TCLHIN Urban Telemedicine Initiative for WMS

1. TCLHIN Urban Telemedicine Initiative for WMS AGHPS 3rd Leadership Summit 2013 November 15, 2013

2. Overview • Context - Urban Telemedicine Initiative • Urban Telemedicine Model Development • Implementation Journey Highlights • MOU • Documentation • Practice Guideline • Evaluation • Lessons Learned • Critical Success Factors

3. Telemedicine • Medical support to patients in remote areas • History • 1900’s - two-way radio connection to Royal Flying Doctor Service of Australia • 1950’s to 1990’s – telephone connection to remote areas • Late 1990’s - urban telemedicine (Britain, US) via computer • 2012 - TC LHIN Urban Telemedicine Initiatives • Client and healthcare provider within the same LHIN • Mechanism to increase access

4. Withdrawal Management Services (WMS) In TC LHIN • Hospital-affiliated, situated off site • Separate facilities with some integrated practices • Non-medical withdrawal system – care by unregulated health care providers • Two-way impact on ED patient flow • High level of client medical and withdrawal related complexity • Patients go to different sites for episodes of care

5. Drivers for Change • ED visits by mental health and addictions clients increasing steadily in TC LHIN • Some sites sending every client to ER for medical clearance prior to accepting – bed held at site • Many WMS clients have issues accessing primary care and use ED as a substitute • Coroner’s Report

6. Urban Telemedicine Model Development • Proposal to Charter & Funding – 4 months • NP role for model included developing an understanding of: • Scope of practice • Clinical consultation • Medical clearance • Primary care focus opportunities • Model for sharing resource across sites • Telemedicine capabilities

7. Final Model • Partnership • TEGH – Lead Agency • St. Joseph’s Health Center • UHN • Nurse Practitioner (NP) hired and paid by TEGH • NP visits a different site daily while supporting others via Telemedicine • Utilize clinical expertise to defer people from ED, provide primary care and WMS staff consultation

8. Legend Planned Milestones Actual

9. Memorandum of Understanding (MOU) • Single MOU • Sets out expectations and accountabilities including; • Role responsibilities of lead and partner hospitals • Human resources and practice accountabilities for NP • PHIPA Compliance, Privacy and Health Information Custodianship • Policy development

10. Implementation Challenges

11. Implementation Challenges

12. Documentation The Situation • Paper based, site-specific client care documentation • Existing data extraction software (Catalyst) • No budget for electronic medical record Ideal System • Unique medical record for each client accessible by NP at any site • Supported by pharmaceutical data base • Integration of diagnostic test results/ reports • Means to flow relevant information for handoff • PHIPA compliance • Capacity for data extraction

13. The Documentation Journey The Process • Several meetings over 6 months with LHIN representation • Goal to balance privacy, IT perspective, user needs and available alternatives Considerations • Cost • Simplicity vs complexity • Approval times for external software vendor • Access to client health care information by unregulated staff

14. Documentation Options

15. Documentation Decision Model • TEGH as health information (HIC) custodian • Separate medical record for each client contiguous if care at more than one site • NP provides needed clinical information to WMS staff on “as needed” basis Strategy • Electronic medical record • Web-based access from all sites to ensure timeliness (Application Service Provider) • Relevant notes to paper chart

16. Practice Guideline Development • Purpose • To establish common Urban Telemedicine Initiative practices among sites. • Intent • Guideline to be a “living” document, reflecting evolving practice. • Process • Involvement of WMS staff, supervisors, managers and directors in development.

17. Practice Guideline Content • Primary Health Care • NP Practice • Telemedicine Practice • Client Eligibility and Priority • Referrals to UTM/NP • Consultation and Continuity • Location, Frequency and Scheduling • Documentation • Privacy and Consent • Health Information Management • Telemedicine Assessments • Infection Control • Evaluation, Program Development, CQI

18. Evaluation Design • Conceptual framework • Access • Integration • Patient centered care • Safety • Development of data elements, definitions, sources, frequency, accountabilities • Need for pre-data identified • Design of data collection tools and scorecard • Reporting accountabilities to LHIN established

19. Key Findings: Client Care • A challenge to distinguish unique clients and encounters ED Diversion Rates Clinical Encounters -NP Follow-up Care Ratio High Risk Clients

20. Key Findings: Client Care • Trending reasons for a visit

21. Key Findings: Patient Satisfaction

22. Scorecard

23. Scorecard

24. Lessons Learned • Our history of voluntary integration and WMS committee structure supported the process of change. • New uses of telemedicine are challenging due to already existing definitions for type of engagement. • Site differences posed both challenge and opportunity. • MOU development can be a lengthy process when combining privacy, human resources and site accountabilities.

25. Lessons Learned • Continuous quality improvement (CQI) is an important part of the initiative, to understand impacts and refine practices through small tests of change. • There is much work to be done to manage the medical complexity of clients and enhance risk management. • In addition to ED diversion, there are several promising practices from this initiative; • virtual rounds, • CAMH patient flow, • using practice guidelines across sites and • establishing a means to track ED interfaces through CATALYST.

26. Client Voice • "I didn't think I could do this (alcohol withdrawal) - and manage my diabetes and liver cirrhosis at the same time“ • 52 year old male: heavy alcohol binge-type use and extensive alcohol use history, admitted from ED • After admission to WMS NP noted that client had both medical and withdrawal related risks • Client was transferred to the medical Withdrawal Management Service of CAMH (Centre for Addiction and Mental Health) for stabilization of his diabetes and acute withdrawal phase • Client then returned to TEGH non-medical WMS site to complete withdrawal and participate in day program, before being admitted to a long-term substance use treatment program • During stay at TEGH WMS, NP and client worked to improve client's diabetic control through assessments, health teaching and assistance with system navigation

27. In Summary:Critical Success Factors • Ongoing dialogue at many levels to understand complexity of service model • Being open to learning and discovering new ways of providing care • Building on the strong foundation that exists in WMS to ensure collaborative input at all levels for shaping initiative.

28. Discussion Questions? Suggestions?

29. Contacts