1. 1 ED iCARE and a Quick Response Team: A Community Pull Strategy Quality Forum February 20, 2015 Shannon Hopkins, Director of Operations, Home Health & Transition Services, Vancouver Susan Seeman, Director, Strategic Initiatives, Care Management Program, Vancouver

2. Ongoing growth averaging 4% per year Call to Action

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4. 4 Vancouver’s True North Goals & Strategic Priorities Providing best care is at the heart of our True North goals and central to what we want to achieve.

5. Home is Best With the appropriate supports, home is usually the best place for frail, elderly patients to recover and manage chronic conditions. In the comfort of familiar surroundings, patients have the best chance to regain their strength and independence. It’s best for the patient, frees beds for patients in need of in-hospital care and eases ED congestion. It’s providing best care. 5

6. iCARE and QRT Partnership in Emergency iCARE daily inter- professional care and discharge planning methodology helps the ED and community teams identify and support priority clients in an effort to prevent unnecessary admissions and create sustainable transition plans for the > 70 year old population

7. ED iCARE Team Care Management Leader (CML) Screens > 70 yrs. old population to identify mod to high risk for readmission patients Ensures medical/functional stability for discharge Facilitates completion of ‘My Discharge Plan’ Sets up post discharge GP appointments within 48-72 hrs of discharge Transition Services Team (TST) Brings HH historical information to planning process Links with HH team to ensure ongoing care Assigns QRT if HH not available for quick response 7

8. ED iCARE Team Quick Response Team (QRT) comprised of 2 nurses, 1 OT and a GP as part of ED iCARE team – collaborates with HH teams Physician bridges primary care between ED and community Available to support discharges when a same day/next day visit is req’d. Can support client for up to 2 weeks following ER visit Will often meet the client in the ER to initiate the ‘warm’ handover to the community Their approach is address any challenges that the client may have that impacts their ability to safely remain in their home Typically they will assist with pain management, mobility challenges and help client settle back into home environment 8

9. We continue to see an increasing number of visits to the ED How are We Doing?

10. *ED admits adjusted for DTU VGH YTD 14/15 ED Admit rate 20.7% - data back to 2003/4 indicates this is the lowest rate achieved (records not available prior to 2003/4).

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12. Success Factors Strategic Priority – ‘One Vancouver’ Shared Vision by entire team Visible Leadership Ongoing coaching and mentorship Standard Work Collaborative Practice Ongoing Evaluation Can’t let up! 12