System of Shared Care (COPD) Learning Session 3

2  Share ideas  Billing  Next steps in collaborating with services in your community  Sustainment Agenda

3 A mind that is stretched by a new experience can never go back to its old dimensions. -Oliver Wendell Holmes, Jr.

4  What have you tried in the last action period  What has gone well? (bring data!)  What has not gone well?  What can help to move this work forward? Sharing our experiences

Storyboard Template

6 Our team aim statement: Our team members (photo encouraged) Our team aim statement: Our Team

7 Insert numeric data, include run charts on key measures for the module. Our Results so far

8 Changes Tested or Implemented

9 Other changes we couldn’t resist testing

10 From all this testing, we have learned

11 We are surprised by

12 Next, we wonder if we should

13  What is one idea that you want to try?  What is one thing you still have questions about? Reflections

Billing

15  GXXXXX (Number to be assigned) – Advance Care Planning Fee › Coming soon › To support effective Advance Care planning Specialist Physician Billing Codes

16  Community Patient Conferencing (G14016) › 4 groups of patients:  Frail Elderly  Multiple Co-morbidities (including COPD)  Palliative/End-of-life  Mental Health › Billed per 15 minutes or greater portion thereof, for conferencing to develop/revise plan to care for patient  Urgent (< 2 hr) Telephone Advice with Specialist or GP with Specialty Training (G14018) › Patient medical acuity requires urgent telephone advice to manage patient in current environment (home, LTC, hospital in home community) – not just based on response time from specialist. Family Physician Billing Codes supporting Shared Care

17  Telephone advice fees with other Physician (GP or Specialist): › G10001 (G14021) – Physician to Physician Urgent Telephone Advice (< 2 hour response time) › G10002 (G14022) – Physician to Physician Patient management Telephone Advice (Up to 1 week response time)  Telephone Follow-up with Patient › G10003 (G14023) – Scheduled Telephone Patient Follow-up Fee Specialist/GP with Specialty Training Billing Codes Supporting Shared Care

18  Effective way of leveraging existing resources  Improving quality of care and health outcomes  Increasing patient access to care and reducing costs.  Provide patients with support from other patients  Physicians can also benefit by reducing the need to repeat the same information many times and free up time for other patients.  Billed per patient, per half hour or greater portion  If more than 1 physician participating, divide patients into equal groups to share the number billed – DO NOT bill both physicians on same patient(s) Group Medical Visits – FP and Specialist

19 Family Physician codes Specialist codes Group Medical Visits – FP and Specialist 19 Fee Code# PtsFee Code# Pts G787633G G787644G G787655G G787666G G787677G G787688G G787699G G G G G78781> 20 G Fee Code# PtsFee Code# Pts >

20  G14017 Acute Care Discharge Planning Conferencing - Family Physician › D/C Planning conference with at least 2 other AHPs (includes specialists) › Per 15 min or greater portion thereof › Must attend in person › FPs with active or courtesy/ associate privileges › To ensure smooth transition to community or LTC.  GXXXXX Acute Care Discharge Planning Fee - Specialists › Coming Soon › Details to come Transition from Acute Care – Discharge Planning Codes

Improving Local Systems of care for COPD patients

22  Insert description… Improving Local systems of care

23 Step 1:  Who is in your local System of care for COPD patients › Clinical Services – community based and specialty services › Educational services › Support services/support groups › Patient groups › Patients and their families  Allocate 1 group to each box What is our Local System

24 Step 2:  What is the role of each of these groups? › List primary purpose of organization › Any inclusions/exclusion criteria  Add description where prompted What is our Local System

25 Step 3:  What are the natural connection points between each group › Connect groups who have existing, active connections › Put a few words describing the connection What is our Local System GP Respirologist Referral request Consult letter

26 Step 4  What are connections that need to be developed between these services › Insert a dashed arrow between the groups › Add a few words describing the new connection What is our Local System GP Better Breathers Education at COPD group visits Referral

27 Step 5  List the actions required to test the new connections in your local systems › Identify who needs to be involved › Who will do what › When will you test this What is our Local System

Are there any new connections that you would like to test?

Sustaining your gains

30 Up to 70% of change initiatives fail, impacting: › Best possible care › Staff and provider frustration › Reluctance to engage in future Why focus on sustainability?

31 The involvement of families and community members in your improvement work will help you sustain › More partners in care › Recognition and encouragement from team mates › Maximizing community and family support You’ve had a head start!

3232 You can all work as one to sustain changes in practice and community!

33 With your community team discuss what you would like to sustain in the practice and community, is it: › A specific change? › A measured outcome from your efforts? › An underlying culture of improvement? › Relationships established in the community? › A combination? (5 min) What are you trying to sustain Source: NHS Improvement leader’s Guide: Sustainability, NHS Institute for Innovation and Improvement, 2007

34  Be clear about the benefits (use measurement)  Establish and document standard processes and have a plan for ongoing training  Establish an ongoing measurement processes  Make changes to job descriptions and procedures to reflect change  Celebrate success! Strategies to sustain the changes Adapted from: NHS Improvement leader’s Guide: Sustainability, NHS Institute for Innovation and Improvement, 2007

35  Staff, providers and patients can describe why they like the change and it’s impact  Providers and staff are confident and can assist in explaining to others  Job descriptions reflect new roles  Measurement is part of the practice and used to monitor progress  The change is no longer ‘new’, but ‘the way we do things around here’ Predictors of sustainability Adapted from: NHS Improvement leader’s Guide: Sustainability, NHS Institute for Innovation and Improvement, 2007

36  At your table, develop a plan for increasing the probability of sustaining your improvement work  Use one or more of the strategies outlined in the previous slide, or come up with others  Share your ideas with the group Sustainability activity

Thank you!