Integrated Care for High Users of   the Emergency Department     Venie Dettmers and Misty Bath          Quality Forum 2013...
Presentation Overview• Provincial and VCH Context• Target Population• Aim and Measures• Integrated Care Process• Successes...
All health authorities in BChave committed to a common goal      “British Columbians have the majority of      their healt...
VCH True North Goals and  Integration Strategy                 Enhance Integration/                 Care Coordination     ...
Target         DowntownPopulation       Eastside                  General Population:             • High incidence of pove...
What we are trying to accomplish   – integrate/connect/coordinate               servicesSt. Paul’s Hospital Emergency Depa...
How do we know that change is      an improvement                                7
What We Are Testing - Integrated        Care Process July                    July 2012                    2013
Registry Summary/Tracking Tool – Integrated Care for High ED Use Clients (DTES IPCC)Last Updated: Jan. 31, 2013           ...
Number of ED Visits at SPH by DTES Core Residents             Known to VCH GP/NP (Active Clients n=59)    140             ...
Number of SPH ED Admissions by DTES Core Residents                    Known to VCH GP/NP (n=59)             FY 2012/13 P1-...
What’s Working/Success• Multi-level engagement of stakeholders – Steering  Committee , Working Group and Site Team Leads• ...
Challenges and Mitigating Strategies       Challenges                 Mitigating StrategiesCompeting priorities e.g.   •Ti...
Emerging Themes• Emergence of specific population cohorts  with un-met needs-   Clients with excessive alcohol misuse-   C...
Next Steps• Provide team education to dispel cross programs  myths and misconceptions i.e. scope, roles etc.• Examine how ...
Thank YouYour Questions?
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B1 Venie Dettmers - Integrated Care for High Users of the Emergency Department

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  • At the centre of the integrated model is the team involving the FP and the HCC and community-based MHSA staff that support the complex patients. - in addition - acute providers – particularly at the interface with the patient’s return home back into the community - specialists that help to support the patient - partners in the community that provide support to help patients be better able to manage their conditions
  • At the centre of the integrated model is the team involving the FP and the HCC and community-based MHSA staff that support the complex patients. - in addition - acute providers – particularly at the interface with the patient’s return home back into the community - specialists that help to support the patient - partners in the community that provide support to help patients be better able to manage their conditions
  • B1 Venie Dettmers - Integrated Care for High Users of the Emergency Department

    1. 1. Integrated Care for High Users of the Emergency Department Venie Dettmers and Misty Bath Quality Forum 2013 February 28, 2013
    2. 2. Presentation Overview• Provincial and VCH Context• Target Population• Aim and Measures• Integrated Care Process• Successes, Challenges and Emerging Themes• Next steps 2
    3. 3. All health authorities in BChave committed to a common goal “British Columbians have the majority of their health needs met by high-quality community-based health care and support services.”…to be achieved through the creation ofan integrated system of primary careand community care services. Development of Integrated Primary and Community Care (IPCC) system in all of VCH communities by 2015
    4. 4. VCH True North Goals and Integration Strategy Enhance Integration/ Care Coordination Across the Continuum of Care
    5. 5. Target DowntownPopulation Eastside General Population: • High incidence of poverty & homelessness • Open air drug trade • Higher morbidity • Higher use of services IPCC Target Population: • High ED Users - People who visit St. Paul’s Hospital ED 10+ during the year & known to VCH GP or NP
    6. 6. What we are trying to accomplish – integrate/connect/coordinate servicesSt. Paul’s Hospital Emergency Department Downtown Community Health Centre Pender Community Health Centre Primary Strathcona Vancouver Outreach Mental Health Native Health Services Team Clinic
    7. 7. How do we know that change is an improvement 7
    8. 8. What We Are Testing - Integrated Care Process July July 2012 2013
    9. 9. Registry Summary/Tracking Tool – Integrated Care for High ED Use Clients (DTES IPCC)Last Updated: Jan. 31, 2013 9
    10. 10. Number of ED Visits at SPH by DTES Core Residents Known to VCH GP/NP (Active Clients n=59) 140 FY 2012/13 FY 2011/12 FY 2011/12 Average FY 2012/13 Average 120 100 80 60DVo#Estfi 40 20 0 1 2 3 4 5 6 7 8 9 10 11 12 13 Period July Dec Period 1 2 3 4 5 6 7 8 9 10 11 12 13 TotalFY 2011/12 73 86 76 92 101 93 91 84 126 99 74 58 68 1121FY 2012/13 51 87 71 55 68 63 87 73 33 57 645 10
    11. 11. Number of SPH ED Admissions by DTES Core Residents Known to VCH GP/NP (n=59) FY 2012/13 P1-P10 FY 2011/12 FY 2012 Average FY 2012/13 P1-P10 Average 14 12 10 8 6 4mNAondbuesrfi 2 0 1 2 3 4 5 6 7 8 9 10 11 12 13 July Period Dec 11
    12. 12. What’s Working/Success• Multi-level engagement of stakeholders – Steering Committee , Working Group and Site Team Leads• Buy-in from Directors and Managers• Clear vision of integrated care• Development of supporting clinical tools: registry, care plan template, case conferencing guidelines• Integrated care process start-up and regular updates of registry
    13. 13. Challenges and Mitigating Strategies Challenges Mitigating StrategiesCompeting priorities e.g. •Timeline adjustedaccreditationSome clients hard to find •Primary Outreach Services made available to helpSlow implementation/ •Funding provided for additionalResources needed RN •Fine-tuning of approach •Ongoing messaging and attention from senior leadership team
    14. 14. Emerging Themes• Emergence of specific population cohorts with un-met needs- Clients with excessive alcohol misuse- Clients attending ED for socialization- Clients with complex & unstable MH issues- Clients with combination Addiction/Trauma/Axis II histories- Aboriginal clients with addictions/trauma• Lack of clarity i.e. program services, roles and time spent engaging high needs clients 14
    15. 15. Next Steps• Provide team education to dispel cross programs myths and misconceptions i.e. scope, roles etc.• Examine how project work can transition to everyday clinical work = developing sustainability• Continue to examine and explore solutions to system wide issues arising from this project work:- Need for after hours community based service?- Developing out-patient infusion clinics for soft skin infections?- Liaising with existing community based outreach resources for wrap around support for complex clients?
    16. 16. Thank YouYour Questions?

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