Julie Kille, Operations Leader Brynn Grierson, MSN, Clinical Nurse Leader Dr. Sarah Stone, IDC Physician Elizabeth Barrett, Administration Coordinator Neil Fowler, Program Assistant

What we’ve been working on: Case management (CM) Patient Advisory Group Addictions Group

CM restructuring Restructure of CM team with more defined roles for each team member Complexity score created CM form and database changed to include complexity score IndicatorsUnstableIn transitionStable Housing/Food/Income □ 0 □1□1 □ 2 Addictions & Mental Health □ 0 □1□1 □ 2 Engagement & Adherence □ 0 □1□1 □ 2 Medical Complexity □ 0 □1□1 □ 2 Score:_______________

CM Restructuring: Why? IDC team retreat Evolving mandate of clinic to see patients with higher levels of medical and psychosocial complexity Creation of complexity score gave us an idea of overall complexity of IDC patients

CM Restructuring: How? After the IDC retreat we realized we need more than anecdotal/qualitative measures to evaluate CM and complexity of patients at the IDC STOP evaluators shared with us the indicators used by the STOP outreach team. THANKS!! Modified these indicators to suit our needs

CM Restructuring: QI Being able to quantify and measure CM. Not just staff and patient reports Helps determine patient care plan Ensures appropriate team members are involved in patients care

Other changes/new initiatives Restructuring of Patient Advisory Group New time and new location (at clinic) More frequent meetings Less formal setting Food available Changes made to increase patient engagement and patient voice

Creation of Addictions Group During addiction clinic hours Low barrier group (new members always welcome) Support, education, and treatment options provided by interdisciplinary team Food available Group created to increase engagement of our most marginalized addiction patients and to offer alternative support and treatment options. Other changes/new initiatives

Lessons Learned Be creative when developing evaluation measures Importance of ongoing evaluation of own process (current process, groups etc). We now have the tools to do it!! Importance of engagement and including patient perspective We are not afraid of change!