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Integrated Care for High Users of the Emergency Department Venie Dettmers and Misty Bath Quality Forum 2013 February 28, 2013. Presentation Overview. Provincial and VCH Context Target Population Aim and Measures Integrated Care Process Successes, Challenges and Emerging Themes Next steps.

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Presentation Overview

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  1. Integrated Care for High Users of the Emergency Department Venie Dettmers and Misty BathQuality Forum 2013February 28, 2013

  2. Presentation Overview • Provincial and VCH Context • Target Population • Aim and Measures • Integrated Care Process • Successes, Challenges and Emerging Themes • Next steps

  3. All health authorities in BChave committed to a common goal “British Columbians have the majority of their health needs met by high-quality community-based health care and support services.” …to be achieved through the creation of an integrated system of primary care and community care services. Development of Integrated Primary and Community Care (IPCC) system in all of VCH communities by 2015

  4. VCH True North Goals and Integration Strategy Enhance Integration/ Care Coordination Across the Continuum of Care

  5. Downtown Eastside Target Population • General Population: • High incidence of poverty & homelessness • Open air drug trade • Higher morbidity • Higher use of services • IPCC Target Population: • High ED Users - • People who visit St. Paul’s Hospital ED 10+ during the year & known to VCH GP or NP

  6. What we are trying to accomplish – integrate/connect/coordinate services St. Paul’s Hospital Emergency Department • Downtown • Community Health Centre • Pender • Community Health Centre Primary Outreach Services Strathcona Mental Health Team Vancouver Native Health Clinic

  7. How do we know that change is an improvement

  8. What We Are Testing - Integrated Care Process July 2012 July 2013

  9. Registry Summary/Tracking Tool – Integrated Care for High ED Use Clients (DTES IPCC) Last Updated: Jan. 31, 2013

  10. July Dec

  11. July Dec

  12. What’s Working/Success • Multi-level engagement of stakeholders – Steering Committee , Working Group and Site Team Leads • Buy-in from Directors and Managers • Clear vision of integrated care • Development of supporting clinical tools: registry, care plan template, case conferencing guidelines • Integrated care process start-up and regular updates of registry

  13. Challenges and Mitigating Strategies

  14. Emerging Themes • Emergence of specific population cohorts with un-met needs • Clients with excessive alcohol misuse • Clients attending ED for socialization • Clients with complex & unstable MH issues • Clients with combination Addiction/Trauma/Axis II histories • Aboriginal clients with addictions/trauma • Lack of clarity i.e. program services, roles and time spent engaging high needs clients

  15. Next Steps Provide team education to dispel cross programs myths and misconceptions i.e. scope, roles etc. Examine how project work can transition to everyday clinical work = developing sustainability Continue to examine and explore solutions to system wide issues arising from this project work: Need for after hours community based service? Developing out-patient infusion clinics for soft skin infections? Liaising with existing community based outreach resources for wrap around support for complex clients?

  16. Thank YouYour Questions?

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