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Innovative practices in transitions between hospital and home: Recommendations in support of advancing a Health Links approach A presentation to the Embracing.

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Presentation on theme: "Innovative practices in transitions between hospital and home: Recommendations in support of advancing a Health Links approach A presentation to the Embracing."— Presentation transcript:

1 Innovative practices in transitions between hospital and home: Recommendations in support of advancing a Health Links approach A presentation to the Embracing Leadership, Engagement and Transformation Primary Health Care Forum 2016 Agnes Gibson, Regional Quality Improvement Specialist Susan Taylor, Director Quality Improvement Program Delivery October 6, 2016 Health Quality Ontario The provincial advisor on the quality of health care in Ontario

2 Faculty/Presenter Disclosure
Name of Presenter(s): Susan Taylor & Agnes Gibson Relationships with Commercial Interests: NONE Grants/Research Support: NONE Speakers Bureau/Honoraria: NONE Consulting Fees: NONE Other: NONE

3 Disclosure of Commercial Interests
This presentation has received financial support from: NONE This presentation has received in-kind support from: NONE Potential for Conflict of Interest: NONE

4 Learning Objectives Learn about a systematic approach to the identification, assessment, selection and dissemination of innovative practices in order to: Champion effective local innovation among Health Links; Enable performance improvements among all Health Links based on evidence-informed and experience-based practices; and Provide information on how to implement innovative practices and connect communities. Describe the opportunities for family physicians and primary care practices to leverage these approaches to improve the care experience for patients living with multiple conditions and complex needs

5 Supporting the Advanced Health Links Model
Improving integrated care for patients with multiple conditions and complex needs MOHLTC LHIN Sets the strategic direction for Health Links Provides overall funding to the LHINs Oversees the overall performance of the Health Links initiative to guide strategy Facilitates operational success by implementing provincial level tools and supports Sets regional priorities for Health Links and ensure alignment with provincial priorities Funds Health Links in accordance with priorities Maintains overall accountability for Health Links performance, LHIN by LHIN Drives operations through implementation of plans and support for adoption of provincial tools Identifies and implements regional supports and tools as required Health Quality Ontario Support data collection, timely reports and analysis Lead systematic identification of emerging innovations and best practices Increase rate of progress through standardization of best practices across all Health Links Support inter-Health Link sharing of lessons learned on regional or pan-provincial basis Connect LHIN HL Leads with other relevant provincial quality initiatives

6 Quarterly Reports Circulated broadly with full transparency among Health Links Includes: Self reported data on two key measures (Coordinated Care Plans and attachment to Primary Care Providers) Local and provincial targets Summaries of discussion on how Health Links are approaching Patient stories Future reports will include uptake of innovative practices endorsed by the Clinical Reference Group

7 Impact of Health Links – Q1 Update
06/12/2018 Impact of Health Links – Q1 Update Coordinated Care Plans Access to Primary Care 22,707 complex patients have been provided with coordinated care plans through Health Links 34,072 Health Links patients have been connected to regular and timely access to Primary Care Data Source: Health Quality Ontario’s Quality Improvement Reporting and Analysis Platform (QIRAP) – self-reported by Health Links Health Quality Branch

8 Clinical Reference Group
The Clinical Reference Group (CRG) is an action-oriented, functional body, designed to assess the quality of evidence, impact, and spread of existing practices within the Health Links for the purposes of identifying suitability and readiness for wide scale spread.

9 Innovative Practices Evaluation Framework

10 Innovative Practices Evaluation Framework
Systematic review of innovative practices, with consideration of: Quality of the evidence Impact/Results Spread Possible recommendations include: • Not at this time • Targeted spread within specific contexts • Provincial spread, with 1 year reassess using Innovative Practices Evaluation Framework • Large scale provincial spread Attachment: Innovative Practices Evaluation Framework - overview

11 That advises on what (and why and who and how) and when
A Continuum… Quality Standards That advises on what (and why and who and how) and when

12 Transitions between hospital and home
An important part of providing coordinated care to patients is improving patient transitions within the system to help ensure patients receive more responsive care that addresses their specific needs.

13 Assessing Innovative Practices

14 Transitions from Hospital to Home
The approach to effective Transitions from Hospital to Home can be outlined as follows:

15 Example 1:

16 Links to Click

17 Transitions between Hospital and Home

18 Evidence-Informed Best Practices
Steps for Transitions between Hospital and Home Evidence-Informed Best Practice (cited in Quality Compass*) Early in the Hospital Admission Perform medication reconciliation on admission Assess patient risk of readmission Assess health literacy Throughout the Hospital Stay and Transition Process Use teach back when building caregiver and patient capacity Enhance patient and caregiver communications with the use of visual tools Close to the Time of Discharge Ensure personal clinician to clinician transfer Perform medication reconciliation at discharge

19 Innovative Practices Endorsed by CRG

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