An Interprofessional Model of Care

OPOP 2009 Annual RetreatOttawa, Ont.2009 Sept. 02

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Presentation Outline

Definitions

National, provincial interprofessional collaboration agenda

Development & implementation of TOH IPMPC ©

Challenges and opportunities

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Definition Interprofessional Care

“The provision of comprehensive health services to patients by multiple health caregivers who work collaboratively to deliver quality health care within and across settings.”

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Definition health care givers (HCP)

“Regulated and/or unregulated health care professionals, personal support workers, volunteers and families who provide health care services at the organizational practice and community levels.”

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Federal provincial agenda

• Ability to provide care to public• Acute shortage impact• Accountability to public• Access to care• Two major strategies: education and

redesign delivery system• Emphasis to date (education,

regulation)

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IPC evidenced benefits

• Improved outcomes for patients with chronic illnesses

• Increase access to health care

• Increased care giver satisfaction

• Decreased health caregiver turnover

• More effective use of health care resource

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Ontario agenda

• Development of a Blueprint: (June 06-July 07)• Building the foundation• Sharing the responsibility• Implementing systemic enablers• Leading sustainable change

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Ontario agenda

• Create Interprofessional Care Strategic Implementation Committee IPCSI (Dec 07-Dec 09): • Advise funding projects (40M)• LHIN & physician engagement• Core competency project• IP education curriculum• Championing IPC

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Inter-Professional

Vision & Progress

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TOH IPMPC© is a guide to organize the delivery of patient care among health

professionals from different disciplines, taking into account their competencies, collaborative patient-centred practice and TOH’s strategic

directions.

What is TOH IPMPC©?

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Who are we talking about?

TOH supports the practice of over 7,500 health care professionals (HCPs):• 9 audiologists• 9 chaplains• 58 dietitians• 3,900 nurses (RNs and RPNs)• 63 occupational therapists• 105 pharmacists• 700 physicians (active)• 182 physiotherapists• 30 psychologists• 6 recreation therapists• 154 respiratory therapists • 108 social workers• 22 speech language pathologists• Other professionals

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Professional Practice Work in Progress

Infrastructure

Processes

Outcome

Role of Chief

Collaborative Practice &Seamless Care

TOH Inter-professionalModel of Patient Care

Core Contribution

Elements of Professional Practice

Improve efficiency &effectiveness

Generic Organizational Model

PAC Revision

Improve quality &Patient safety

Implementation with each program

RT reorganized; PT/OT in review

3 priorities selected

Completed

Completed

Funding & implementation

Monitoring elements of Professional Practice

Research in progress

Evaluation framework for each program

Vision

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Multidisciplinary Professional Practice Model

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TOH IPMPC© - Visual Representation

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• The patient is at the centre• The rings represent the different

disciplines/professionals working with the patient and family

• Each ring is similar in size indicating the valued contribution of each HCP to the patient-centred care and to the team

• Each professional is on its own trajectory • Each profession’s rotation around the center can vary in

frequency and intensity depending on the patient and family care needs

• The rings intersect where contributions are shared• There is a balance when all of its parts

collaborate

TOH IPMPC© - Visual Representation

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Development of TOH IPMPC©

• Multidisciplinary team

• Patient focus groups

• Approved by senior management

• TOH Board and strategic direction

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TOH IPMPC© – Guiding Principles

There are 22 Guiding Principles

Divided into 2 sections:

• Guiding Principles related to Care Environment and Community Linkages

• 10 guiding principles

• Guiding Principles related to Inter-Professional Team Work

• 12 guiding principles

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TOH IPMPC© - Guiding Principles

GUIDING PRINCIPLES RELATED TO CARE ENVIRONMENT AND COMMUNITY LINKAGES

1. The patient/family will receive seamless care/services across settings including transition to and from the community, through coordination of care by the appropriate provider and through processes that meet the clinical pathway of the patient/family.

2. Patient/family will receive safe and competent care from the most appropriate health care providers.

3. The patient/family will receive continuity of care by interacting as much as possible with the same health care provider in their respective areas of expertise.

4. Care provision will occur in a supportive environment that facilitates compassionate care.

5. The plan of care will include the comprehensive assessment of patient and family needs from referral to discharge, implementation of plan & evaluation of outcome.

6. The patient will receive required care within an acceptable timeframe determined by evidence regarding their specific diagnosis or care needs.

7. Patient and family clinical information will be available to all health care providers, guided by the privacy act, across settings to ensure seamless and timely care delivery.

8. Caregiver needs will be identified and included in the plan of care.

9. The patient/family will receive care in either of the two official languages and resources will be sought to facilitate communication in other languages.

10. Patient and family will have their individual beliefs and values recognized and respected by all health care providers.

GUIDING PRINCIPLES RELATED TO INTER-PROFESSIONAL TEAM WORK

11. Each health care provider will be accountable for the care provided.

12. Patient/family will have access to information to assist in decision making, treatment management options, support, and self-care.

13. Patient/family will be active participants, in the decision-making process about their plan of care. The degree of involvement will be defined by the patient.

14. Ongoing two-way communication between the health care providers and with the patient and family will guide the development, understanding and implementation of the multidisciplinary plan of care.

15. The patient/family will have the opportunity to develop therapeutic relationships with health care providers.

16. Health care providers will be knowledgeable of the resources available in the community and will communicate these to the patient and family.

17. Primary care providers will have access to resources (e.g. guidelines) required to provide appropriate ongoing care and will ensure that the patient and family are aware of follow-up guidelines.

18. Health care provider will have access to appropriate information technology to ensure optimal management of care.

19. The health care providers will collaborate and provide support to foster team spirit and teamwork.

20. The health care providers will ensure, to the best of their abilities, that the patient/family’s expectations of care are aligned with the capacity of the healthcare team to provide services within recognized standards.

21. The health care provider will have access to continuing professional development that facilitates the acquisition of knowledge and the maintenance of competence.

22. Education and research are values held by TOH as being essential to the maintenance and development of the most appropriate and effective models of patient care.

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Planning Implementation

• Steering Group

• Model Facilitators

• Research Team

• Education Team

• Support Team

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Phases of Implementation

• Phase One - PreparatoryPhase One - Preparatory• Team issuesTeam issues• Selection of Advance TeamSelection of Advance Team• Research baselineResearch baseline

• Phase Two - Advance TeamPhase Two - Advance Team• Review of Guiding PrinciplesReview of Guiding Principles• Development and Implementation of ADevelopment and Implementation of Action Planction Plan• Communication Plan to teamCommunication Plan to team• Set Implementation dateSet Implementation date

• Phase Three – ImplementationPhase Three – Implementation• TOH IPMPCTOH IPMPC©© ‘goes live’ ‘goes live’• Advance Team support and problem-solvingAdvance Team support and problem-solving

• Follow-upFollow-up• Annual team self-reviewAnnual team self-review• Research evaluation: at 6 months and 12 months post-Research evaluation: at 6 months and 12 months post-

implementationimplementation

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Challenges and opportunities

• Challenges:– Multiple project in a system in transformation– Finding time and setting priorities– Preconceive idea between health care providers – Physician engagement– Legislative impact

• Opportunities:– Learning from effective teams and projects– Changes in education of future professional– Changes in scope of practice between professional– Increase efficiencies– Time to reflect and solve issues– Physician engagement

An Interprofessional Model of Care

OPOP 2009 Annual RetreatOttawa, Ont.2009 Sept. 02