Bridging the Gap - Central West LHIN

Report
TELEHOMECARE
Telehomecare
Central
West LHIN
Steering Committee
Central West LHIN
William
Osler Health System
Steering
Committee
Bonnie Burnes
Andrea Martin
Allison Philpot Bonnie Burnes
William Osler Health System
May 29, 2013
May 29, 2013
Telehomecare in Central West LHIN
Program Hosted by William Osler Health System
Progress to date:
• Funding for fiscal 2012-13 confirmed on January 2, 2013
• Program officially launched January 28, 2013
• Five nurses and one Coordinator hired
• Issues including software inefficiencies have been resolved
• E-referral model originally contemplated more complex
• Referral and Enrollment trending upward
Originally stated Patient Targets included:
• 75 patients by March 31 - 59% of this was reached
• 250 by July – at current rate, may not be reached
2
Telehomecare in Central West LHIN
Program Hosted by William Osler Health System
Lessons Learned to date:
• Starting with “sickest” patient not the ideal target group
• Home visit design – learning curve
• External Working Group – major support to program initially
• Internal IT involvement – absolutely required to achieve program efficiencies
• Hospital model works – discharge planners a significant source of referrals
• Engagement role – required and critical to ongoing referral process
3
Telehomecare in Central West LHIN
Program Hosted by William Osler Health System
Osler
Other
(Cardio,
Physio)
3%
CCAC (1%)
Headwaters
(39%)
MD
Offices
36%
Osler
Discharge
Planners
21%
Sources of THC Referrals
TOTAL NUMBER OF
REFERRALS: 153
INELIGIBLE or
DECLINED REFERRALS:
44 (29%)
TOTAL NUMBER OF
ENROLLMENTS:
84 (55%)
Died during referral: 19
No interest: 17
No phone/line: 4
Too sick/palliative: 4
TOTAL NUMBER
PENDING:
25 (waiting for connection
with patient or MD)
Major referrers: Wise
Elephant FHT; Headwaters
Heath Care Centre, Osler
Discharge Planners
TOTAL NUMBER OF
DISCHARGES: 14
Pending referrals
expected: DAFHT; Rexdale
CHC, CCAC
(4 expired, 4 admitted to
acute care, 4 admitted to
nursing home, 1 too sick to
continue, 1 didn’t like
program)
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Telehomecare in Central West LHIN
Program Hosted by William Osler Health System
THC Patient Enrollment Numbers (updated May 27, 2013)
80
70
60
50
40
30
20
10
0
5
Telehomecare in Central West LHIN
Enrollment Strategy 1- Targeted Adoption
Description: Easily identified and implementable activities to increase patient numbers.
What have we done?
Activities
Outcomes
•
47% of referrals from discharge planners
•
•
•
•
Presented at huddles – Medicine,
Cardiology, Respirology
Presented at Osler’s CHARM (HF) and
COPD clinics, LHIN Diabetes SelfManagement
Presentations to EGH and BCH
Primary Care groups
Assisted DAFHT and Wise Elephant
FHT to scan records for potential
patients
Engagement Lead Posting approved
46% from community doctors
Resulted in 80+ referrals (pending)
Telehomecare in Central West LHIN
Enrollment Strategy 1- Targeted Adoption (con’t)
Description: Easily identified and implementable activities to increase patient numbers.
Activities
Outcomes
What have we done?
•
Presentations and electronic support
materials provided to Rexdale CHC,
DAFHT and Central West CCAC, Rapid
Response Nurses, Headwaters Health
Care Centre
Pending referrals from CCAC and CHC
Next Steps
•
Further presentations: Osler ED, Osler Diabetes clinics, Headwaters General
Medicine and Headwaters ED
Follow up presentations: FHTs and CHCs
Hire Engagement Lead
Gaining updated list of recently discharged patients for active calling from Osler
Ongoing presentations: Bramalea CHC and four remaining FHTs, HealthLinks
Connect with clinical leads to learn how to build Telehomecare into pathways for
COPD and HF
•
•
•
•
•
Telehomecare in Central West LHIN
Enrollment Strategy 2- Broad Awareness
Description: Communications activities to support awareness across the LHIN
What have we done?
Activities
Outcomes
•
•
Increased community knowledge and
recognition of program service for
community and internal staff
•
At least five referrals from newsletter
•
•
•
•
Created THC program page on Osler
external website
Joined Yammer THC Group to share
program development with community
care providers
Published article in Osler Voices and
Inside Osler newsletters
Participated in Telehomecare video
produced by OTN – Osler provided
patient and physician
Issued joint news release with Central
West LHIN
Telehomecare in Central West LHIN
Enrollment Strategy 2- Broad Awareness (con’t)
Description: Communications activities to support awareness across the LHIN
What have we done?
Activities
Outcomes
•
•
•
•
•
Next Steps
Included THC content in Osler feature in
Rexdale Community News
Aligned THC program with Central West
CCAC and Rapid Response Nurse
program
THC featured in CEO blog on OslerNet
Two THC articles in eVoices newsletter
(internal)
THC articles of references appeared
in Brampton Guardian, Orangeville
Citizen and YourMississaugaBiz.com
•
Telehomecare email message and
information sheet posted to Central
West LHIN website
•
•
•
“Learn to Live Well with Osler” community education sessions
Rogers Daytime TV – Osler segment on THC
Health Fairs
Telehomecare in Central West LHIN
Enrollment Strategy 3 – Key Champions
Description: Use of Key Champions and Key Influencers to raise awareness and increase
referrals.
What have we done?
Next Steps
Activities
Outcomes
•
• 46% of referrals to date from
community MD offices
Email from Drs. Frank Martino, and Jeffrey
Ashley; two follow ups sent at bi-weekly
intervals
• THC referral form accessed 34
times as a result of email
campaign
•
Dr. Frank Martino participated in
Telehomecare video produced by OTN
•
Lunch and Learns and other presentations on-site by key champions
10
Telehomecare in Central West LHIN
Enrollment Strategy 4- Executive Leads
Description: Meet with organizational Executive Leads to gain program support to advocate for
Telehomecare
Activities
Outcomes
What have we done?
•
Connected with CCAC, Headwaters
and Osler Leadership to target
potential patients
•
Next Steps
•
•
Refreshed patient list from Headwaters
Refreshed patient list from Osler
Ongoing referrals
Telehomecare in Central West LHIN
Program Hosted by William Osler Health System
Next Steps:
Requested Engagement Lead role in 2013-14 budget; no confirmation yet

Hire Engagement Lead

Continue Targeted Adoption

Pursue Broad Awareness

Foster Relationships with Key Champions and Executive Leads
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