Hospital Home Teams - Government of Manitoba

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?
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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
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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
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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?
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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
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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
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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
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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
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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
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■ This has been a very rewarding
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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
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Video of RC
Lessons Learned
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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
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[email protected]
[email protected]
[email protected]
[email protected]