integrated client care project (iccp) palliative care

Integrated Client Care Project (ICCP)Palliative Care

Achievements to Date and the Platform for Palliative Care

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Integrated Client Care Project

With Health Quality Ontario providing quality improvement coaching and capability-building

What is the Integrated Client Care Project (ICCP)?A multi-year initiative developing, implementing and evaluating new and existing models of home care delivery to improve value and quality for the client, and the healthcare system, through:

Coordination Establishing mechanisms to ensure the seamless delivery of care across the

continuum, including primary and acute care

Integration Integrating services through the development of multi-disciplinary care

teams (professional and other); and

Specialization Organizing care around clinical circumstance/client care groupings and

focusing care to achieve higher quality and better value

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Pharmacist

Speech Language Pathology

Social Worker

Respiratory Therapy

ER visit

PersonalSupport &

Homemaking

PrimaryCare

Physician

Physiotherapist

Dietician

Diagnostic and

Laboratory technician

CCAC Case Manager

Lab Technician Occupational Therapist

Supplies & Equipment

NursingDay program

Meals on Wheels

Transportation

The ICCP is a response to current pressures and challenges facing clients in navigating the current landscape of home and community care (e.g., unmet client needs; caregiver burden; equity concerns; wait lists; system utilization pressures).

What was the case for change?

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Who is involved in the ICCP?ICCP Co-sponsors: Ontario Ministry of Health and Long Term Care (MOHLTC) Ontario Association of Community Care Access Centres (OACCAC) Collaborative for Health Sector Strategy at the University of

Toronto’s Rotman School of Management Local Health Integration Networks (LHINs)

Governance: Leadership by a Provincial Steering Committee which includes

representation from the broader health care continuum Supported by Provincial and Local Oversight Groups

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How will coordination, integration and specialization be realized?

Specialized Case Management

Coordinated Multidisciplinary

Assessment

Enhanced System Wide Navigation

Integrated ClinicalService Delivery Teams

Clinical Best Practices/Leading

Practices

Reimbursement basedon Outcomes and

Innovations

It will bring together CCACs and service providers to create opportunities for change using 6 interrelated elements of design:

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What are the client groupings?The Project is focused on 4 client groupings:

Wound care

Palliative care

Frail seniors

Medically complex children

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How are the groupings being implemented?

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Each of the client groupings are being rolled out in a staged manner beginning with wound care.

Subsequent population groupings will build on learnings from wound care and continue to test the new home care model, while adding new elements supporting systemic, organizational and client care integration across the health care continuum.

Wound care: 4 early implementation sites involved 2 types of wounds were chosen (venous leg ulcers; diabetic foot ulcers) related to the high

cost of servicing this population and to avoid disrupting current contractual arrangements

Palliative care: 6 sites Palliative care will be a system-wide approach integrating all partners in regions: hospitals,

hospice care, community support services, physicians. A broader definition of palliative will be used rather than end-of-life

Strengths and gaps will be identified in each participating region, and ways to improve them

ICCP Wound Care Background Information

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Participating sites: Champlain; Central West; Erie St. Clair; North East CCACs

Participating service providers: Saint Elizabeth Healthcare; Carefor Health and Community Services; Bayshore Home Health

Wound Care Outcomes:

Clinical

% Wound reduction: degree of healing at 4 weeks and 12 weeks

Length of stay on CCAC wound services

Chronic Disease Management: % clients adhering to treatment plan at 4 weeks post discharge

SystemCost per Client from referral to CCAC for wound care services to discharged (healed or self management)

Service QualityOverall client &/caregiver experience satisfaction with CCAC Case Management and Service Provider Morale

CCAC & Service Provider staff satisfaction

What are the processes for implementing ICCP?Quality Improvement A key component is the identification of redundancies and bottlenecks in current practice

through tools such as Value Stream MappingValue Stream Mapping (VSM): VSM sessions provide the opportunity for improvement teams (CCACs and partners) to work together to identify inefficiencies in the current state, to leverage opportunities for improvement, and to prepare a full improvement plan including timelines

The results of this work will inform knowledge transfer

Impact Assessment Evaluation will demonstrate value and the impact on clients and the health care system,

thereby firming up the commitment to client-centered care

Spread & Sustainability Spread: The extension of new ideas or work processes beyond the initial population and site Sustainability: New ideas becoming the “norm”

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What is the system impact for wound care? New model expected to have a significant impact on quality of

care, improved health outcomes and more affordable health care delivery

At full implementation, net annual savings/cost avoidance of $100M to $200M, compared to current costs

The acute care sector also stands to gain a 10% reduction in avoidable hospitalizations due to recurring wounds (reduced infections, complications, amputations, etc)

Clients will benefit from wound care practices that are better integrated with chronic disease management, deliver faster healing times, improve client and family experience, and ultimately improve quality of life

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Extrapolation based on Canadian Association of Wound Care data as well as OACCAC/OHA/OFCMHAP Bending the Cost Curve report

Extrapolation based on Canadian Association of Wound Care data as well as OACCAC/OHA/OFCMHAP Bending the Cost Curve report

ICCP Wound Care – The CCAC PerspectiveProject Background Central West: urban / rural, highly diverse / rapid growth region 180 lower leg clients in one year in the Project ICCP services in urban home and nursing care centres Clients are triaged to the ICCP

Lessons Learned: Keys to Success Process for selecting a provider is important (considerations: geography, capacity,

volume, proposal, goals to be achieved, LHIN and CCAC priorities) Collaborative relationship: early trust building and transparency are important Executive leadership / engagement is important to the frontline staff and to ensure

momentum Identify and address issues early. This will move the Project forward and avoid

frontline frustration and disengagement Better opportunities to leverage what’s working well in other Project sites

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ICCP Wound Care – The CCAC PerspectiveLessons Learned: Resources / Roles Project is resource intensive (0.5 FTE Project Lead, 1 FTE Improvement Advisor, dedicated

Case Manager, improvement team members, Executive Sponsor) The Project has built internal improvement capacity within our organizations Improvement Advisor is a team resource however underutilized by SPO

Lessons Learned: Outcomes Improvement in outcome measure takes longer than expected (cost, wound healing) Need to ensure balance between volume / effort / outcomes Paying attention to process measures is important! Data collection has been difficult and

took too long to address Would benefit from periodic review: what’s working keep going; what’s not working

stop! Evolving roles of the CCAC / service provider takes time. Alternate payment plan

implementation will help Recognize that participants may feel at times that this project is : “Exciting, stressful,

inspiring, ambiguous, stimulating, frustrating, or overwhelming - but worth it”!

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ICCP Wound Care – The CCAC PerspectiveThoughts from the CCAC Case Manager: Can focus on one population who have similar problems and co morbidities. Enjoys intensive case

management and the ability to connect more with clients and provide closer follow-up Enjoys working with the ICCP nursing team and has a stronger sense of team. Gets frequent

updates from the team. Overall stronger relationship with the service providers Client feedback is positive – they know who the team is and how to get in touch with them. Better

continuity of care and relationships The pathways are innovative, out of the box thinking to achieve better outcomes for the clients

Feelings from the Clinical Team: Overall results of a recent survey are positive. There is a strong sense of team involvement, pride

and collaboration for ICCP accomplishments; improved client care and commitment to program success. There was valuable feedback on ways that we can improve the committee team meetings, which we intend to capitalize on

The team recognizes that the Project is new and transformative – outcomes will take time and patience is required

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ICCP Wound Care – The Service Provider PerspectiveLessons Learned: Resources / Roles Highly resource intensive project, dedicated team to Project Very positive and collaborative relationship with CCAC Understanding need for change management at operational level

Lessons Learned: Outcomes “If you can not measure it, it will not improve” Evidence-based clinical data reporting elements critical to model Identifying clinical management data elements for clinical system and reporting

more sustainable than development of standardized or common forms

Outstanding Issues: Significant need for an electronic solution to collect amount of data needed Significant definition of system interoperability still required Chronic disease self management still in development

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Data challenges: Paper-based system Achieving consensus on evidence-based indicators Evolving requirements Need for data analysis and verification processes

Outstanding issues for reimbursement model development: Geographic travel Differences in acuity between clients and regions Criteria needed for program entry, exclusion and clinic

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ICCP Wound Care – The Service Provider Perspective

ICCP Wound Care – The Service Provider Perspective

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How is the ICCP palliative care initiative being implemented? Three Streams of Involvement:

Spotlight Sites: System-wide approach to implementing the ICCP model (i.e., integration of the entire system e.g. acute care, hospice, Community Support Services etc.). Participating sites include: Hamilton, Niagara, Haldimand, Brant; Mississauga Halton; Waterloo Wellington CCACs and LHINs.

Home Care Quality Improvement Sites: Mechanisms to improve the quality and impact of CCAC palliative care delivery through exploration of some of the ICCP design elements. Participating sites include: Central West and Toronto Central CCACs.

Leading Practice Assessment Site: LHINs and CCACs seen as leaders with a willingness to be profiled and evaluated. Participating site is South East CCAC.

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What are the benefits of involvement?Opportunity to participate in an innovative project Redesign processes of care, improve business processes and practices First scientific assessment of effectiveness of system level programming First detailed evaluation of system level implementation

Utilization of continuous QI methods that will: Involve frontline workers and senior leadership in change management, education supports and impact

assessment Encourage a review of the current processes identifying bottlenecks and redundancies (VSM) Encourage a move toward an outcomes-based approach for clinical and process measurement Build Quality Improvement capacity in home care Inform palliative care pathways Integrate client care chart

Test new approaches that will inform future policy changes Provide key knowledge for spread & sustainability planning Document the learnings from site implementation with recommendations for leading practices and policy

changes that add value to the system

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What are the opportunities for change in palliative care? Based on evidence, a number of opportunities exist in palliative care to improve value for clients over a full cycle of care. These include:

Better links with chronic disease management to capture populations who are on a trajectory to become palliative, within the 6-12 month end-of-life period

Better links with other sectors: e.g. primary physicians, hospice, and hospitals

Use of shared care approaches to integrate clinical care

Avoid and/or reduce hospital admissions in last months of life

Improve access to community-based care while reducing, or without adding to, family burden

Reduce length of stay for patients who die in hospital

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What are the changes we are trying to achieve in palliative care? Specialized Case ManagementPalliative care clients and their families require different levels of care, at different points in time. Specialized Case Managers will: Assess the client’s needs and eligibility for services, and identify the appropriate level of case management

support

Implement a standardized needs assessment process to inform the development of the initial plan of service, and use standardized tools to prioritize clients for service. The level, intensity and duration of case management support will be adjusted according to the client's needs, as per the CCAC Client Care Model. For complex and high needs clients, longitudinal and caregiver-centred case management including client advocacy is essential

Have overall responsibility for the integration of continuing care services for clients. This includes being accountable for the overall client / family experience of the health care system and for optimal utilization of available resources (while providers in each sector continue to be responsible and accountable for how the care and support they provide contributes to that overall experience)

Shift from authorizing units of service to providing one-window system access, monitoring population health trends and outcomes

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Coordinated and Shared (Multidisciplinary) AssessmentPalliative care clients enter the system through multiple access points that involve a number of different assessment practices.

A coordinated method, including clear accountability, to collect and share assessment information across these multiple access points will:

Inform assessment by all relevant disciplines resulting in a single client record amongst the care team / circle of care

Increase efficiency, eliminate duplication and reduce the burden on the client and family for repeated “story-telling”

Improve current assessment and reassessment processes

Inform standardization of intake assessment and eligibility, as well as support consistent application of relevant assessment information

Promote sharing of information, role clarification and accountabilities across providers and clients (e.g., single client record), and development of care pathways/clinical service plan

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Enhanced System Wide NavigationPalliative care clients require services from different parts of the healthcare and social service systems.An enhanced system navigation role provided by the CCAC Case Manager that supports clients throughout their cycle of care will: Enhance the quality of care and system effectiveness by maximizing linkages,

smoothing transitions, and improving communication across the system, especially with primary care

Provide an opportunity to test strategies to: Better connect clients to other services (e.g., Meals on Wheels, supportive housing,

income supports, primary and secondary care) Facilitate sharing of information Facilitate seamless transitions between sectors Establish a single point of contact for the client. CCAC Case Manager can better

and proactively monitor outcomes

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Integrated Client Service Delivery TeamsPalliative care clients receive care from a variety of healthcare providers.

Accountability for clinical coordination and the achievement of client outcomes by the integrated clinical service delivery team will:

Enhance service integration and improve quality through better communication, joint care planning and the adoption of common tools, practices and standards

Provide the opportunity to review the role and function of a lead provider responsible for coordinating clinical services (in palliative care)

Apply models of “shared care “

Require a sharing of clinical information and the use of common care pathways as per the multi-disciplinary assessment and client record

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Clinical Best Practices/Leading PracticesPalliative care services vary across the province based on local differences and services available.

Identifying clinical leading practices will:

Better support the provision of appropriate services based on client need in their setting of choice, contributing to enhanced quality of care, service equity and standardization including services which may not be currently provided (spiritual, bereavement, etc.)

Demonstrate value in application and effective use of standardized ‘best practice’ clinical tools (e.g., Edmonton Symptom Assessment System (ESAS); Palliative Performance Scale (PPS); standardized integrated end-of-life care pathways)

Encourage new ways of communication / delivering care (e.g., technology for remote communication - assessment, ongoing consultation, trouble shooting, etc.; education/knowledge transfer)

Involve clients and families in Experience-based Design

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What are the expected outcomes for palliative care?

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Key performance and outcome indicators will be confirmed but may include:

Key Outcome Indicators Quality of death RAI CHESS (Changes in Health End-Stage Disease

and Signs and Symptoms) scores (pain and symptom management)

Avoidable hospitalizations

Key Quality Indicators Caregiver burden Client and care giver experience / satisfaction Adherence to evidence based treatment

pathways

Cost-Effectiveness Indicators

Improved cost/service efficiency in home care as a result of integrated care Rate of change in home care costs over a cycle of care: Services and supplies costs (provider) Administrative and case management costs (CCAC)

Cost avoidance in health care system as a result of integrated care Rate of change in client utilization of health system

resources Reduced unscheduled ED visits (especially in last weeks

prior to death) Reduced ALC days Reduced LOS for deaths occurring in hospital

Ultimate outcome Improved valueImproved outcomes relative to cost compared to usual practice

Alternative ReimbursementWound Care Bundled Reimbursement Model work to date:

Due to complexity of process, we will be testing this model initially in Champlain CCAC with Carefor Health and Community Services in summer months

Currently preparing a reference price for utilization during testing - this price will be a starting point based on ICCP CCAC expenditures to date, and will allow us to collect data that we require to evaluate the price further

Process for implementation has been drafted by workgroup comprised of Champlain CCAC, Carefor, Health Quality Ontario and ICCP Project Office

** Work has been completed specific to this setting for testing, however this team must be commended for thinking so broadly and for their hard work and dedication to the success of this innovative model

Expert consultation will occur over the next month to ensure model viability

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Alternative ReimbursementCost of palliative care in all parts of the system needs to be better understood.

Funding differently through ICCP will: Fund providers based on defined ‘episodes of care’ (e.g., all the home care services for

a palliative/EOL client over an appropriate course of time – daily, weekly, monthly, etc.). Payment will be linked to outcomes on specified measures, for example: pain and symptom management, caregiver burden and satisfaction with the care. This will ensure funding rewards outcomes, incents behavior change, and promotes innovation to achieve value

Encourage providers to test alternative technologies and practices as an enabler for improving value where appropriate (e.g. telehomecare access to specialists; tablets, etc.)

Potentially provide much needed information regarding costs of delivering palliative care across all sectors and all provider partners

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QUESTIONS?

integrated client care project (iccp) palliative care

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