1. 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

2. 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

3. 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

4. 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

5. 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!

6. RRN Primary Care Communication
Home visit within 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

7. RRN Performance Metrics 2015/16
Over 1200 RRN home visits provided last year
Average Time to first visit 82% within 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

9. 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 or fax to

10. 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

11. 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

12. 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)

13. ‘When to call the NP”

14. Expanded NLOT Areas

15. 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

16. 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

17. 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.

18. SECCAC
HPC NP
HL Areas

19. 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

20. 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)

21. 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

22. Outstanding care – every person, every day