
Conference
Client/Care Giver
develops the plan
to achieve their
goals with
assistance form
Care team
Client/Care Giver
develops my goals
(Physical, Mental,
Social Heatlh)
Lead Care
Coordinator
updates Care Plan
with changes from
Case Conference
(if applicable)
Lead Care
Coordinator
provides Client/
Patient with HL
Binder
HL Client/
Patient
Binder
Page 27
5.0 Update & Action Care Plan
 “Patient-centered care is about an overall philosophy
and approach that ensures that everything individual
providers or healthcare organizations do clinically or
administratively is based on patient needs and
preferences. This covers a range of activities – planning,
care, evaluation and research, training, and even staff
recruitment.” The Patient Experience in Ontario 2020:
What Is Possible?
 For Health Link Clients this approach is extremely
important as Health Link Clients are long-term clients.
Page 28
5.0 Update & Action Care Plan
The following Health Links Update and Action Care Plan
CCP Processes will help Health Service Providers
improve CCPs.
 Client Access to Health Link CCP
 CCP Updates
 Health Link Client Status Change
Page 29
5.1 Client Access to Health Link Care Plan
5.1 Health Links Client Access to Care Plan
HL Client / Care Giver
HSP Partner
Health Links - Update and Action Care Plan
HSP Care
Coordinator or
Care Team
Member
Updates Care
Plan
HSP Care
Coordinator
Provides copy
of Plan to
Client
Print copy and
provide to
Client
Page 30
5.2 CCP Updates
5.2 Health Links – Update Care Plan
HL Client / Care Giver
HSP Partner
Health Links - Update and Action Care Plan
HSP Partner
accesses CCP and
enters Update
HSP Partner
shares CCP with all
Health Care Team
Members
HL CCP
Training
Guide
Client / Care Giver
receives copy of
updated Care Plan
Page 31
5.3 Client Status Change
5.3 Health Links Client Status Change
HL Client
HSP Partner
Health Links - Update and Action Care Plan
HSP Care Team
updates Client
status
HSP Care Team
member informs
Care Team
Members
Client Status
Changes
Duplicate, deceased,
moved, withdrawal
consent
Page 32
6.0 Re-Assess Client/Patients
 Clients will be periodically assessed using a variety of
methods.
Page 33
6.0 Re-Assess Client/Patients
The following Health Links Re-Assess Client/Patients
Processes will help Health Service Providers improve
CCPs:
•
Periodic Assessments (RAI, OCAN, etc.)
Page 34
6.1 Periodic Assessments
6.1 Health Links Client Re-Assessments
HSP Partner
Health Links – Re-Assessments
HSP Lead Care
Coordinator ReAssessing Client
HSP Lead Care
Coordinator
books Home Visit
HL Client / Care Giver
Eg. Discharge
Notes
Client has Health
Status Change or 6
months has passed
since last
assessment
HSP Lead Care
Coordinator
reviews history,
medications,
providers, etc with
Client
Cumulative
Patient
Profile
HSP Lead Care
Coordinator
creates
Assessments and
uploads to IAR
platform if
required
Eg. OCAN
Eg. RAI
HL Lead Care
Coordinator
Updates CCP
Eg. Geriatric
Assessment
Client provides
information
during Home Visit
HL Client receives
copy of new CCP
with Team
changes
Page 35
7.0 Client/Patient Transitions
 Health Link clients normally have complex chronic conditions
and medical needs that are not likely to improve.
 A HL client is often on a sliding scale somewhere between
being able to totally self-manage to requiring intensive case
management. Health Links care management is fluctuating.
 It is very possible for a HL client can be receiving selfmanagement supports during a more stable phase of their
Health Links journey, and at another time receiving intensive
care in the hospital during an acute exacerbation of one or
more of their chronic conditions, and then return to selfmanagement when the exacerbation diminishes.
 Clients also have to get accustomed to living on the
continuum.
Page 36
7.0 Client/Patient Transitions
The following Health Links Client Transition Processes
will help Health Service Providers improve CCPs:
 Primary Care Provider Appointments
Scheduled Prior to Hospital Discharge (TBD)
 Self- Management Transitions (TBD)
 Warm Handoffs
Page 37
7.3 Warm Hand-Offs – Providers
7.3 Health Links Client Warm Hand-Off Providers
Health Links - Transitions
HL Client / Care Giver
HSP Partner
HSP Lead Care
Coordinator
transitions to
another
HSP Care
Coordinator
conducts warm
hand-off with new
Lead Care
Coordinator
HSP Care Team
notifies Lead Care
Coordinator of
team membership
transition
Care Team
member conducts
warm hand-off
with new member
and notifies Lead
Care Coordinator
of Change
HSP Care Team
notifies Lead Care
Coordinator of
service completion
Care Team
member updates
My Services
Section
HSP Care
Coordinator
updates My Care
Team in CCP
HSP Care
Coordinator
notifies Client of
Team change
HL Client receives
copy of new CCP
with Team changes
Page 38
Health Link Roles –Client/Care-Giver
 Client/Care Giver responsibilities include:
• Consenting to sharing your Coordinated Care Plan
• Identifying health care team members if not already
identified
• Establishing health care goals and needs
• Advising Integrated Care Lead of change in Health
Care Status
• Work towards achieving their goals as per the
Coordinated Care Plan
• Inform new health care team members of existing
Coordinated Care Plan
Page 39
THE LEAD HEALTH LINKS LEAD CARE COORDINATOR
 The Lead Care Coordinator (LCC) has a unique role in the Health
Links client’s journey. They ensure care continuity.
• Obtaining Client Consent for Health Links
• Conducting Client Interview
• Conducting required Assessments, if required
• Initiating Care Team Referrals, if required
• Contacting Care Team Members, acknowledging existing
members
• Initiating the Care Plan (if started in the Hospital may not need
to do this).
• Support the Client in the Health Links Care Plan
• Acts as the Client Advocate
• Organizing and facilitating the Care Team Case Conference,
inviting Care Team Participants, building relationships with key
partners
Page 40
THE LEAD HEALTH LINKS – THE CARE TEAM MEMBER
 Team members act as the eyes and ears for the Integrated
Care Lead and the Primary Care Provider often learning of a
worsening condition before it is too late. As a member of an
inter-professional care team, the team member has
responsibilities to:
• Identify clients who would benefit the most from an
collaborative care plan
• Participate in Coordinated Care Conference
• Provide past medical history if available
• Add Client Services to the Care Plan
• Update Client Services on the Care Plan
• Support the Client in the Health Links Care Plan
• Advice Care Team members of any concerns or issues with
Health Link Clients.
Page 41
Questions
Page 42