D10 2 designing a better experience for patients and providers with patients and providers

Primary Care Health Link Coordination / System Navigation Experiences

Laura Cassidy, QI and Decision Support, Maple FHT Alicia McCullam, RHHL Project Manager, Gateway CHC June 14th, 2018

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Disclosures • • • •

Not faculty No relationships with financial sponsors No potential conflicts of interest No commercial affiliations to disclose

Objectives •

Align with the South East LHIN 2017-2018 Strategic Work Plan: Provider engagement priority

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Compare and contrast provider experiences with the Health Link best practice of coordination & system navigation in an urban Family Health Team (FHT) and a rural Community Health Centre (CHC) & FHT 3

QI Methods and Design • Literature Review • Healthcare provider interviews using a semi-structured interview tool • Analysis of Findings: 1. Experienced Based Codesign approach 2. Thematic Analysis using NVivo software

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Literature Review on Navigation in Primary Care •

Navigation roles and models that are developed speak to unmet needs for coordination & facilitation of care & services

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Navigation models lead by health care professions (nurses) and inter-professional teams were focused on addressing populations with complex health and social needs

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Navigation involves coordination, liaison and patient-centred decision-making, health promotion of health literacy and self-care 5

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Primary care populations that may benefit from a system navigator: • Multiple specialists • Using internal resources frequently (high staff demands, frequent phone calls or visits) • Requiring social services • Needing a difficult or complex referral • Homebound • Requiring mental health or pain management coordination

• The major focus of a Navigator role is to enhance care transitions by building people’s capacity for decision-making and selfmanagement as they learn to navigate the complexities of the health and social services most appropriate to meet their needs.

• Patients reported overall positive experiences with care integration and there was improved access, communication, coordination and involvement in decision-making and better health care transitions

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Case management in primary care for frequent users of health care services with chronic diseases: A qualitative study of patient and family experience •

Patients confirmed that the case manager nurse was their preferred contact with primary care

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Patients reported overall positive experiences with care integration and there was improved access, communication, coordination and involvement in decision-making and better health care transitions.

Hudon, C., Chouinard, M. C., Diadiou, F., Lambert, M., & Bouliane, D. (2015). The Annals of Family Medicine, 11 13(6), 523-528.

Participants KHL

RHHL

Role

Lead Agency: Maple FHT – Early Adopter

Lead Agency: Gateway CHC- Early Adopter

Geography

Urban

Rural

Patients

40,000 enrolled at Maple FHT

Combined 32,000 patients

# of Primary Care sites within the HL

Embedded across 6 clinic sites at the Maple FHT

Embedded across 3 FHT and 1 CHC clinic sites

# of Staff Interviewed

9 staff from 4 sites

9 from 4 sites

Disciplines

NP, RN, RPN, RRT

RN, RPN, SW 13

Interview Questions The HL Approach 1.

Since embedding the Health Link (HL) approach with your patients, can you describe your experience(s)?

2.

How do you select or identify patients that you think would benefit from a coordinated care plan?

3.

How do you introduce the topic of Health Link to your patient?

4.

What are some examples of coordination and navigation you helped your patient with?

5.

What training is required to apply the HL approach? i.e. mental health system navigation, advanced care planning process, social determinants of health?

6.

In your current clinical practice, has the current health link approach influenced your care with other patients? If so, how?

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Do you have any pearls of wisdom or lessons learned that you can share for others beginning to apply this approach?

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Results: Demographics Discipline

Education

6% RN

College

33%

RPN

University

NP

17%

RRT

67%

61%

Masters

SW

Professional Experience 80% 60% 40% 20% 0% 0-2

3-4

5-6

Years Working in Profession

7-8

9-10

10+

Years in Primary Care

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# of Care Plans Initiated

Experience Initiating Care Plans

11+

6-10

1-5

44%

0%

56%

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Patient Experience Definition: “Patient experience refers to the quality and value of all of the

interactions – direct and indirect, clinical and non-clinical – spanning the entire duration of the patient/provider relationship.”

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Patient Experience Themes What specifically makes a positive patient experience?

What is important in a health care provider?

ATTRIBUTES

Willing & competent to attend to my health care needs, & respect me as a person

Equip to deliver consistently good care

ACTIONS

ENABLER

Be & do what I value being & doing, within and beyond my healthcare encounters

19 Entwistle.,V. et all (2012)

ATTRIBUTES

Have attributes/characteristics that equip them to deliver consistently good care

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Confidence, Self Starter, Critical Thinker

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Offer holistic approach

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Non-judgemental

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Time Management Skills/ Flexibility

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Keeping an open-mind

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Relationship building with patients

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Building trust and credibility across/within sectors 20

ACTIONS

Act in ways that show they are willing & competent to attend to my health & care needs

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Active Listening: Inviting feedback from patients on what is working & what is not

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Training / Coaching Mentoring Required for Success • Understand/Learn Health Link best practice • Understand Privacy eg. HIC differs across Org’s and Sectors • When/What/How to Advocate • When/What/How to access services across the health & social sectors • Make available/accessible assessment & screening tools in the workplace

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Buy-in support is needed from members of the team & circle of care

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HL model should avoid single points of failure i.e. shared care model/team based approach 21

ENABLER

Enable me to be & do what I value being & doing within & beyond my healthcare encounters

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The right person/fit with an interest in delivering the HL Approach

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Mentor the patient to build skills to improve self care/management

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Goal setting & plan to work towards goals

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Continuously closing loops

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Improve communication between health & social sectors & primary care

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Work towards reducing system barriers i.e. telephone contact during lunch hours 22

Experienced Based Co-Design Definition:

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An emerging method used to capture the emotional content of patient and family member healthcare experiences, and can serve as the foundation for patient-centered healthcare improvement.

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‌about using experience to gain insights from which you can identify opportunities for improvement.

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Emotion Overwhelming

Frustrated

Tiring Difficult

Associated Process • Finding the Time • Not having answers to all the questions/needs • When Patient Declines/Does not want your help • Training/Continuous Learning •

• • •

Data Collection, needs streamlined, too many clicks Chart reviews/finding the time Time consuming Trying to contact the patient

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Identifying Patients • Need more time with each patient

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Emotion

Associated Process

Confidence

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Helpful

• •

In ourselves as professionals, committed to learning the skillset needed for system navigation Discussing the social determinants of health That I am able to help in these diverse difficult situations

Patient-Centered •

True patient-centric and holistic type of thinking

Positive

• • •

Patient has input into their care Don't just look at medical problems For the patient

Rewarding

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Patient Outcomes More rewarding experiences and successes

Excited

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Patient Engagement - excited to be heard and feel someone cares

Feels Good

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Job Satisfaction- knowing someone is happy with what I am doing

Gratifying

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Patient Outcomes: makes them feel good, bond, patient feels special

Less Frustrating

• • •

Trusting relationship developed Maximize effectiveness of appointment time Get to know the patient, build trust 25

Health Link Coordinated Care Management Framework

Overwhelming, Frustrated, Tiring, Difficult

Confidence, Positive, Rewarding Experience, Excited, Feel Good, Gratifying, Less Frustration

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Findings / Recommendations •

Primary Care Health Link Coordination/ System Navigation: • primary care needs to have dedicated resources (time, space, funding) to support medically & socially complex individuals and their families • The health link approach has different levels of coordination/navigation to meet the social and medical needs • Primary Care training support and resources are needed e.g. initial training, continuous coaching and mentoring support • Right Fit

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Experienced Based Co-Design identified where the challenges/frustrations/personal successes occur with health link best practice (staff value the HL approach for the top 15% of complex patients)

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Discussion •

How will this information be used to advance the HL approach in your primary care organization?

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References Case management in primary care for frequent users of health care services with chronic diseases: A qualitative study of patient and family experience. Hudon, C., Chouinard, M. C., Diadiou, F., Lambert, M., & Bouliane, D. (2015). The Annals of Family Medicine, 13(6), 523-528 Russ, L. R., Phillips, J., Brzozowicz, K., Chafetz, L. A., Plsek, P. E., Blackmore, C. C., & Kaplan, G. S. (2013, December).

Experience-based design for integrating the patient care experience into healthcare improvement: Identifying a set of reliable emotion words. In Healthcare (Vol. 1, No. 3, pp. 91-99). Elsevier.

Health Quality Ontario. 2018. Health Coordinated Care Management Framework. Retrieved from: http://www.hqontario.ca/Quality-Improvement/Quality-Improvement-in-Action/Health-Links/Coordinated-CareManagement Navigation delivery models and roles of navigators in primary care: a scoping literature review. Carter, N. et al. BMC Health Services Research. (2018) 18:96 Patient Experience. Mar 2018. Retrieved from: https://hmcgrp.wordpress.com/2015/07/03/patient-experience/Deloitte The Nurse Navigator: An innovation role to optimise patient transitions across primary and secondary care settings.

Cooper, H et al (2017.) International Journal of Integrated Care, 17(5):A285,pp.1-8 .

Translating the patient navigator approach to meet the needs of primary care. Ferrante, J. M., Cohen, D. J., & Crosson, J. C. (2010). The Journal of the American Board of Family Medicine, 23(6), 736-744 The nurse navigator: An evolving model of care. McMurray, A., & Cooper, H. (2017). Collegian, 24(2), 205-212.

Which experiences of health care delivery matter to service users and why? A critical interpretive synthesis and conceptual map Entwistle.,V. et all (2012). (J Health Serv Res Policy, Vol 17;2. April.)

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Project Team Marg Alden, Executive Director, Maple FHT

Kingston Health Link

Linda Robb Blenderman, Project Manager

Laura Cassidy, QI and Decision Support

Rural Hastings Health Link

Lyn Linton, Executive Director, Gateway CHC

Alicia McCullam, Project Manager

Julia Swedak, Director of Quality & Knowledge Management

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