Quality Improvement Plan Central East - Community Care Access...

Central East CCAC QIP – FINAL DRAFT-March 1-17 1

Quality Improvement Plan Central East - Community

Care Access Centre

April 1, 2017 (2017/18 – Plan)


Overview

Fulfilling the Central East Community Care Access Centre’s (CCAC) Vision of Outstanding Care – every person, every day, requires a commitment to promoting the core values, strategic directions and strategic goals of the organization. Given the CCAC’s current transition to the Central East LHIN on or about May 2017, the Central East CCAC extended the use of the 2013-2016 Strategic Plan for its final fiscal years as a stand-alone organization, although a process to reset the strategic priorities was undertaken as the previous strategic priorities had been achieved.

Promoting outstanding patient care and developing a culture of continuous quality improvement also requires a structure that involves all levels of the organization and focuses on bringing value to patients. The Central East CCAC’s Performance Excellence Program provides the structure to achieve its mission of delivering a seamless experience through the health system for people in diverse communities, providing equitable access, individualized care coordination and quality health care. The Performance Excellence Program utilizes four well established Performance Excellence Teams. These quality teams align with the Central East CCAC three strategic directions of the organization’s strategic plan and drive progress towards achieving the organization’s strategic directions and goals. These teams meet on a regular basis and consist of both frontline employees and management. A number of key performance metrics are monitored by the teams to evaluate success and identify opportunities for improvement. In addition to providing advice and/or direction to quality improvement initiatives, he teams are accountable to follow the progress of existing improvement initiatives, and recommend additional Transformational Teams (quality improvement teams) be created as needed to achieve success and ensure sustainability. Like the Performance Excellence


Teams, management and employees are represented on the Transformational Improvement Teams along with patients and/or family members who provide advice on patient improvement opportunities. Our Quality Improvement Plan (QIP) indicators are reviewed regularly and evaluated through the work of the Performance Excellence Program as well as through the organization’s Board Performance Quality and Effectiveness Committee to ensure that the Central East CCAC is continuously advancing the quality of care delivered to our patients. The Central East CCAC QIP indicator initiatives have, as much as possible, been aligned to promote best practice and support the achievement of organizational priorities that optimize outcomes for patients. With the Central East CCAC preparing to transition to the Central East Local Health Integration Network (LHIN), the Central East LHIN’s Integrated Health Services Plan 4 (IHSP) 4 - Living Healthier at Home 2016-2019 was reviewed to ensure alignment of the Central East CCAC QIP to the Central East LHIN’s Overarching Goal: Living Healthier at Home – Advancing integrated systems of care to help Central East LHIN residents live healthier at home.

Quality Improvement Achievements from the Past Year The Central East CCAC has had many achievements arising from the 2016/17 Quality Improvement Plan. Reducing Emergency Department Visits and Hospital Readmissions The CCAC has actively worked on reducing unnecessary emergency department visits by implementing a Central East CCAC Emergency Diversion initiative. The goal of this initiative, and the related tools has been to improve communication and collaboration with hospital partners, hospital palliative care units and primary care providers across the Central East LHIN region. The Central East CCAC’s Emergency Diversion reporting tool was developed and introduced to clearly identify patients who access the Central East area emergency departments two or more times in a 90 day period. The reporting tool flags these patients for care coordinators, which provides them with the trigger to reassess service plans, link patients to other Central East CCAC-led programs and/or community support services, improve support of our palliative patients requiring pain and symptom management and promote independence. Where needed, a Coordinated Care Plan is completed to improve service delivery and help prevent future emergency department visits. Through a newly developed communication tool, patients’ primary care providers are more regularly informed of their patients’ care plan, and better supporting the referral of their patients to the appropriate community resources and CCAC programs. Early results are very encouraging. In addition, the Central East CCAC continues to meet with Family Health Teams to identify opportunities for improving access to the after-hours community health care team versus non-emergent use of the emergency department.


The Central East CCAC Telehomecare Program enables nurses to remotely monitor a patient’s health status, as well as provide education and health coaching related to the patient’s condition. Telehomecare has had a positive impact on reducing both hospital emergency department visits and hospital readmission rates for patients with chronic obstructive pulmonary disease and congestive heart failure. Quality improvement efforts to reduce hospital readmissions also include continuing to build upon the Health Links initiative. The aim has been to use Coordinated Care Plans within the Health Link’s framework for seniors and patients with complex conditions to promote early community-based intervention strategies to minimize hospital readmission. We introduced a Falls Prevention Pilot Project over the past fiscal year to decrease the number of patients falling. The Falls Project has improved communication between care coordinators, service provider agencies and physicians, and has reduced hospital emergency department visits by ensuring that falls are consistently reported and action plans are created specifically to decrease the likeliness of a fall, thus reducing fall-related emergency room visits. Chart audits of active home care patients that do get admitted to hospital continue to be performed in order to establish root causes. This has led to better understanding of patient need and has facilitated the identification of additional opportunities for improvement. Supporting Palliative Patients Central East CCAC has worked hard to ensure that over seventy percent of our palliative patients die in their preferred location. The implementation and continued enhancement of our Combined Palliative Care team has improved the ability for patients dying at preferred location. Three new provincial patient and caregiver experience surveys were rolled out to evaluate the overall experience of selected patient populations. The VOICES survey will assess the experience of Palliative Care Patients and their families. In addition, the Hospital Discharge survey evaluates the transition experience from Hospital to Community and the Mental Health and Addiction Nursing pilot survey will provide an overview of the satisfaction level of parents and students with mental health needs. Strengthening our Urgent and Emergency Patient-Related Communications The Patient Services team has increased the minimum requirement for the number of patients with a primary contact designated in our Client Health Related Information System (CHRIS). This is important as there are situations where the Central East CCAC must be able to reach the patient or primary contact, in cases when the care provider or care coordinator is unable to locate a patient or an emergency event has occurred.


Driving Greater Wound Care Management Our Patient Services team has implemented a new wound care treatment modality called total contact casting. Total contact casting uses a specially designed cast to take weight off the foot in patients with diabetic foot ulcers. Reducing pressure on the wound by taking weight off the foot is the gold standard for wound care management as it will assist our patients who suffer from diabetic foot ulcers to have improved healing time and higher quality of life, reduce long term medical supplies costs and overall nursing costs. Improving our Patient Experiences The Central East CCAC Welcome Booklet includes our Vision, Mission and Values, as well as two pages for our patient’s Service Plan. The inclusion of the service plan pages in the book supports the care coordinator to provide each patient with a written copy of their updated service plan during home visits. The booklet has also been revised to include information about two new programs, Telehomecare and Self-Management. The Welcome Booklet provides the patient with a single location for Central East CCAC information, their service plan and contact information for service providers and their care coordinator. The booklet is produced in French and Chinese; a Tamil booklet is in presently in progress.

Population Health

Work supporting the implementation of the Patient First Act, 2016 will enhance collaboration amongst the network of health service providers and patients, in particularly home and community care, and primary care. As part of this work, the newly established LHIN sub-regions will serve as geographies for population-based planning that will lead the advancement of integrated sustainable system of care that meets the needs of each of the sub-regions and consequently of the entire Central East region.

The Central East health system partners will be collaborating to understand each of the sub-region populations (i.e. health and socio-economic demographics, available services and service needs in order to ensure services meet the needs of the population.

Equity Helping Meet the Needs of a Diverse Population The Central East CCAC Cultural Competency and Diversity plan addresses persons served, personnel, and other stakeholders and considers culture, age, gender, sexual orientation, spiritual beliefs, socioeconomic status and language. This plan describes current activities within the Central East CCAC that illustrate our commitment to providing equity through outstanding care, every person, every day to all people in the diverse communities served by Central East CCAC. The Central East CCAC Cultural Competency and Diversity Committee members have analyzed the various communities and vulnerable populations to identify needs for our employees to work with the Central East diverse population. The Central East CCAC has launched a Cultural and Diversity an internal intranet page that features a cultural competency health assessment, access to online cultural competence training modules, and external resources.


Educators from the Central East LHIN Self-Management Program and our Learning and Development Team have completed a Cultural Competency and Diversity Train-the-Trainer Program offered by the Hospital for Sick Children. In addition, the Central East CCAC Patient and/or Caregiver Experience survey is offered in multiple languages and the Central East CCAC has established Tamil and Chinese Patient Service Caseloads to assist patients of those backgrounds with accessing services.

Integration and Continuity of Care The Central East CCAC continues to nurture and leverage strong relationships with health care partners throughout the Central East Region and beyond, to enhance the patient experience and improve the overall quality of care for our patients. Highlights include:

• The implementation of the Combined Palliative Care model or a standardized Palliative Care Community team has allowed for improved communication and coordination of services between selected service providers and the Central East CCAC The service providers provide specialized care to patients that are admitted onto a palliative caseload utilizing teams of nursing and personal support workers with enhanced training in palliative care.

• The recruitment of a Palliative Care Lead to assist with establishing partnerships within the Palliative Care Community Teams and Palliative Care Hospice to improve the quality of end of life care.

• A self-directed funding model for home care services that gives eligible patients greater control over the selection of their care providers, scheduling and service options. Eligible patients are given the option to receive funding they can use to directly obtain services from a provider of their choosing, rather than having those services arranged for them.

• Implementation of the Bayshore Ordering Supply System (BOSS) which is an electronic medical supply ordering system that will reduce the number of order errors.

• The Central East CCAC continues to be an active participant in hospital committees focusing on readmission avoidance.

• The Central East CCAC and hospital partners work collaboratively with community partners to reduce readmissions to hospitals. Joint meetings with Long Term Care Homes as well as Retirement Homes are taking place that are facilitating the discussion of challenges during transitions from hospital to home and the creation of an improved communication and information sharing processes.

• The Central East CCAC has established organizational Rapid Response Nursing (RRN) program referral targets across hospitals sites which are being monitored to increase referrals to the RRN Program. Tracking of the referral rates and subsequent analysis has resulted in the development of strategies to facilitate improvements in the referral rates.

• Infusion pumps used in the Central East CCAC region have been upgraded following a review with its partners. The new infusion pumps have a multi-therapy infusion


platform that is safe and simple with smart technology and will facilitate the reduction of medication errors/programming pump errors.

• The Central East CCAC continues to work with its service providers to reduce missed patient visits and care. Service Providers continue to research and implement mobile electronic solutions to alert their employees who are out in the community of changes to their schedules.

These quality improvement initiatives support the Central East CCAC efforts to align with the provincial government’s roadmap of Patients First and with the Central East CCAC commitment to provide better communication and integration with health care providers.

Access to the Right Level of Care – Addressing ALC issues The Central East CCAC hospital care coordinators actively work with hospital partners to complete Long-Term Care Home applications and provide thorough placement counselling, including discussion of placement options; however there is limited long-term care bed availability within the Central East CCAC region which increases the time that patients wait to be admitted to a long-term care home. Central East CCAC has been working collaboratively with the Central East LHIN and hospital partners to implement a Common Electronic Regional Referral and Intake (CERRI); CERRI will facilitate the process of referral for patients transitioning from acute hospital care to rehabilitation, and patients transitioning from acute hospital care to complex continuing care.

Engagement of Leadership, Clinicians and Staff As previously noted, the Central East CCAC Performance Excellence Program provides a structure to engage frontline employees, managers, the Board of Directors as well as system partners in establishing shared quality improvement goals and commitments. The Performance Excellence Teams utilize the Institute for Healthcare Improvement (IHI) quality improvement framework approach to establish an aim statement, measures for improvement and a change initiative that facilitates quality improvement. These teams are accountable to the Leadership Team and the Board of Directors. In addition to leadership and clinician engagement, there are structures in place to engage contracted service providers in order to align their respective QIPs with the QIP of the Central East CCAC, and to ensure that efforts are shared and collaborative. Ongoing collaboration with these service providers assists with identifying the Central East CCAC QIP priorities for the year and will help with achieving the QIP objectives. In addition, the Central East CCAC has reached out to engage its hospital partners to seek opportunities of alignment of QIP initiatives.


Client, Patient, Resident Engagement The Central East CCAC continues to seek patient stories to engage patients and improve overall patient experience and satisfaction. The patient stories that are gathered are then used in a variety of ways, including incorporation into the Central East CCAC Board of Director meetings. The themes and sentiments help viewers to truly understand the patient perspective, generate discussion and often point to opportunities for improvement, or just a chance to formally celebrate success. Patients are also being engaged through various social media channels (e.g. Twitter, Facebook and YouTube). These avenues enable the organization to connect directly with patients and stakeholders and help raise awareness of new initiatives and resources available. They also afford the organization the opportunity to receive feedback and directly respond in real time to concerns raised publically. The Central East CCAC has a dedicated Patient Relations program that monitors a dedicated phone line available for patients and caregivers to provide direct feedback regarding service related issues, concerns and compliments. The creation of a Central East CCAC Patient and Family Advisory Council was planned as part of improving the overall patient and family experience. The material to launch the Patient and Family Advisory Council had been drafted; however given that the Central East Local Health Integration Network (LHIN) was launching its Patient and Family Advisory Committee at the same time, a decision was made to put a hold on the Central East CCAC Patient and Family Advisory Council with a plan for the Central East CCAC to work on promoting patient advisors. Patient Advisors will support the Central East CCAC in planning for new programs and provide input on continuously improving the patient and caregiver experience. Patient Advisors have been utilized on a number of improvement initiatives to provide input into policy and program development Staff Safety and Workplace Violence The Central East CCAC ensures every employee, Board member, student, volunteer, contractor, and other persons acting on behalf of the CECCAC the right to freedom from discrimination and harassment in the workplace. The organization has established two policies: Workplace Violence and Workplace Harassment and Discrimination and Home Visit-Security. These policies are a mandatory “must read” for all employees and all employees are required to read and sign off that they have read and understood each policy. Preventing discrimination and harassment is everyone’s responsibility. The Central East CCAC completes a risk assessment of the organization on a regular basis. The risk assessment involves reviewing site visits and interviewing employees to rate a number of elements by evaluating them through the failure, effects mode analysis rating scale of severity, frequency and detectability. Any recommendations from the risk assessment are brought forward to appropriate personnel and a report is reviewed by the Joint Health and Safety Committee who in turn provides recommendations.


Since the 2016, Bill 132, Sexual Harassment and Violence legislation was put in place; the Central East CCAC has required all employees to complete a mandatory e-learning course. The Central East CCAC has also updated its risk event management electronic software system to capture all incidents of workplace harassment in order to ensure complete investigation and to identify any opportunities for improvement. All employee incident reports are reviewed at the applicable Joint Health and Safety Committee meetings.

The Central East CCAC has an ongoing practice that requires all employees to attend amandatory workshop on Non-Violent Crisis Intervention and Prevention. This course is a full day followed by a half day refresher every two years. The workshop reviews all resources available on the intranet for employees including the Home Visit -Security e-learning modules.

Contact Information

For any questions or information on the Central East CCAC 2017- 2018 Quality Improvement Plan, contact at 1-800-263- 3877, extension 2273 or email [email protected].

Sign-off

We have reviewed and approved the Central East CCAC Quality Improvement Plan:

____________________________________Len LifchusBoard Chair, Board of Directors

_____________________________________Nicola CrowPerformance Quality and Effectiveness Committee Chair

____________________________________Kathryn RamsayChief Executive Officer

____________________________________Date

mailto:[email protected]

Quality Improvement Plan Central East - Community Care Access...

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