CUPS presentation 2 from Sept 2017 CACHC conference
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Presentation from CUPS Calgary on Connect 2 Care during 2017 CACHC Conference site
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CUPS presentation 2 from Sept 2017 CACHC conference
- 1. Community Supports for the Socially Vulnerable During Transitions of Care Dr. Van Nguyen, CUPS Health Director Elaine Wilson, Program Manager, CUPS
- 2. Calgary Urban Project Society (CUPS) EDUCATION HEALTH HOUSING
- 3. CUPS Health Clinic Primary Health Care Women’s Health Prenatal care Obstetrics Pediatrics Mental Health Hepatitis C On-site lab Outreach Clinics Dental Clinic Optometry Dietician Foot Care Visiting Specialists Opioid Agonist Treatment PATIENT Over 5000 unique patients per year Over 28,000 visits in 2016-17
- 4. ‘Alberta urged to re-think how it spends health-care dollars as costs soar’ (November 9, 2014) ‘A study released recently by the Canadian Institute for Health Information (CIHI) indicates Alberta will spend nearly $4,700 per capita on health care this year... more than any other province besides Newfoundland and Labrador’.
- 6. Challenges with the Current System • Patient factors for those living in poverty – Homelessness, poverty – Addictions, mental illness, cognitive impairment – Mobility, disability – Lack of transportation – Lack of Alberta Health Care # (11% of patients at CUPS) and health insurance benefits plan (Alberta Works, AISH) to cover medications • Health system factors – High volumes in the ED, pressures to discharge – Social stigma – Inadequate knowledge about social determinants of health – Inadequate knowledge of community resources in ED staff – Health information privacy, agencies work in silos
- 7. We Need Better Care Coordination • Initial partnership between CUPS and Emergency Medicine in 2015 • Identified gaps in care for homeless/low income patients accessing the ER • Communication • Information sharing • Transition care
- 8. Calgary 2015 Frequent Users In patients with No Fixed Address (NFA) who visited the ED in 2015: 1213 unique patients with >3 visits 7.4 visits per person 482 unique patients with >6 visits 13.3 visits per person Top diagnoses: Alcohol related problems Cellulitis COPD Abdominal pain Drug related problems Other mental health complaints
- 9. A Community Based Approach • Evidence-based • Studies have shown that intensive case management approaches that work together with hospitals have: o Lowered ER visit rates o Improved engagement with primary care and community programs o Reduction in homelessness o Cost-effective Primary Care Housing Specialty Care Addictions Treatment Health Insurance Income Support Transportation Mental Health Family Employment Education Hospital
- 10. Connect 2 Care Team • Beyond the 2 year pilot……… • Alberta Innovates – Health Solutions PRIHS 3 funded for 3 years starting October 2016. • Calgary scale and spread • The TEAM: – 2.0 FTE RN (CUPS) – 4.0 FTE Health Navigators (DOAP Team) – MOBILE – 2 vehicles • Direct partnership between CUPS and Alpha House • Research: O’Brien Institute for Public Health
- 11. Alpha House • Shelter • Detox Program • Housing-First • Outreach o Encampment Team o DOAP Team (Downtown Outreach and Addictions Partnership)
- 12. CAMPP • Calgary Allied Mobile Palliative Program • Nurse navigator from CUPS + palliative care consultant • Advocacy to support navigation of palliative, housing, and health/addiction services
- 13. • Low-income adults AND • Homeless or vulnerably housed AND • 3 ED/UC visits in past year OR 2 inpatient admission • OR end of life diagnosis C2C Target Population
- 14. C2C Activities • Provide intensive case management that is very client-driven and includes extensive outreach into the community • In acute care we are ADVOCATES • Housing support • Advocate for appropriate housing placement and support the transitions to housing or treatment programs • Provide ongoing case management focused on addressing health concerns – both in shelter and when housed • Coordinate services to support clients in maintaining their housing • Provide addictions support including advocacy, harm reduction and care through points of transition • Support connection to primary care • Connect client to appropriate PCP and communicate/advocate • Palliative care and end of life supports
- 15. EVALUATION AND EARLY DATA
- 16. Acute Care Use Based on 127 patients seen Nov 2015-Feb 2016 ED and Urgent Care visits Avg Visits/yr 12.7 Range 1-140 Arrival by EMS 38.4% Top 3 Diagnoses Alcohol related Cellulitis COPD Admissions Medical/ Surg Psychiatry Avg Admissions/yr 1.4 0.5 Mean LOS 8.9 7.2 % with ICU 5.6% 4.7% Top 3 Diagnoses Cellulitis Sepsis Pneumonia Alcohol related Stress reaction Drugs
- 17. C2C Demographics 220 individuals referred since Feb 1, 2017 Mean Age (years) 46.5 Male 69% Indigenous 24% Addictions 93% Dx Mental Illness 47%
- 18. C2C Client Status 0 10 20 30 40 50 60 70 80 Not ready to engage Active On the radar Deceased Graduated Lost to follow- up Not willing to engage Referral only
- 19. Primary Referral Reason 0 10 20 30 40 50 60 70 80 90 Medication coverage Dental referral Mental health supports Frequent acute care use Addiction supports Care coordination Advocacy in hospital Discharge planning Housing supports PCP attachment 0.5% 1% 4% 6% 9% 11% 12% 14% 22% 22%
- 20. C2C progress update • 78/115 (68%) unhoused and engaged clients have been housed since working with C2C • 7 of the 38 housed individuals have been supported by C2C to move to more appropriate housing • 52/84 (62%) engaged clients who were previously not connected are now connected to PCP 19% 81% Housed Unhoused 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% Housing status on intake
- 21. STAGE 3 STAGE 2 STAGE 1 ROCKYVIEW HOSPITAL 2RNs +2HNs PETER LOUGHEED CENTER FOOTHILLS HOSPITAL CONSOLIDATION SOUTH HEALTH CAMPUS Jan 2017 Apr 2018 Jan 2018 Jul 2018 Stakeholder Meetings and Plans for Upscale with other urban centers in Alberta Jan 2019 Calgary Scale Edmonton & Provincial Implementation and Scale +2HNs
- 22. STRUCTURE PROCESS OUTCOMES Program Goals Evaluation Methods Expected Outcomes ↓ ED visits, hospitalizations ↑ Self-reported health Understand the Mechanism Developmental evaluation Refined, consistent, and effective program ↑ Care Experience Qualitative interviews Understand the personal experience ↓ Acute Care Use ↑ Patient Health Pre-post study with comparator group Survey (PROMs) at 0, 6, 12 months
- 24. Questions to the Group 1. How can we continue to improve the communication between acute care and community partners regarding this population? 2. How do we support graduation from C2C? Should this be a goal?
- 25. QUESTIONS Dr. Van Nguyen vann@cupscalgary.com Elaine Wilson, RN elainew@cupscalgary.com 403-613-8736
Editor's Notes
- Around 5000 unique patients per year with over 25,000 visits across all health programs We see patients without valid Alberta health care, who otherwise would not be able to access mainstream fee for service clinics. We keep statistics on the # of patients who lack Alberta health care for 2013, this percentage was 11% of our total patient visits. We connect people to our CUPS ID clinic which helps them to obtain their identification, birth certificate so that they can apply for Alberta health care insurance. Almost 4500 total visits in our shelter outreach clinics in 2013/14, averaging about 375 patients per month
- We are all familiar with the revolving door care pathway: highly complex individuals are using the hospitals A LOT These include people who are homeless or unstably housed. They who may have nowhere else to turn or are simply not accessing the care need in the community. As a result, many end up in crisis. Hospital staff, primary care providers, community organizations and patients are all frustrated by the ineffective transitions in care and the lack of communication across silos Just last week while I was on inpatient service, I admitted a patient who had been in and out of hospital x times in the last 6 months, had discontinued his x treatment 3 times, and was … We believe the Coordinated Care Team is the missing link for a long needed integrated system of care for this population (ER pic – creativecommons.org; person – pexels.com; sleeping outside – commons.wikipedia.org; alcohol – pixabay.com)
- We see patients without valid Alberta health care, who otherwise would not be able to access mainstream fee for service clinics. We keep statistics on the # of patients who lack Alberta health care for 2013, this percentage was 11% of our total patient visits. We connect people to our CUPS ID clinic which helps them to obtain their identification, birth certificate so that they can apply for Alberta health care insurance.
- Higher users can be defined by # visits, length of stays or cost. In this case we have chosen to define by # ED visits. 2013 – 3247 total visits by homeless patients across 4 Calgary ER and 2 urgent care sites= ~500 visits per site So total for 2 hospital EDs, would target 500 or more referrals.
- “A collaborate process of assessment, planning, facilitation and advocacy for options/services to meet an individual’s health needs through communication and available resources to promote quality cost-effective outcomes”
- 30% of Calgary income earners make less than $15,000 per year (CHF annual report 2013) Emphasize that most of the data we are presenting are for homeless and not for vulnerable pops Why this population? Higher morbidity/mortality rates than general population, least able to access services.
- Acute care: Advocate for appropriate assessments, admissions, specialist consults, OT/Physio, addictions support Attend case conference meetings in hospital and advocate for appropriate care Support discharge planning
- Self identified indigenous peoples make up 2.2% of Calgary’s population according to 2012 census
- The C2C program was launched on November 1, 2015 with two Registered Nurses and we plan to increase the program scope and capacity by incorporating 4 community health workers starting January 2017. We have been working closely with the Foothills hospital emergency department to institute a formalized referral process, such that the C2C nurses are notified within X hours of a … Also, working closely with the Emergency department at the Foothills hospital we have instituted a simple formalized referral process for C2C. This has resulted in a significant increase in the number of referrals received from the ED from 20/month to begin to now over 40/month – we can’t say this... Our scale plan is based on going from 20-25 now to 40 with 2 CHWs . Further, we have been working closely with the Peter Lougheed Hospital where I work clinically, to help the ARCH team recruit patients for our shared control group. This, in combination with our with with the Foothills hospital, will pave the way for expansion to this site. As such, we will be ready to expand to this site next. We are confident that we can institute similar referral processes across all 4 hospitals where we have partners in the ED, and also among the hospitalist, internal medicine and psychiatry services where we focus our recruitment. Finally, we have a strong working partnership with the Inner City Health and Wellness program in Edmonton, and have already begun to identify potential collaborating sites partners for future scale through our joint learning collaborative
- Our evaluation plan was designed to be efficient and practical. Using the Donabedian framework of structure, process, and outcome to evaluate complex health interventions, we will use both qualitative and quantitative methods to evaluate 4 primary objectives: Number 1: “Understand the Mechanism”. We aim to understand how and why the CCT program works. We will use a developmental evaluation process, which is similar to formative evaluation but makes explicit the process of iterative improvement. Our team will meet regularly to define short-term implementation goals, what, if any, obstacles we are encountering, and how to overcome these. Number 2: “Improve the care experience”. We will use one-on-one interviews to investigate patients’, CCT staff, and referral partners’ experiences with the CCT intervention. This qualitative analysis will enable us to understand the personal impact of the program. Number 3: “Reducing acute care use”. Our overall objective is to decrease acute care utilization and its resulting costs. We will use administrative health data to determine the change in utilization metrics for CCT clients pre and post intervention. To overcome the potential for regression to the mean, we will use a comparison group of similar Calgary patients provided in-kind through our ARCH program partners in Edmonton. Finally, “Improving patient health”. Importantly, we aim to improve the overall health of our target population. Quality of life and other patient reported outcomes will be measured using repeated surveys at baseline, 6 months and 1 year post-enrollment. Again, we will compare the changes in scale scores over time with those of the ARCH Calgary control group.
- Alberta Health Services University of Calgary, Department of Family Medicine Calgary West Central Primary Care Network 6 homeless shelters City Case Management Group Network of “Inner City Clinicians” and clinics serving vulnerable populations Calgary Homeless Foundation Long list of social service agencies