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Regional Integrated Complex Patient Care Planning: Familiar Faces Helping Those who Frequently Revisit Multiple Emergency Departments
Regional Integrated Complex Patient Care Planning: Familiar Faces Helping Those who Frequently Revisit Multiple Emergency Departments
Regional Integrated Complex Patient Care Planning: Familiar Faces Helping Those who Frequently Revisit Multiple Emergency Departments
Regional Integrated Complex Patient Care Planning: Familiar Faces Helping Those who Frequently Revisit Multiple Emergency Departments
Regional Integrated Complex Patient Care Planning: Familiar Faces Helping Those who Frequently Revisit Multiple Emergency Departments
Regional Integrated Complex Patient Care Planning: Familiar Faces Helping Those who Frequently Revisit Multiple Emergency Departments
Regional Integrated Complex Patient Care Planning: Familiar Faces Helping Those who Frequently Revisit Multiple Emergency Departments
Regional Integrated Complex Patient Care Planning: Familiar Faces Helping Those who Frequently Revisit Multiple Emergency Departments
Regional Integrated Complex Patient Care Planning: Familiar Faces Helping Those who Frequently Revisit Multiple Emergency Departments
Regional Integrated Complex Patient Care Planning: Familiar Faces Helping Those who Frequently Revisit Multiple Emergency Departments
Regional Integrated Complex Patient Care Planning: Familiar Faces Helping Those who Frequently Revisit Multiple Emergency Departments
Regional Integrated Complex Patient Care Planning: Familiar Faces Helping Those who Frequently Revisit Multiple Emergency Departments
Regional Integrated Complex Patient Care Planning: Familiar Faces Helping Those who Frequently Revisit Multiple Emergency Departments
Regional Integrated Complex Patient Care Planning: Familiar Faces Helping Those who Frequently Revisit Multiple Emergency Departments
Regional Integrated Complex Patient Care Planning: Familiar Faces Helping Those who Frequently Revisit Multiple Emergency Departments
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Regional Integrated Complex Patient Care Planning: Familiar Faces Helping Those who Frequently Revisit Multiple Emergency Departments

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This presentation was delivered in session A3 of Quality Forum 2014 by: …

This presentation was delivered in session A3 of Quality Forum 2014 by:

Laura Cross
Project Manager, Integrated Primary and Community Care
Vancouver Coastal Health

Roy Ang
Clinical Supervisor, Vancouver Community Older Adult Mental Health
Vancouver Coastal Health

Published in: Health & Medicine
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  • 1. Regional Integrated Complex Patient Care Planning (RICP2) Helping Those Who Frequently Revisit Multiple ED’s BC Quality Forum 2014 February 27, 2014 Laura Cross, Project Manager, Integrated Primary, Acute & Community Care, Vancouver Coastal Health Roy Ang, Clinical Supervisor, Vancouver Community Older Adult Mental Health & Addiction Services, Vancouver Coastal Health 1
  • 2. What we plan to share today….  RICP2 – background  Case study example  Successes, Challenges  Next Steps  Questions & Discussion 2
  • 3. Opportunity Knocks ED’s working mostly in isolation with inconsistent care planning process EDs identifying, partnering with the patient, primary care, home health, mental health teams to develop a sustainable shared care planning process Wrap Around Care 3
  • 4. Who are the Familiar Faces? 4
  • 5. Starting the PDSA Journey Shared Care Plan (SCP) Tool based on IHI Secure Point Persons • ED’s (ED PP) • Community (CPP) Coordinated & Initiated SCP’s • Multidisciplinary for all Clinicians • My Health for Patient • Care Conferencing • Developed by Community PP • Registry at ED 2 Trials of developing SCP’s for FF’s from each Community of Care/ED site Standard Operation Procedures Evaluation & Sustainment Planning
  • 6. Familiar Faces at ED With Shared Care Plan FF presents at ED and is flagged as having a SCP SCP is pulled and put on chart Medical Staff use SCP SCP is developed & coordinated by Most Responsible Clinician in Community EDPP partners with CPP if changes are needed to be made to SCP
  • 7. A CASE STUDY 7
  • 8. The Hilly and Winding Journey 8
  • 9. Sustaining This Work 9
  • 10. SUCCESSES Quick Wins Heart Warming Culture Shift 10
  • 11. CHALLENGES & BARRIERS Processes Systems Professionals Patients 11
  • 12. Integration Care Coordination Flexible Services Communication Consistent Messaging Intensive Resources It’s About Time! Patient Centered Behaviour Change Required All Round Leadership Support KEY MESSAGES Systems & Processes Clout! Preventative
  • 13. Next Steps Messaging Out to All Relationship Building Plan for Sustainment Evaluate & Track Refine Processes 13
  • 14. Discussion & Questions? 14
  • 15. THANK YOU! Laura.cross@vch.ca Roy.ang@vch.ca 15

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