Through my Eyes - Providing Personal Care.
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Connecting General Practitioners and Home Health through Care Conferencing Susan Lim, VCH IPCC Project Manager ([email protected] ) Debra Sanderson, VCH Community Health Nurse ( [email protected] ) JoAnne Douglas, VCH IPCC Integration Lead ( [email protected] ) Quality Forum 2015 February 19, 2015 1
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Transcript of Through my Eyes - Providing Personal Care.
Connecting General Practitioners and Home Health
through Care Conferencing
Susan Lim, VCH IPCC Project Manager ([email protected])Debra Sanderson, VCH Community Health Nurse ([email protected])
JoAnne Douglas, VCH IPCC Integration Lead ([email protected])
Quality Forum 2015February 19, 2015
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Disclosure
We have no involvement with commercial interests, no potential
conflict of interest and have nothing to disclose.
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Overview of Care Conferencing
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• Implemented throughout Home & Community Care
• Clients in the community have: Increasing complexity Unstable health status or acute medical
needs
• Effective collaboration & communication between Home Health & GPs is key
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• GPs + Home Health Clinicians• Pre-scheduled• 15-minute conference call or face-
to-face meeting• Exchange information• Collaborate on a plan of care for
shared clients
What is GP Care Conferencing?
How is care conferencing different from a phone call with a GP?
An in-depth discussion
Results in a new, change or revision to a care plan
Proactively facilitates best outcomes for the client
Providing information only (i.e. can be faxed)
Confirmation or receipt of orders
Quick question
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• Local Divisions of Family Practice• GP Reference Group• Practice Support Program (PSP)• GPs with large # of Home Health
clients
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How did we engage GPs?
GPCC Survey Highlights% Agreed or Strongly Agreed GPs HH
More aware of other issues affecting client health
89% 78%
Better able to exchange info with other providers in timely manner
86% 68%
Better supported in providing patient care 96% 75%
Enables a more proactive approach to patient care
93% 67%
Improves coordination of care 89% 69%
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1. Identify appropriate clients.2. Consult other team members.3. Schedule time with the GP.4. Prepare for the care conference.5. Conduct the care conference.6. Document the care conference.7. Fax summary to GP.
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Key Steps to Care Conferencing
• Educate GPs about Home Health • Learn about GP services• Provide proactive care• Develop a plan of care together
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What’s the value of care conferencing?
Patient Stories
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Care Conferencing in Action
• Prepare for the care conference• Collaborating is a culture shift • Builds relationships • Care conference champions are
needed
“It takes time but, in the end, saves time.”
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What have we learned?
• Simplify the care conference process
• Mentor new clinicians by: Providing hands-on support Developing scripts they can use Sharing success stories
• Establish protocols to care conference (e.g. every new palliative client)
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How will we spread the practice?
?Questions
