1. cfhi-fcass.ca Improving Patient-centred Chronic Care through Collaboration in Atlantic Canada April 9, 2014 Jenn Verma, Sr. Director, Collaboration for Innovation & Improvement, CFHI (for Vickie Kaminski, President & CEO, Eastern Health, NL) IHI-BMJ Forum

2. Atlantic Healthcare Collaboration for Innovation and Improvement in Chronic Disease CharterCharter signed by all health regions in Atlantic Canada CFHICFHI is a not-for-profit organization funded by the Government of Canada No conflicts of interest to report 2

3. How can we close the gap, to make best practice, the common practice? MIND THE GAP > Healthcare improvement 3

4. Healthcare spending: PacMan of provincial budgets (40% of public spending) New mantra: cost containment, waste reduction, efficiency gains, value for money Hospital care: dependency is high; difficult to enter & exit! 4

5. Multi-morbidity Diabetes Mental Health COPD * Self-management System design Decision support Community action Newfoundland & Labrador 17 health regions + CFHI 4 provinces 10 Improvement projects *Based on the Expanded Chronic Care Model 5

6. * Halifax 6 * Saint John How can we reach young adults with mental illness and help them to thrive?  1.2 million Canadian youth have a mental illness  < 20% receive the care they need 6

7. PEER 126 (Peers Engaged in Education & Recovery)  Age- & culturally appropriate programming  Upstream investment  Working at the edges of the system healthcare, social services, mental health & addictions 7 Horizon Health team lead, Sue Haley-LaJoie

8. * Halifax 8 * Gander/ Grand Falls How can we prioritize dignified, proactive chronic care and reduce reliance on hospital care?  12% of Ontarians with COPD account for 1 in 4 ER and hospital visits  16 million (1 in 2) Canadians have a chronic disease  49% of adults 65-79 years of age and 59% of adults 80 years and older report having at least two chronic diseases 8

9.  >60% fewer ER visits, hospital admissions and days in hospital  $900,000 in indirect ‘cost-savings’  Patients at end-of- life had lower LOS & were more prepared (advance care plans) INSPIRED COPD model of care 9 Patient with Capital Health INSPIRED Medical Director, Dr. G. Rocker

10. INSPIRED -like COPD model of care Community outreach pilot with 3 patients complete 9-month adult ambulatory respiratory care pathway developed  60% of care maps/standard patient order sets developed  April 1 st set to implement standard care maps & accept ambulatory referrals 10 Central Health team lead, Valerie Pritchett (3 rd from left)

11. 11 How can we deliver care that’s truly centred around the person and their family, not their disease(s)? Capital Health team leads, Tara Sampalli and Lynn Edwards

12. Prince Edward Island 12  1 in 7 has a high- impact, high-prevalence chronic illness  Self-management support provided by a trained health professional can ↓ healthcare use and ↑ health status How can we deliver care that’s truly centred around the person and their family, not their disease(s)? 12

13. Supporting Realistic Behaviour Change 10 community providers developing new skills to help patients 14 facilitators teaching providers these skills 4.8, 3.99, 4.76 scores (out of 5) for provider changes in attitude, use of new skills and training satisfaction Increased confidence in delivering new skills (14-point improvement) 13 Health PEI team lead, Donna MacAusland (3 rd from left)

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16. “ meeting with our academic mentor and improvement coach has proven invaluable. The amount of knowledge transfer, on the spot decision-making and the ability to get things done…has given us great ability to move things.” 16

17. cfhi-fcass.ca June 9-10, 2014 St. John’s, NL Workshop on the Rock Contact: Jennifer Verma, Senior Director, Collaboration for Innovation and Improvement, CFHI T: 613-728-2238 (x.348) C: 613-618-1639 jennifer.verma@cfhi-fcass.ca @CFHI_FCASS 17