1. Integrated Comprehensive Care – Bundled Care Pilot Project Hospital – Home a Vertical Integration Concept

2. Patient Value Statement "Please help me fully understand my health challenges so that I can make informed choices about my care.” “I would like timely care when it is necessary, in the most suitable location.” “I want to be clear about what will happen next so I can prepare properly and try to worry less.” “Help support my recovery at home."

4. Unique opportunity to demonstrate an alternate model of care The St. Joseph’s Health System (SJHS) includes an Acute Teaching Hospital, Long-Term Care Facilities and a Home Care provider in the same city Perfect setting to demonstrate and evaluate an alternate model of care. – Better, Faster, Cheaper The SJHS has the governance, management and service delivery alignment to act as an early adopter of this approach. Local Health Integration Network (LHIN) support for this project

5. Alignment with Provincial Strategies Commission on the Reform of Ontario’s Public Services -2012 Co-ordination across a continuum of care Patient-centered care System centered on patients, not institutions or providers Hospitals make discharge summaries available electronically to other care providers Improving access to care: remote communities Key Principles Simple for the patient Patient knows what will happen next Focus on what adds value to the patient Improve the patient experience

6. Accountable Care Organizations Accountable for overall cost and quality of care Strategic integration of care Manage the full continuum of the patient’s care Performance measurement Holds health systems and providers accountable for care

7. Primary Care Primary care physicians key stakeholders in this project Integrated delivery of care with hospitals, specialty services and home care Critical role in supporting the patient after discharge, and collaborating with the broader healthcare team to keep patients at home, prevent ER visits

8. Model: Total Joint Replacement Patient Integrated Care Coordinator

9. Patient Population Three patient groups with broad applicability in Ontario Total Joint Replacements – 500/year Thoracic Surgery, Complex Pleural Space – 450/year Chronic Diseases (COPD, CHF) – 120/year

10. Regional Program: Thoracic Surgery Hamilton: 35%* Greater LHIN region: 65%* *April 1, 2012 – June 30 th 2012

11. 3 rd Party Program Evaluation – PATH group at McMaster University Hospital 60 days Before Surgery Data Validation Home care Home Care Outpatient ER visits Readmissions Home Care Outpatient ER visits Readmissions Length of Stay Diagnosis Length of Stay Diagnosis

12. Patient Satisfaction Questionnaires Pre-hospital Admission Homecare In hospital 60-days Questionnaire 2 Transition Home & Homecare Discharge Questionnaire 1 Pre-hospital & Inpatient Care Referral

13. Early Results Elective Hip and Knee Replacement SJHH Jan-Mar 2012 Ontario Jan-Mar 2012 SJHH April-May 2012 Acute LOS4.2 3.8 Rehab referral rate12.2%12% 8.5% Thoracic Surgery Apr-Dec 2011Mar-July 2012 SJHH Average Length of Stay 7.8*5.1 *Hay Benchmark (Canadian Academic Hospitals): 7.6

14. Project Successes More efficient home visits Remote electronic access to the patient medical record Central contact number for patients: access to the team 24/7 Integrated Carepaths (hospital to home) Standard templates for clinical documentation Cross-training/knowledge transfer Team integration Total Joint Replacement: Physiotherapy within 24 hours of discharge

15. Challenges Building confidence and trust within the team Consistent messaging to patients regarding discharge date Technology implementation

16. Patient Experience/Engagement 60 day follow up calls: overwhelmingly positive feedback Easy and timely access to the team 24/7 Coordination of care and support has been very evident Patient concerns are directed to the most appropriate member of the healthcare team Feel supported after discharge, less anxiety

17. Enablers of success – Team Process mapping, review of current state Knowledge transfer and cross-training The “Expert Team” Empowered Team: Responsibility with Authority

18. Enablers of success – Communication Real-time access to patient information Remote access on mobile devices Email communication Pictures Skype

19. 2 fundamental questions that challenged the Team “How do we provide the team with real-time patient- specific information before the patient leaves the hospital?” “How can we provide integrated care if everyone has their own discrete care plan and documentation?”

20. IT – Critical success factor for integration The clinical team identified a common integrated health record as a critical success factor If we were going to provide comprehensive care, we needed: Common integrated care plan Opportunity to communicate with other members of the team Communicate information from the HOSPITAL to COMMUNITY Communicate and document all patient information during the community component of their care

21. Strategies to support electronic health record We leveraged the St. Joseph’s Home Care information system, Procura, as the platform to establish the electronic health record Devices used by the care providers in the home to support real-time, secured access to view and document in the patient health record

22. Content of the Health Record Procura Tracking Form Contact Info Clinical Documentation Visit Workload Patient Folder Scanned Documents Contact Information Team Interactions

23. Integration with Hospital and Family Physicians Documents are scanned from the hospital record and uploaded real-time to the Procura database Documents that are uploaded to Procura are also shared with the Family physicians Communication to the team from Family physicians is uploaded to the Procura database to be accessible to the entire team

24. Patient Tracking Tool Living document that serves as a dashboard for all ICC clients Updated by the Integrated Care Coordinators in real-time The tracking form is maintained within the Home Care database All team members, Hospital and Home Care can access the database from any location on iPads, computers) Communicates the following information to the hospital and home care team, for each patient: Clinical stream Home care serves required after discharge Expected length of stay Discharge status

25. Investment in IT Purchased iPads with 3G capability for each hospital and home care team member ($20,000) Monthly data charges for remote access ($500/month) Blackberries for specific team members ($2,000) IT resource at STJH to configure/develop Procura ($22,000) Total investment for 1 year: $50,000

26. Criteria for selecting the device Cost-effective: approximately 30 team members will require access to the system Mobility: patients are located throughout the HNHB LHIN Training: user friendly tool, limited training time Battery life: required a device that would not need to charged during the shift Picture quality: pictures a routinely uploaded to the patient file to track progress of wound healing for example Access: required very quick access to the tool and software (time to turn on and log on had to be minimal) Secure access: patient information

27. Enablers of success – Access to Medical Care Physician champions Family physician/Primary Care Outpatient clinic Direct admit to hospital

28. Enablers of success – Adaptability Build a carepath for the entire continuum of care Adjust the process with feedback from the entire team Ongoing self-assessment Right care – right provider – right time

29. Collaboration with key partners The HNHB LHIN and HNHB CCAC are members of the ICC-Bundled Care Steering Committee A memorandum of understanding (MOU) between the HNHB CCAC, SJHH and SJHC outlines the funding transfer

30. Our Patients’ Experience

31. Opportunities for further spread St. Joseph’s Healthcare Hamilton Esophagectomy/Head and Neck surgery Complex pleural space – malignancy Hip fractures Complex medical patient Palliative care: extension of our clinical streams St. Joseph’s Health System St. Mary’s Hospital, Kitchener: COPD/CHF St. Joseph’s Villa Regional Programs Thoracic surgery/CCO