Collaborating with Primary Care CCAC NP/RRN Services Primary Health Care Forum October 2016 Laurie French, Senior Manager, Clinical Support & Utilization Andrea Campbell, Nurse Practitioner, Manager, Clinical Services South East Community Care Access Centre

Presenter(s) Disclosure South East Community Care Access Centre Laurie French Andrea Campbell Relationships with commercial interests: Nil Grants/Research Support: Nil Speakers Bureau/Honoraria: Nil Consulting Fees: Nil Potential for conflict(s) of interest: Nil

SECCAC Direct Care Nursing Services Funding to CCACs since 2012 for 3 Direct Care Nursing Services: Hospice Palliative Care Nurse Practitioners (HPC NP) Rapid Response Nurses (RRN) Mental Health & Addictions Nurses in Schools (MHAN) One local program: Nurse Practitioner/Nurse Led Outreach Team (NLOT) Also funded for Palliative Pain and Symptom Management Consultants, and Palliative Educators Consideration to provincial consistency and several performance metrics Focus on complex transitions to home, and hospital avoidance

Rapid Response Nurse (RRN) Program To reduce rehospitalization and avoidable emergency department visits by improving the quality of transition from acute care to home care for two population groups: Frail adults and seniors that are medically complex or have chronic diseases that tend towards frequent hospitalization including: CHF, COPD, Diabetes, Mental Health and Behavioral Issues, Other complex/chronic Conditions Medically complex/vulnerable children, and their families

RRN Eligibility & Referrals Assessed by CCAC Care Coordinators, target patients are high risk, medically complex/vulnerable patients - frail adults, seniors and children who may:  Poly-pharmacy (e.g. more than 3 medications for multiple chronic diseases) Repeat hospital admissions or ER/Urgent Care visits Assessed to have a brittle or poor support network Chronic disease exacerbations Referral sources now include: Hospital ER and inpatient departments Primary Care for Complex Health Link patients NEW! Hospital based clinics (CHF, COPD) NEW!

RRN Primary Care Communication Home visit within 24-48 hours Update on patient’s acute care event and post discharge regime, clinical assessment and medication reconciliation Arrange follow-up appointment with PCP within 7 days of hospital discharge When there is no PCP, support finding a PCP through Health Care Connect/ or arrange appointment through a walk-in-clinic

RRN Performance Metrics 2015/16 Over 1200 RRN home visits provided last year Average Time to first visit 82% within 24-48 hours post D/C Average Length of stay on the program was 10.1 days including follow-up All patients receive a full medication reconciliation – over 33% resulted in the discovery of a significant discrepancy that the RRN resolved with the PCP and/or pharmacist Many RRN patients are not receiving CCAC services, but some were referred for ongoing support once seen

What will contribute to shared success? Help us identify high risk/frequent admission patients (not always the traditional CCAC referral) Access to hospital discharge summaries/Best Possible Medication History (BPMH) Review RRN assessment documents and medication reconciliation report (via fax on day of visit) Access to F/U PCP appointments within 7 days Make a referral to the CCAC requesting RRN for complex HL patients Call 310-2222 or fax to 613-544-1494

Nurse Practitioner/Nurse Led Outreach Team(NLOT) 36 LTCHs with 4146 LTCH beds in South East 4 Homes funded for embedded NPs - Providence Manor, Extendicare, Helen Henderson and St Lawrence Lodge Independent/municipal funding for an NP in three other LTCHs (Rideaucrest, Fairmount, Trillium) Since 2012 the LHIN has funded the South East CCAC to support LTCHs with an acute care Nurse Led Outreach Team – now expanding to 6 NPs for all other LTCHs Accessible to hospital ER and in-patient departments

Goals of Nurse Practitioner Care by NLOT in LTCH’s Diversion of avoidable ER transfers and readmission avoidance Enhancement of communication and collaboration across the system for necessary transfers to ER Provision of care of residents for acute and episodic health problems or change in baseline health or symptoms Capacity building with the LTCH staff to enhance the level of care provided in the home

NP Patient Care in LTCHs Ongoing promotion of the NP service with staff & Physicians Reducing ER transfers by responding to calls to assess and develop a treatment plan for the resident with changing health status or acute illness Assessing residents when transferred back from ER or hospital admission, or new admission to LTC; development of treatment plans as required Full scope of practice: complete medication reconciliation, treat dehydration/hypodermoclysis, wound care/debridement, exacerbation of chronic conditions such as CHF, COPD, diabetes, pain management. Physical assessment, diagnosis, prescribing, treating and follow-up with staff, physicians, and family Providing point of care teaching with LTCH staff and residents Diagnostic testing (bladder scanner, vascular doppler ABI,TBI)

‘When to call the NP”

Expanded NLOT Areas

Top Ten Diagnoses seen by LTCH NPs Chronic & acute wounds/debridement Responsive behaviours Viral URTI/influenza Pain issues Skin & soft tissue infections Rashes Pneumonia; AE COPD; chest infections CHF Falls Dehydration *Regular use of bladder scanner & vascular doppler

LHIN/NLOT Performance Metrics 2015/16 119 direct ER visits were diverted for LTCH residents 1095 individual residents received NP visits with 1292 treatment plans 13 admissions/hospital returns were supported Response rates: 99.4% within one hour to calls, and 97.7% within 4 hours to visit (significant geography) CTAS scores for NP calls are rising indicating higher acuity in LTC and appropriate calls to divert avoidable ER visits LHIN data showed significant decrease in CTAS 3/4/5 ER visits for CCAC NLOT Homes

Hospice Palliative Care Nurse Practitioner Program 5 FT Hospice Palliative Care (HPC) Nurse Practitioners Currently 3 HPC NPs accepting referrals in the South East (one on maternity leave) Goal to enrich the value of HPC delivery at home by supporting the patient and family through their journey Full scope NP practice: pain management, collaboration with Palliative care and family physicians, education to families and service providers, mentor students, enhancing knowledge of others with advance care planning, and work with families and patients to transition to end of life with more ease Collaborate with the inter-professional care team including home care, primary care, specialized hospice palliative care, and community supportive care agencies to patients living and dying in their place of choice.

SECCAC HPC NP HL Areas

HPC NP Eligibility & Referrals Referrals accepted through the CCAC for patients who: Have a life limiting disease (e.g. cancer, COPD, CHF, or end stage illness Be aware of their palliative care diagnosis, with a life expectancy of 6-12 months Be identified as having HPC needs currently, or the potential to need complex pain and symptom management in the future Be receiving or referred for CCAC services Be supported by a Most Responsible Physician or Nurse Practitioner who agrees to a Shared Care Model with the HPC NP

HPC NP Performance Metrics 2015/16 56 Referrals received last year 682 HPC NP home visits were provided (Average 17 home visits per patient) Average length of stay on program was 75.9 54.3% Deceased in preferred place of death Now requiring Medication Reconciliation for all referrals 90% referrals are Cancer diagnosis, with 10% chronic disease (CHF, COPD, ALS or immune disorder)

Lessons Learned and Opportunities to Strengthen Links to Primary Care Continue to promote program(s) (HPC NPs under-utilized) Streamline referral processes and criteria Continue to share Direct Care Nursing outcomes and results of performance metrics Align more to Primary Care structures and processes Further partnerships to increase shared care opportunities with Primary Care and increase regional capacity

Outstanding care – every person, every day www.southeasthealthline.ca