1. The New Brunswick Extra-Mural Program and MY Health Plan REACH Conference 2015 David Arbeau & Mary Williams 1

2. The New Brunswick Extra-Mural Program Mandate Provide an alternative to hospital admissions; facilitate early discharge from hospitals; and provide an alternative to, or postponement of, admission to nursing homes. Services: acute, palliative, supportive and maintenance care, rehabilitation services, coordination & provision of support services & home oxygen program 2

3. The New Brunswick Extra-Mural Program 3

4. The New Brunswick Extra-Mural Program Team RHA Extra - Mural Program Director RHA Extra - Mural Program Director Secretarial Support Nursing Occupational Therapy Occupational Therapy Physiotherapy Speech Language Speech Language Social Work Social Work Respiratory Therapy Respiratory Therapy Clinical Nutrition Clinical Nutrition Clinical Coordinators/Unit Managers Registered Nurses Licensed Practical Nurses Rehabilitation Assistant Physicians Clinical Nurse Specialists Liaison Nurse Quick Response Nurse Personal care aids 4

5. The New Brunswick Extra-Mural Program Long Term Care Services Single Entry Point: Social Development, MH & EMP A range of personal support & physical/mental health services required by residents age 19+ Long term functional limitations Need assistance to function as independently as possible Coordination of & access to a range of services Reduce the premature institutionalization of seniors 5

6. The New Brunswick Extra-Mural Program Care Coordination Client-focused process –Appropriate care; at the right time; in the right place; by the right provider Involvement of other team members & partners Case management System navigation “My Health Plan” Timely & responsive care to meet the client’s goals 6

7. Our patients… 64.6% over the age of 65 –23% over the age of 85 Acute (36%), Rehabilitative (25%), Supportive Care (Chronic) (34%) Palliative Care 62.1% of home care clients with household income less than $ 25k EMP Indicator Report, 2014/15 7

8. Chronic conditions Chronic conditionCitizens receiving home care (%) NB General Population (%) Hypertension56.825.7 Arthritis48.318.0 Chronic pain40.715.0 Heart disease35.38.3 Gastric reflux31.516.1 Diabetes30.49.2 Cancer26.27.0 Depression24.512.7 Emphysema/COPD18.32.7 Stroke15.82.0 8

9. Our patients… Staff gave information needed for clients to take care of themselves (% strongly agree) 49.3% How often providers seemed informed about all care/treatment received at home [Among clients with services from more than one person] (% always) 77.1% NB Health Council, 2012 9

10. Our patients… Confidence: Ability to control and manage health condition 10 Citizens receiving Home Care (%) NB General Population (%) Very confident25.539.6 Confident55.953.5 Not very confident12.25.8 Not at all confident6.41.1

11. The New Brunswick Extra-Mural Program “My Health Plan” Client’s goals & wishes Client choice in decision making Client self-care & family participation Open exchange of information within client’s circle of care Care is coordinated, integrated & supports individuals to remain in their homes and communities 11

12. What do you need to know? My Health Plan encourages clients and their families to actively participate in service delivery. The health plan is related to client goals and service provision that will enhance the resources that they already have. Utilizing one common plan enhances interprofessional practice so each member of the client’s team is aware of what the client’s plan is, who is involved, and what actions need to be taken. 12

13. Why is it important to engage our clients in care planning? Enhances client motivation to make changes Involves the client more directly in the decision making Put the client in the driver’s seat and the health clinician acts as a coach and a guide. 13

14. Clients motivation to change starts with their confidence that they can do it. success with goals client confidence 14

15. “All EMP team members play an important role in carrying out tasks, identifying what other members of the client’s circle of care team can do to help achieve the goals, promoting independence, working toward the client’s goals in a flexible, responsive way, encouraging clients to perform an activity, & stepping in to provide more hands-on help when appropriate, such as in the event of illness or deterioration in the person’s condition.” The EMP Client My Health Plan backgrounder and tips 15

16. Goal Setting Focuses on client’s strengths and what they want to be able to do. Is a joint responsibility between the client and the EMP provider. Where appropriate involving the client’s family and circle of care. Requires sensitivity, negotiation and professional judgment. 16

17. 4 main steps of goal setting Identifying an end point Working out what steps are needed Establishing what structures must be in place Constant reiteration throughout the period of care. 17

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19. Goal 19 I want to be able to stay at home. I would like to be able to go to the Sunday church service with my wife.

20. Strengths 20 My wife and kids are a big help. A lady comes in to help a couple days a week

21. Challenges 21 I rely a lot on my wife. She’s tired and has her own health concerns; If I could do more for myself it would be easier on her; My breathing makes getting around difficult and I’m not as strong as I used to be because of my stroke.

22. Steps to Focus on 22 Jan 25, 2015 Every morning, I want to be able to get myself dressed 1.Wanda will help me get out of bed and get my clothes for me 2.I’ll get dressed the way Connie showed me and use the aids she gave me to make it easier 3.Wanda will be there in-case I need help 4.I’ll do the arm strengthening exercises Connie recommended with Amanda every day for at least 10-15 mins. (see care plan for exercise program) Wanda – PCA Connie – OT Amanda – RA

23. Another example Date What do I want to focus on? What steps will we take to achieve this? Who will help me do this? Date goal reached or revised Jan 27, 2015 On a daily basis, I want to be able to manage my breathing 1. Mrs. Clause will help me get my medications and watch that I take them right 2. I’ll check how I’m doing everyday using the monitor Linda set up for me. 3.I’ll do my lung hygiene daily, Linda will teach me how to do it right 4. I will learn more about my COPD and how to do things easier ways Mrs. Clause - wife Linda – RT Linda – RT Amanda - RA 23

24. Follow up 24 Once a week Linda or Patty : 9 weeks

25. 25 Professional's story Focused Assessments/Intake assessment Client’s Story Client Goals My Health Plan (over-arching plan for the client) EMP Care Plan (specific clinical plans i.e. Skin and wound, COPD management, rehab exercise program)

26. 26 The New Brunswick Extra-Mural Program

27. 27 The New Brunswick Extra-Mural Program