There’s no Place Like Home: Building a Hospital Home Team Health Innovations Conference 2013 November 18, 2013 Introductions •Amanda Condon, MD, CCFP •Jan Williams, RN •Arle Jones, BSW, RSW •Paul Sawchuk, MD, CCFP, FCFP, MBA Conflict of Interest We all receive the majority of our income from the Winnipeg Regional Health Authority No other conflicts to declare What is Our Hospital Home Team? ■ ■ ■ Funded by the Manitoba Government in March 2013 for two communities in Winnipeg Goal is concurrent management of 50 active patients by February 2014 What is Our Hospital Home Team? •We serve the River East/Transcona community area in urban/suburban Winnipeg with 130,000 people •Referrals from Home Care, Emergency, EMS program, Hospital and community MDs Our Hospital Home Team ■ ■ ■ ■ Full time Home Care Case Coordinator Full time administrative support Primary care nurse -~ 50% of primary care clinic time devoted to HHT work 7 physicians/NPs –for total of several hours/week, as regular clinic schedule allows Our Hospital Home Team ■ ■ ■ ■ ■ ■ ■ Weekly team meetings –including patient review and summary of active issues After hours coverage and accessibility Electronic notification of emergency presentation Email/text/in-EMR communication amongst team members Physician and CC involvement in hospital discharge planning Coordinated, interprofessional home visits Home visits –average 7-12 per week Who do we care for? ■ ■ ■ Mean age of patients 75.5, range 29 –101 Involved with patients with dementia, end stage cancer, mental health challenges, morbid obesity, immobility, and chronic pain Coping and socio-economic challenges, lack of social supports and significant care giver burden Case Mr. RC ■ ■ ■ RC is a 61 year old man with severe COPD and bipolar disorder. Past history of living on the street and incarceration. Highest user of EMS in Winnipeg, 77 trips to ER in one year, once six trips in one day. Required oxygen, refused to stop smoking and was substantial security issue. Badly in need of proactive, outreach primary care to help develop a care plan that better met his needs. Case Mr. RC - continued ■ ■ ■ Partnering with the Community EPIC Paramedic Program Planned joint HHT and EPIC Paramedic home visits to proactively address client’s medical needs and reduce EMS use HHT was integral in bringing Long Term Care, EMS and Community Care Programs together expedite his transfer to long term respiratory chronic care Case Mr. RC - continued ■ ■ ■ Access the most appropriate care in a timely manner Client’s feeling of being cared for and safe, something he had not felt at any other time in his life He ultimately passed away in hospital from his end stage respiratory disease process. A place that he identified as ‘home’ Outcomes ■ ■ ■ In our first six months, we took on the care of 38 individuals. Together these individuals had 192 presentations to ER and 943 hospital bed days in the year prior to our involvement. Since our involvement, we have seen a 16%decrease in the use of ER and a 51% decrease in Hospital Bed Days. Outcomes Outcomes ■ ■ This has been a very rewarding ■ experience for our providers as we look for better ways to care for our patients with highest needs. Our patients/ their families tell us that their experience of the health care system has improved dramatically Case Mr. RC revisited ■ Video of RC Lessons Learned ■ ■ ■ ■ ■ ■ Regular team meetings Create partnerships with other community programs/agencies Caregiver and family support Most interventions were supportive rather than medical; medical needs came up quickly Physician commitment and engagement Case coordinator involvement in discharge planning Lessons Learned - Cultural Shifts Traditional Healthcare Culture Emergent Culture Need to get things done immediately Taking the time for discovery and learning Evidence-based practice (scientific proof) Practice-based evidence (social proof) Information and data are trusted Stories and relationships are trusted Culture change is complicated Changes can be simple Leaders need to ‘step-up’ Leaders need to ‘step-back’ Top-down leadership from traditional leaders Bottom-up leadership from the front line Contact Us ■ ■ ■ ■ [email protected] [email protected] [email protected] [email protected]