Hamilton Niagara Haldimand Brant
Hamilton Niagara Haldimand Brant Health Links Coordinated Care Planning Toolkit
April 1, 2016
Who should use this toolkit? This toolkit is for any individual or organization who will be participating in coordinated care planning.
What is the purpose of this toolkit? This toolkit will describe the Coordinated Care Planning Framework and will provide staff with the tools, templates, and resources to support the creation and maintenance of Coordinated Care Plans (CCP) within an interdisciplinary care team. This toolkit contains all key documents and the links to each individual document. Simply click on the document title under the Table of Contents and you will be directed to the working tool, form, or template.
Table of Contents Contents Page Introduction Health Link Model of Care Process and Key Requirements………………………………………………..2 Process Diagram………………………………………………………………………………………………..14 5% Cohort Target Population Definition and Criteria………………………………………………………..15 Coordinated Care Plan Process and Practice Coordinated Care Plan Detail Template……………………………………………………………………...16 HQO CCP User Guide………………………………………………………………………………………….20 Identification and Invite Health Link Patient Introduction Outline………………………………………………………….…………...58 Client Engagement Outline……………………………………………………………………………………..60 Generic Health Link Referral Form………………………………………………………………………….…62 CCAC Referral Process………………………………………………………………………………………....63 CCAC Referral Form………………………………………………………………………………………….…64 Consent Health Link Consent Form……………………………………………………………………………...... 65 Sharing Personal Health Information for Health-care Purposes………………………………………..…...67 Primary Care Provider Letter to MD Health Link Model of Care……………………………………………………………………..…95 Letter to MD Patient Detail…………………………………………………………………………………..…..96 Physician Billing Codes………………………………………………………………………………………....106 Interview Goal Setting Tips and Pitfalls………………………………………………………………………...... 115 Motivational Interviewing Outline………………………………………………………………………....…….117 Conference Care Conference Request Template………….……………………………………………………………….119 Care Conference Facilitator Checklist……………………………………………………………………....…121 How to Arrange a Lync Meeting………………………………………………………………………...….…..123 Additional Resources Health Link YouTube Videos……………………………………………………………..……………...……..127 Patient Information Example 1…………………………………………………………………………...….….128 Patient Information Example 2…………………………………………………………………………....…….130
Hamilton Niagara Haldimand Brant
Hamilton Niagara Haldimand Brant Health Links Model of Care Process and Key Requirements April 1, 2016
Introduction
The government’s Patients First plans focus on the commitment to put people and patients first by improving the health care experience, reducing gaps in care and strengthening patient-centred care. This includes supporting the advancement of Health Links, a new model of care to improve care for patients living with complex chronic conditions. The 5% cohort are large consumers, accounting for close to 65% of health care service utilization, and who may also be utilizing social services.
The Hamilton Niagara Haldimand Brant Local Health Integration Network’s Health Links Model of Care Process and Key Requirements document is a compilation of best practices and lessons learned attained through: Ministry documents HQO, CIHI and OHA webinars HNHB Health Links and other Health Links across the province Literature reviews
The scale and spread of this new model of care will require all health service providers to leverage, align and optimize existing resources around the 5% cohort population. This document and related tools and templates will aid in communicating the standard approach to coordinated care planning.
The Health Link Model of Care Process and Key Requirements draft document will be trialed by Health Service Providers over a six month period of time beginning February 1, 2016 and ending August 31, 2016. The document will undergo a review in fall of 2016 based on lessons learned and best practice. Please direct all feedback to your Health Link Project Lead or: Linda Hunter Director of Health Links and Strategic Initiatives Email: [email protected] Tel: 905-945-4930 ext 4218
Hamilton Niagara Haldimand Brant Local Health Integration Network Health Links Model of Care Process and Key Requirements 2
Health Link Model of Care
Description The Health Link Model of Care is an intensive integrated model of care that focuses on patient-centred goals to address the needs of people living with complex chronic conditions and needs, through a collaborative coordinated care plan and more meaningful patient engagement. Leveraging, optimizing and aligning existing resources, the model of care embeds the coordinated care plan (CCP) process into existing programs that service patients with complex conditions and issues.
To support the scale and spread of the Health Link Model of Care all health service providers (HSPs) will be required to leverage and align existing resources around the 5% patient population that they are funded to serve. It will take all HSPs working collaboratively across organizations focused on meeting the needs and defined goals of each of the patients identified in this 5% cohort.
Hamilton Niagara Haldimand Brant Local Health Integration Network Health Links Model of Care Process and Key Requirements 3
The Model of Care is a shared model and will require embedding the CCP process into existing programs that service the identified patients with complex issues. All HSPs will have the capacity to be an Integrated Care Lead and also participate as member of the patient’s care team. The Integrated Care Lead will take the lead in building the multidisciplinary team associated with the patient’s care as a virtual team providing seamless integrated care. The patient’s primary care provider will be important and central to the delivery of this model.
The Process involves six steps starting with identification and inviting patients in real-time through to transitioning patients and ongoing management. A more acute intensive integrated care coordination is generally required up front working towards maximizing patient self-management with or without support. It is important to note that solutions to patient’s goals or needs may require “thinking outside of the box” in order to find the one that fits and makes the difference.
The CCP is developed with the patient, along with his or her family/caregiver in collaboration with members of the care team. Engaging the patient in the planning and decision making process is central to the model.
5% Cohort Target Population – Definition/criteria Patients living with 4+ chronic conditions
Important Note:
Patients who meet the criteria may not benefit from the Health Link Model of Care, while patients who would benefit from the Health Link Model of Care may not be flagged through criteria. Clinical judgment is an important consideration. These patients may be ones that use multiple services across sectors (health and social) and can be difficult to care for.
The following vulnerable populations are a priority focus of care planning where there is high acute utilization (5+ emergency department visits +/- in-patient admissions): People living with mental health and/or addiction problems People who are frail People who are palliative
Other considerations include people who are at risk for hospital admissions including: Individuals who are frail Unstable conditions / frequent exacerbations Indications of declining health Low health literacy and self-management skills Unsupported (no caregivers to help) Others: o Living alone o Low income (household) o Housing o Transportation
Hamilton Niagara Haldimand Brant Local Health Integration Network Health Links Model of Care Process and Key Requirements 4
Roles and Responsibilities Integrated Care Lead
The Integrated Care Lead role depends on existing supports and patient’s self-management capability. The role can vary from advisor and coach to well supported patients, to a more intensive level of case management and coordination support for those that have complex issues.
The Integrated Care Lead will be a part of the most responsible organization for the care of the patient and/or who is anticipated to be involved in the patient’s care for the longest span of time. Ideally the Integrated Care Lead has an existing positive therapeutic relationship with the patient. Where this is not possible, the lead should be chosen with the patient’s preference considered as first choice. The person acting as the Integrated Care Lead may change more than once based on the patient’s needs and goals of care.
Core roles and responsibilities include: Leads in the development of the CCP following the Health Link Model of Care Process and Key Requirements Identified as the single point of contact for the patient and their family/caregiver, as well as members of the care team Establishes the care team including community, primary and acute health service providers in consultation with the patient and their family/caregiver Develop and foster collaborative approach to care planning Acts as a liaison between transitional points of care and facilitates communication Patient advocate Effective coordinator Complex care development with innovation Patient support which includes: o Helping patient identifying sources of services especially community services o Tracking referrals and help resolve problems o Ensure transfer of information o Build relationships with key partners o Promoting self-management skills
Care Team Members Involved in the patient’s care Identifies patients who would benefit the most from a collaborative CCP Shares in and contributes to the development, implementation, monitoring of the CCP Ongoing communication in changes in the patient’s plan of care and condition Works collaboratively with the patient and members of the care team to assist the patient in achieving their goal (s) and the implementation of the action items identified in the CCP Completes and updates appropriate sections in the CCP Teams members will collect and disclose their usual information such as patient identifiers, past medical history
Hamilton Niagara Haldimand Brant Local Health Integration Network Health Links Model of Care Process and Key Requirements 5
Coordinated Care Plan A Coordinated Care Plan (CCP) is either a paper or electronic plan that documents the patient’s (family/caregiver) goals(s) and related action(s), along with important clinical and provider/patient information. The CCP is defined as being completed with: The patient/family/caregiver Two or more health care professionals One or more goal(s) One or more action(s) Utilization of the CCP Health Link Model of Care Process
Identification & Invite
1. Identification and Invite
Identification
1.1. Real-time identification Patients with 5+ emergency department visits within the past 366 days are flagged in ClinicalConnect in real-time and are identified visually by stacked folders. Those with a puzzle piece are people who have a CCP already completed.
Every acute care provider will have a defined process for identifying patients in real-time utilizing the new functionality in ClinicalConnect as part of the care for a patient.
1.2. Eligibility Clinician(s) to review eligibility criteria against the patient’s case findings and any assessment tools completed to determine if the patient that has been flagged is appropriate for receiving a collaborative coordinated care plan If ineligible follow standard process of referring to the appropriate services
1.3. Invitation for referral Clinician to provide information to the patient about collaborative CCPs and invite them to participate o Utilize script Obtain patient’s consent (expressed) to participate
Hamilton Niagara Haldimand Brant Local Health Integration Network Health Links Model of Care Process and Key Requirements 6
Identify the patient to the appropriate agency to be considered for the Health Link Model of Care approach (note: the identifying agency may also be the most appropriate agency to lead the development of the CCP) The appropriate agency will identify the most appropriate Integrated Care Lead Central intake mechanism (pending)
1.4. Integrated Care Lead Identified The appropriate agency will identify the most appropriate lead and will take into consideration the patient’s preference, history with the agency etc.
Invite
1.5. Contact Integrated Care Lead to contact patient in real-time where possible or as close to real-time o Utilize the script
1.6. Consent Obtain consent Health Link standard consent form to be utilized Process to be established at each care site for tracking consent over time
1.7. Primary Care Provider Confirm and then link with primary care provider If patient does not have a Primary Care Provider, ask if they would like help to become attached Connectivity and involvement of primary care provider is very important for establishing, and implementing the CCP, as well as providing a source for transitioning the patient when considered appropriate, as well as establishing a strong partnership o Discussion with the Primary Care Provider lays out a framework for what has already happened with the patient, what has been tried and discuss next steps
1.8. Home visit (s) Arrange a home visit, as a holistic home assessment must be done at some point, ideally within 30 days The home visit has been identified as a key component of a comprehensive assessment and therefore completion of a CCP requires at a minimum one home visit, though multiple visits may be appropriate o It is considered a time for uncovering pertinent and relevant patient information that can help with the care plan
1.9. Populating the CCP Start gathering information, if possible, and start populating the CCP o The provincial CCP template must be used Review patient’s clinical records (utilizing ClinicalConnect) to begin to understand background to the patient’s story and identify potential health service providers to be involved in the care team Documentation of CCP will continue and be updated throughout the process o Complete as much of the care plan template as possible outside of the care conference so that the care conference can focus on the development of the actions
Hamilton Niagara Haldimand Brant Local Health Integration Network Health Links Model of Care Process and Key Requirements 7
Interview
2. Interview
2.1. Interview Set up an interview time with the patient in the patient’s preferred location o May include individuals of patient’s choice (family members, caregivers, friends) Engage the patient in what matters and help them articulate their concern(s) and need(s) Utilize patient centred tools and resources that support the communication of key messages Utilize patient centred interview techniques such as motivational interviewing to have a holistic understanding of the “lived experience” Identify any socio-economic barriers or patient safety issues that could impede outcomes
2.2. Setting goal(s) Explore the circumstance(s) contributing to the reasons for the ER visits +/- acute care admissions Assess and understand the patients concerns and utilizing this information assist the patients to formulate their goal(s) Update CCP and notify/communicate any important information or changes to the care team members
2.3. Establish Care Team Members Confirm with the patient who needs to be involved in the care team and the development of the CCP Begin to explore with the patient additional services and supports needed Confirm Primary Care Provider (Physician and/or NP) is engaged o Verbal or face to face discussion to inform them of Health Links Model of Care – role of Integration Care Lead o Confirm agreement and best approach to partner with the primary care provider in the development of the CCP, and ongoing coordination o Maintain communication and ensure updates are provided in collaboration with the primary care provider Initiate contact with members of the care team o Identify existing members o Invite/refer to new members Single point of contact identified for the care team Establish a shared understanding of the role each provider plays to support the patient at each point of care or when updating the CCP Care conference participation by all pertinent providers in the care team is required and can be done via teleconference, tele-health, or in person, location etc. Consider assessment tools (e.g. cognitive assessments) and or strategies to maintain maximal independence Communicate the patient’s goals of care with care team
Hamilton Niagara Haldimand Brant Local Health Integration Network Health Links Model of Care Process and Key Requirements 8
Care Conference
3. Care Conference:
Conference Planning
3.1. Conference Planning Review the purpose of the care conference and in particular the patient’s goal(s) with the Team members Structure case conference to be responsive to the individual patient’s preference about how to participate o If the patient or his or her delegate doesn’t want to attend, the Integrated Care Lead is responsible for articulating the patient’s goals and communicate the action plan back to the patient for agreement Confirm with the patient and the Team members the location or use of technology Confirm with the patient the team members and who should be in attendance o Update the consent if required Case conference can take many forms and required multiple care planning sessions; small number of providers to larger numbers depending on circumstances
3.2. Prepare the patient Review the purpose of the care conference and in particular the patient’s goal(s)
3.3. Prepare the providers Share with the providers the CCP populated to date, which will include the best possible medication history Continue to connect with all providers to have a beginning understanding of issues/needs to be addressed Confirm that the Primary Care Provider is engaged and identifies preferred approach to working with care team Pre-conference with providers where necessary o Consider phase of chronic disease progress and suitability for palliative care
Conference
3.4. Care Conference Conduct conference o Primary Care Provider will be key to the conference Empower the patient to play an active role in their plan of care and expected outcomes Link the patient’s goal(s) into care and treatment options
Hamilton Niagara Haldimand Brant Local Health Integration Network Health Links Model of Care Process and Key Requirements 9
Ensure action(s) are documented in CCP: o Are shared among care team members and the patient o Are documented in a way that the patient can understand o Identify most responsible lead for each action Discuss medication history and adjust as appropriate Review roles and responsibilities and ensure agreement with the plan and expectations are understood Identify any next steps
3.5. Circulate actions Action items from the care conference to be circulate to the members of the care team and the patient within two days for implementation and confirmation Primary Care Provider will play a key role in the CCP o Will partner with the Integrated Care Lead to develop, implement and monitor the CCP
Implementation of Actions
4. Implementation of Actions
4.1. For each action item the individual who takes the lead is responsible for the timeline and for implementing the action(s)
4.2. Monitoring Maintain contact with the patient and monitor: o For change in condition or new barrier o For achievement of patient’s goal(s) o For implementation of action(s) o For risk of readmission Frequency of monitoring and need for reassessment will be dependent on the patient’s condition, needs and goals Home/virtual visit(s) as required
4.3. Updating CCP as required Each partner will communicate back to the care team on any new information including decline in a patient’s condition, progress in achieving the CCP actions and any updates Acuity/need will determine frequency of updates to CCP with more acute situations requiring more frequent updates Monitor the progress and effectiveness of action plan and adjust as required, and timely communication back to appropriate care team members Additional care conference(s) may be required to update goal(s) and action(s)
Hamilton Niagara Haldimand Brant Local Health Integration Network Health Links Model of Care Process and Key Requirements 10
Update CCP according to new information, therapeutic progress and consultation(s) Reconvene care team for case conference as needed
4.4. Assessing readiness for transition Patient Readiness for transition o Patients will be transitioned to other more appropriate supports as their needs change and they are better supported o Once some or all sections of the CCP has been completed/implemented, assess readiness for transition to a new Integrated Care Lead o The patient demonstrates capacity for self-management and has had a period of 2-3 months with a documented reduced use of EMS and ER resources o The patient has an agency case manager who will be able to take over the Integrated Care Lead role and be able to continue supporting the patient with the CCP and call on members of care team for support o The patient is considered to be well supported and linked to and with their community supports and has alternatives to accessing acute care that can support them better Decisions and agreement about transition should occur with members of the care team and patient/family consultation o Transitioning patients between Integrated Care Leads will depend on the acute or chronic event and may occur more than twice depending on the patient’s journey Provider(s) o A new Integrated Care Lead to be identified and clearly communicated as a new single point of contact for the patient prior to transition . Ideally the most responsible organization for the care of the patient and/or who is anticipated to be involved in the patient’s care for the longest span of time o The care team members will continue to collaborate and be responsible for the care of the patient based on their goals, as appropriate
Transition
5. Transition
5.1. Warm hand off process is required Requires a joint visit (home/virtual) Clear communication of the CCP, next steps etc. Plan to ensure continuity of care Clear communication and involvement with the Primary Care Provider A safety net needs to be in place to allow for support of the new point of contact Integrated Care Lead. This includes: o Access to the care team members for problem solving and support o Access to other Integrated Care Leads for problem solving and support o Access to an escalation process defined by each Health Link lead Hamilton Niagara Haldimand Brant Local Health Integration Network Health Links Model of Care Process and Key Requirements 11
Each member of the care team is committed to continue to support the patient in achieving their goals through the actions outlined in the CCP
Ongoing Management
6. Ongoing Management
6.1. Integrated Care Lead continues to: Maintain contact with the patient Monitor the patient for: o Change in condition or any new barriers o Achievement of patient’s goal(s) o Risk of readmission Evaluate the need for organizing care conference(s) Update the CCP and disseminate to members of the care team Assess for the frequency of monitoring the patient Assess the need for home/virtual visit(s)
6.2. Ongoing communication among members of the care team Clear communication and involvement with the Primary Care Provider
6.3. Assesses the readiness or need to transition to a new Integrated Care Lead
Hamilton Niagara Haldimand Brant Local Health Integration Network Health Links Model of Care Process and Key Requirements 12
Insert Your Health Link Name Here
April 1, 2016
Insert Your Health Link Name Here
5% Cohort Target Population – Definition/Criteria
Patients living with 4+ chronic conditions
Important Note:
Patients who meet the criteria may not benefit from the Health Link Model of Care, while patients who would benefit from the Health Link Model of Care may not be flagged through criteria. Clinical judgment is an important consideration. These patients may be ones that use multiple services across sectors (health and social) and can be difficult to care for.
The following vulnerable populations are a priority focus of care planning where there is high acute utilization (5+ emergency department visits +/- in-patient admissions): People living with mental health and/or addiction problems People who are frail People who are palliative
Other considerations include people who are at risk for hospital admissions including: Individuals who are frail Unstable conditions / frequent exacerbations Indications of declining health Low health literacy and self-management skills Unsupported (no caregivers to help) Others: o Living alone o Low income (household) o Housing o Transportation
April 1, 2016
My identifiers Last verified: Click here. Last verified by: . Given name: . Preferred name: . Surname: . Gender: Choose an item. Date of birth: YYYY-MM-DD Health Link: . Address: . City: . Province: ON Postal code: . Telephone #: . Health card #: . Issued by: Choose an item. Alternate Telephone #: . Email address: . Preferred contact by: Choose an item. Mother tongue: . Official language: Choose an item. Ethnicity/culture: . Religion: . Marital status: Choose an item. Where I currently live: Choose an item. People who live with me: Choose an item. People who depend on me: . Primary contact: . Relationship to me: Choose an item. Telephone #: . Emergency contact: . Relationship to me: Choose an item. Telephone #: .
My care team Last verified: Click here. Last verified by: . Care team Role or Regular care Lead care I rely on most member name relationship Organization name Telephone # team member coordinator at home . . . . Choose an item. ☐ ☐ . . . . Choose an item. ☐ ☐ . . . . Choose an item. ☐ ☐ . . . . Choose an item. ☐ ☐ . . . . Choose an item. ☐ ☐ . . . . Choose an item. ☐ ☐ . . . . Choose an item. ☐ ☐ The people I rely on most at home are feeling: Choose an item.
My health issues Last verified: Click here. Last verified by: . Issue type Description Clinical description Date of onset Stability Notes Choose an item. . . YYYY-MM-DD Choose an item. . Choose an item. . . . Choose an item. . Choose an item. . . . Choose an item. . Choose an item. . . . Choose an item. . Choose an item. . . . Choose an item. . Choose an item. . . . Choose an item. . Choose an item. . . . Choose an item. . Choose an item. . . . Choose an item. . Choose an item. . . . Choose an item. . Baseline vitals Height: . ☐ cm ☐ in Weight: . ☐ kg ☐ lb HbA1c: . ☐ % ☐ mmol/mol
Copy – Confidential document, to be disposed of in a secure manner Date printed: 2016-03-29 Printed by: Windows User Page: 1 of 4
My known, current allergies and medications Last verified: Click here. Last verified by: . Allergies and intolerances No known allergies (NKA): ☐ Be sure to review these allergies before treating the person Substance Allergy or intolerance Symptoms Severity . Choose an item. Choose an item. Choose an item. . Choose an item. Choose an item. Choose an item. . Choose an item. Choose an item. Choose an item. Medications Be sure to review these medications before treating the person Date of last medication reconciliation: YYYY-MM-DD Performed by: . My last medication change was: . It made me feel: Choose an item. Aids I use to take my medications: Choose an item. Challenges I have taking medications: . Drug name Dose Route Direction Reason Pharmacy Start date Change date Prescriber . . Choose an item. . . . YYYY-MM-DD YYYY-MM-DD . . . Choose an item...... Choose an item...... Choose an item...... Choose an item...... Choose an item...... Choose an item...... Choose an item...... Choose an item...... Choose an item...... Choose an item...... Special notes or instructions: .
My plan to achieve my goals for care Last verified: Click here. Last verified by: . Care team members who contributed to this plan: . What is most important to me right now: . What concerns me most about my healthcare right now: . What I hope to Suggested What we can do to Who will be Expected Barriers and Results achieved Review achieve by achieve it responsible outcome challenges so far date . . Choose an YYYY- ...... item. MM-DD . . . . Choose an ...... item. . .
Copy – Confidential document, to be disposed of in a secure manner Date printed: 2016-03-29 Printed by: Windows User Page: 2 of 4
. . Choose an ...... item. . . My plan for future situations Future situations What I will do What I will not do Who will help me Telephone # Review date . . . . . YYYY-MM-DD ...... I have received information about advance care planning: Choose an item. I have a completed advance care plan: Choose an item. My ACP is located here: . As I understand it, my advance care plan says: . I have a Power of Attorney (POA) for personal care: Choose an item. My POA document is located here: . Name of POA attorney: . Relationship to me: Choose an item. Telephone #: .
My situation and lifestyle Last verified: Click here. Last verified by: . How I work: Choose an item. How adequate my income is for my health: Choose an item. Supplementary benefits I receive (select all that apply): ☐ Private Insurance ☐ Ontario Disability Support Program (OSDP) ☐ Special Service at Home (SSAH) ☐ Canada Pension Plan (CPP) ☐ Ontario Drug Benefits ☐ Veteran’s benefits ☐ Canada Pension Plan Disability (CPPD) ☐ Ontario Guaranteed Income Supplement (GAINS) ☐ Other . ☐ Guaranteed Income Supplement (GIS) ☐ Ontario Works ☐ Decline to answer I follow my recommended diet: Choose an item. How adequate my food is for my health: Choose an item. How I travel: Choose an item. How difficult it is to travel: Choose an item. How difficult it is to read and understand Choose an How adequate my housing is for my health: Choose an item. information about my health: item. I smoke tobacco: Choose an item. # of cigarettes/day: . # of pack years: . Quit date: . I drink alcohol: Choose an item. # of drinks in one sitting: . # of drinks/week: . I have ever used other substances: Choose an item. Substance How recently How frequently Choose an item. Choose an item. Choose an item. Choose an item. Choose an item. Choose an item. Choose an item. Choose an item. Choose an item. Choose an item. Choose an item. Choose an item. I gamble responsibly: Choose an item. Most recent date I gambled: . # days in last 90 days: . I get 30 minutes of physical activity 5x/week: Choose an item. I have had social interaction in the last 7 days: Choose an item. Other considerations (e.g., sleep habits): .
Copy – Confidential document, to be disposed of in a secure manner Date printed: 2016-03-29 Printed by: Windows User Page: 3 of 4
My recent health assessments Last verified: Click here. Last verified by: . Assessment type Assessment name Completed Date completed Score Actions taken Frailty . Choose an item. YYYY-MM-DD . . Health literacy . Choose an item. . . . ADL . Choose an item. . . . IADL . Choose an item. . . . Pain . Choose an item. . . . Hospital re-admission risk . Choose an item. . . . Cognition . Choose an item. . . . Aggressive behaviour . Choose an item. . . . Risk of self-harm . Choose an item. . . . Mood . Choose an item. . . . Risk of falls . Choose an item. . . .
My most recent hospital visit Last verified: Click here. Last verified by: . Hospital name: . Type of visit: Choose an item. Visit date: . Date of discharge (if applicable): . Reason for visit: . Complications: . Hospital physician name: . Hospital physician telephone #: . Key advice from hospital physician: . Follow-up appointment made with: . Date of follow-up appointment: .
My other treatments Last verified: Click here. Last verified by: . Significant surgeries and/or implanted devices . (e.g. pacemaker, transplant, stent): Health education or counselling (e.g. group counselling): . Next planned date: . Assistive devices (e.g. oxygen cylinder, wheelchair): . Self-monitoring routines (e.g. daily home blood pressure readings): . Other treatments (e.g., traditional healer): .
My current supports and services Last verified: Click here. Last verified by: . Contact name Organization name Services provided Telephone # Email address Start date ......
My appointments and referrals Last verified: Click here. Last verified by: . Date Time Provider name Purpose Notes ......
Copy – Confidential document, to be disposed of in a secure manner Date printed: 2016-03-29 Printed by: Windows User Page: 4 of 4
v1.0.0
Coordinated Care Plan User Guide Guidelines and Examples
2015-07-27
COORDINATED CARE PLAN USER GUIDE 1
v1.0.0
Table of Contents
Purpose ...... 3 Guiding principles for coordinated care plans ...... 3 Coordinated care plan template information fields ...... 4 All sections ...... 4 My identifiers ...... 5 My care team ...... 10 My health issues ...... 12 My known, current allergies and medications ...... 14 My plan to achieve my goals for care ...... 18 My situation and lifestyle ...... 22 My recent health assessments ...... 29 My most recent hospital visit ...... 30 My other treatments ...... 32 My current supports and services ...... 33 My appointments and referrals ...... 34 Appendix A: Assessment types and examples ...... 35 Appendix B: Field options for care coordination tool ...... 36
COORDINATED CARE PLAN USER GUIDE 2
v1.0.0
Purpose
This document describes how the coordinated care plan template is intended to be used and the purpose of each individual information field that is part of the plan. A “user” of the coordinated care plan could be a care coordinator authoring the plan, a clinician viewing the plan, the client/patient for whom the plan was made, or an informal caregiver. The descriptions in this guide allow users to have a common understanding of the information contained therein so that these clinical documents can be used consistently and reliably.
Note: This user guide applies to coordinated care plans regardless of how they are created (e.g., using the Care Coordination Tool or the Microsoft Word template).
Many Health Links continue to develop coordinated care planning processes that define how providers, clients/patients and their families work together to coordinate and deliver care for Health Link clients/patients. The coordinated care plan user guide is not meant to impose any particular processes on Health Links nor be a substantive tool to help Health Links develop those processes. However, recognizing that there should be some common aspects of care coordination in place in order for the coordinated care plan to be a useful tool, the user guide does suggest some guiding principles on using care plans (noted below). These guiding principles may inform the development of coordinated care planning processes, although for the most part, they simply reflect the work that is underway in many Health Links already.
Please note that information collected using the Care Coordination Tool is personal information or personal health information and must be collected, used, and disclosed only for the purposes of providing health care or assisting in the provision of health care to the client/patient to whom the coordinated care plan relates, as permitted by and in compliance with PHIPA.
Guiding principles for coordinated care plans Trust When potential users of coordinated care plans trust in their quality, accuracy and reliability, they are more likely to adopt and embed coordinated care plans into their workflow. This creates a positive feedback loop whereby the more coordinated care plans are used, the greater their value, since more frequent use leads to more comprehensive and timely information being captured in care plans. Comprehensive and timely information furthers users’ trust in care plans, and the cycle continues. Thus, it is crucial that guiding principles that ensure the integrity of coordinated care plans are agreed upon and shared by all users. Value Adoption
Below are five guiding principles to encourage the trust, use, and value of coordinated care plans:
1. The client/patient is informed of all information included in the coordinated care plan, who has access to the information and how the information is intended to be used. 2. Each coordinated care plan is developed with direct input from the client/patient. Care plans reflect the client/patient’s stated goals, needs and preferences and are written in clear, accessible language, using the client/patient’s own words where possible. 3. Coordinated care plans are accessible to clients/patients and the circle of care in any setting where care may be delivered. 4. Coordinated care plans are actively used and reliably maintained according to the clinical practices established in each Health Link by all in the circle of care. 5. Coordinated care plans are based on current evidence and use generally accepted clinical guidelines.
COORDINATED CARE PLAN USER GUIDE 3
v1.0.0
Coordinated care plan template information fields
This guide applies to coordinated care plan template version 1.0.0. All sections Two information fields are common to all sections: “Last verified” and “Last verified by”. They help to establish the authorship of each section as well as the currency of the information in that section.
Information field What it tries to capture Paper form / CCT Format Examples The most recent date and time on which the information in Last verified Free text / Auto-populated YYYY-MM-DD HH:MM:SS 2014-01-18 14:51:43 this section was verified and/or reviewed for accuracy The name of the individual who most recently verified Last verified by Free text / Auto-populated Kate Austen and/or reviewed this section
COORDINATED CARE PLAN USER GUIDE 4
v1.0.0
My identifiers This section helps to establish the identity of the client/patient by providing both basic information about him/her (e.g., name, date of birth, address), as well as other information that will help the care team understand the client/patient, such as his/her ethnicity, religion, marital status and living conditions.
Examples (red) & Information field What it tries to capture Paper form / CCT Format probing questions (blue)
Given name The client/patient’s given name Free text Michael
Mike Preferred name The name by which the client/patient prefers to be identified Free text Do you prefer to be called by a different name?
Surname The client/patient’s surname or family name Free text Jones
The client/patient’s identified gender Drop down (Refer to list below) Gender Option Description Male The client/patient identifies as a male Female The client/patient identifies as a female Transgender male The client/patient identifies as a transgender male Transgender female The client/patient identifies as a transgender female Other The client/patient identifies as a gender other than the ones listed Decline to answer The client/patient declined to answer Date of birth The client/patient’s date of birth Free text / Date picker YYYY-MM-DD 1965-10-15
A flag to indicate that the client/patient’s date of birth is an Date of birth estimated? Check box estimate The name of the Health Link from which the client/patient’s Health Link Free text / Pop-up Barrie Community coordinated care plan was created
Address The address of the client/patient’s primary residence Free text / (2 lines) 123 Main Street, Apt 234
City The city of the client/patient’s primary residence Free text Barrie
MY IDENTIFIERS — COORDINATED CARE PLAN USER GUIDE 5
v1.0.0
Examples (red) & Information field What it tries to capture Paper form / CCT Format probing questions (blue)
Province The province of the client/patient’s primary residence Drop down ON
Postal code The postal code of the client/patient’s primary residence Free text A1A1A1 M4W2A2
Telephone # The client/patient’s primary telephone number Free text XXX-XXX-XXXX 613-555-1234
The client/patient’s health card number, if they have one Health card # Number 0123456789 (version code is not required) Whether or not the client/patient has provincial health Drop down (Refer to list below) Issued by coverage Option Description (Select a province or territory) Uninsured The client/patient does not have any insurance for core services Other insurance The client/patient has non-OHIP (or other provincial) insurance for core services (e.g., RCMP) Unknown It is unknown if the client/patient has any insurance for core services Decline to answer The client/patient declined to answer An alternate telephone number by which to contact the Alternate telephone # Free text XXX-XXX-XXXX ext XX 613-555-1234 ext 44 client/patient
Email address The client/patient’s primary email address Free text [email protected]
The method by which the client/patient prefers to be Drop down (Refer to list below) Preferred contact by contacted Option Description Telephone The client/patient prefers to be contacted by telephone Email The client/patient prefers to be contacted by email Translator The client/patient prefers to be contacted via a translator Other The client/patient prefers to be contacted by a method other than the ones listed (e.g., mail) Decline to answer The client/patient declined to answer Mother tongue The client/patient’s mother tongue Free text / Type ahead Arabic
MY IDENTIFIERS — COORDINATED CARE PLAN USER GUIDE 6
v1.0.0
Examples (red) & Information field What it tries to capture Paper form / CCT Format probing questions (blue) The official language in which the client/patient is most Drop down (Refer to list below) Official language comfortable Option Description English English is the official language in which the client/patient is most comfortable speaking French French is the official language in which the client/patient is most comfortable speaking Neither The client/patient is unable to speak in either official language (neither English nor French) Decline to answer The client/patient declined to answer Free text / Type ahead Polish Ethnicity/culture The client/patient’s self-identified ethnicity or culture (Refer to list in appendix B) First Nation – Status The client/patient’s self-identified religion or social group (in Free text / Type ahead Religion CCT, choose “Other” to record multiple options and/or a Hindu (Refer to list in appendix B) social group)
The client/patient’s marital status Drop down (Refer to list below) Marital status Option Description Never married The client/patient has never been married Married The client/patient is currently married Common law The client/patient is currently in a common-law relationship Separated The client/patient is separated from his/her spouse Divorced The client/patient is divorced from his/her spouse Widowed The client/patient is widowed/a widower Decline to answer The client/patient declined to answer Unreported The client/patient did not provided this information The client/patient’s current living arrangements Drop down (Refer to list below) Where I currently live Option Description Private dwelling Residence that is privately owned or leased by the client/patient Assisted living home Residence that provides support services but no medical monitoring Retirement home Residence that provides care for seniors
MY IDENTIFIERS — COORDINATED CARE PLAN USER GUIDE 7
v1.0.0
Examples (red) & Information field What it tries to capture Paper form / CCT Format probing questions (blue) Group home Residence that provides for persons with developmental disabilities Long-term care home Licensed home providing 24-hour nursing care or supervision Hospital Institution that provides treatment to injured or sick persons Hospice Home for end-of-life care Correction centre Institution that houses offenders serving sentences from 60 days to 2 years Shelter Temporary residence for homeless persons Rooming house Residence where inhabitants share a kitchen and bathroom Homeless Lacking stable, permanent, appropriate housing Other Residence other than the ones listed Decline to answer The client/patient declined to answer Those people with whom the client/patient currently lives Drop down (Refer to list below) People who live with me Option Description No one The client/patient lives alone Partner only The client/patient only lives with his/her partner Partner and others The client/patient lives with his/her partner and others (e.g. children) Children only The client/patient only lives with his/her children Parent(s) or guardian(s) The client/patient lives with his/her parent(s) or guardian(s) Sibling(s) The client/patient lives with one or more of his/her siblings Other relative(s) The client/patient lives with one or more relatives other than the ones listed (e.g., cousin, uncle) Other The client/patient lives with one or more people other than the ones listed Decline to answer The client/patient declined to answer People who depend on Those people who are dependent on the client/patient (e.g., Free text My two children me to whom the client/patient is a caregiver) Hugo Reyes The name of the client/patient’s primary contact (should Who is your main “go-to” person Primary contact Free text match what is recorded in “My care team” section) who you would want involved in your care?
MY IDENTIFIERS — COORDINATED CARE PLAN USER GUIDE 8
v1.0.0
Examples (red) & Information field What it tries to capture Paper form / CCT Format probing questions (blue)
The relationship of the primary contact to the client/patient Drop down (Refer to list below) Relationship to me Options [primary contact] Brother Daughter Friend Grandparent Sister Spouse / Partner Caregiver Extended family Grandchild Parent / Guardian Son Other – free text (specify) Telephone # The primary contact’s primary telephone number Free text XXX-XXX-XXXX 613-555-1234 [primary contact] Benjamin Linus The name of the client/patient’s emergency contact who is to In an emergency, if Donald Emergency contact Free text be contacted when primary contact cannot be reached wasn`t available, who would you want us to call?
The relationship of the emergency contact to the client/patient Drop down (Refer to list below) Relationship to me Options [emergency contact] Brother Daughter Friend Grandparent Sister Spouse / Partner Caregiver Extended family Grandchild Parent / Guardian Son Other – free text (specify) Telephone # The emergency contact’s primary telephone number Free text XXX-XXX-XXXX 613-555-1234 [emergency contact]
MY IDENTIFIERS — COORDINATED CARE PLAN USER GUIDE 9
v1.0.0
My care team This section records the members of the client/patient’s care team, including both formal and informal caregivers, and provides some information to describe each member’s role in the care team. This section also serves as a “directory” for anyone who may view the care plan. Where possible, individuals should be identified although in some cases it may be more appropriate to identify an organization (e.g., a retail pharmacy). Where care team members are listed elsewhere in the care plan (e.g., “primary contact”) their name and contact information should be the same as it is listed in this section.
Examples (red) & Information field What it tries to capture Paper form / CCT Format probing questions (blue)
Care team member name The name of the particular care team member Free text James Ford
The care team member’s professional role or relationship to the Free text / Type ahead Dietician Role or relationship client/patient (Refer to list in appendix B) Parent / Guardian If applicable, the organization with which the care team member is Organization name Free text Guelph FHT, Home, N/A affiliated
Telephone # The care team member’s primary telephone number Free text XXX-XXX-XXXX 613-555-9999
Whether or not the client/patient sees the care team member at least Drop down (Refer to list below) Regular care team once a year on a planned basis member Option Description Yes The client/patient sees the care team member at least once a year on a planned basis No The client/patient does not see the care team member at least once a year on a planned basis A flag to identify which member of the care team is the lead care Lead care coordinator Check box coordinator and primary author of the coordinated care plan A flag to identify which member of the care team the client/patient relies I rely on most at home Check box on the most at home or informally – up to client/patient’s discretion
MY CARE TEAM — COORDINATED CARE PLAN USER GUIDE 10
v1.0.0
Examples (red) & Information field What it tries to capture Paper form / CCT Format probing questions (blue) An indication of “caregiver burnout” - the ability of informal members of Drop down (Refer to list below) The people I rely on the care team to continue to provide support to the client/patient most at home are feeling Option Description Able to continue They have no difficulty in continuing to provide care for the client/patient Not satisfied They are dissatisfied with some aspect of the situation, but are able to continue providing care Angry or distrustful They are angry or distrustful due to some aspect of the situation, but are able to continue providing care Unable to continue They cannot continue providing care to the client/patient without new supports Other They feel other than the ones listed; free text (specify) Not applicable This field is not applicable to the client/patient Decline to answer The client/patient declined to answer
MY CARE TEAM — COORDINATED CARE PLAN USER GUIDE 11
v1.0.0
My health issues This section records the various factors that may negatively affect the client/patient’s health ranging from physical and mental conditions to social conditions. This section serves to provide a holistic assessment of the client/patient’s health by giving brief descriptions of each aspect of their health as well as some chronology by providing dates of health issue onset. Entries in the physical health row should pertain to problems, issues, or concerns of the body as should entries in the mental health row pertain to problems, issues, or concerns of the mind. Social health relates to social determinants of health such as relative income level, relationships with others, or any aspect of a client/patient’s social history that may affect their health
Examples (red) & Information field What it tries to capture Paper form / CCT Format probing questions (blue)
The category of health issue Drop down (Refer to list below) Issue type Option Description Physical Health The client/patient’s issue is related to physical health (e.g., arthritis) Mental Health The client/patient’s issue is related to mental health (e.g., anxiety) Social Health The client/patient’s issue is related to social health (e.g., isolation) A plain language description of one of the client/patient’s health Description Free text Arthritis issues (it can be related to physical, mental or social health)
Clinical description A clinical description of the client/patient’s health issues Free text Osteoarthritis
The approximate month and year the client/patient first became Free text / Date picker 2014-10 Date of onset aware of the issue or was diagnosed with the issue YYYY-MM,YYYY-MM-DD 2014-10-23 An indication of whether the issue is stable or not – note that this Stability is at the discretion of the care team considering likelihood of Drop down (Refer to list below) deterioration, disease flare, crisis, or other relevant factors Option Description Stable The client/patient is stable in regards to the particular health issue Unstable The client/patient is unstable in regards to the particular health issue Not applicable Stability is not relevant to the particular health issue Decline to answer The client/patient declined to answer
MY HEALTH ISSUES — COORDINATED CARE PLAN USER GUIDE 12
v1.0.0
Examples (red) & Information field What it tries to capture Paper form / CCT Format probing questions (blue) ED visits due to pain How severe are your symptoms? Notes Any other notes to explain or contextualize the issue Free text What triggers tend to cause your disease to flare?
Baseline vitals
165 Height Height of client/patient using the specified unit of measure Number 65
The unit of measure of the client/patient’s height Check box / Radio button (Refer to list below) Height units Option Description cm Centimetres in Inches Weight of client/patient using either the imperial or metric system – 95 Weight Number up to provider discretion to pick one and ensure it is noted 209
The unit of measure of the client/patient’s weight Check box / Radio button (Refer to list below) Weight units Option Description kg Kilograms lb Pounds Most recent HbA1c test result (a proxy for the average level of 4.2 HbA1c Number blood sugar over time) 22.4
The unit of measure of the client/patient’s HbA1c Check box / Radio button (Refer to list below) HbA1c units Option Description % Percentage DCCT (Diabetes Control and Complications Trial units) mmol/mol mmol/mol IFFC (International Federation of Clinical Chemistry units)
MY HEALTH ISSUES — COORDINATED CARE PLAN USER GUIDE 13
v1.0.0
My known, current allergies and medications This section lists known allergies and intolerances. This section also lists current and past medications, providing details such as drug name, method of drug delivery, the pharmacy that provides the drugs, and the prescriber’s name. The start dates and change dates create a chronology of the client/patient’s medication usage and how they may have changed over time.
Examples (red) & Information field What it tries to capture Paper form / CCT Format probing questions (blue)
Allergies Indication provided by the client/patient that, to the best of No known allergies his/her knowledge, there is no known history of allergy or Check box (NKA) intolerance to medications or substances. Name of the compound or factor, which elicits a reaction – Corn Substance if it’s a medication follow the naming guidelines in the Free text Aspirin medication section Whether the reaction between the client/patient and the Drop down (Refer to list below) Allergy or intolerance substance is that of allergy or intolerance Option Description Allergy Immune system dependant hypersensitivity reaction to said substance Intolerance Inability to digest or dispose of said substance A description of which bodily system is most affected by Drop down (Refer to list below) Symptoms exposure to the substance Option Description Skin The skin is primarily affected by said substance Respiratory The respiratory system is primarily affected by said substance Gastrointestinal The stomach and intestines are primarily affected by said substance Behavioural The mental or motor response of the client/patient is primarily affected by said substance Blood The blood is primarily affected by said substance Other The parts of the body that are primarily affected do not fall under the ones listed; free text (specify) Decline to answer The client/patient declined to answer
MY KNOWN, CURRENT ALLERGIES AND MEDICATIONS — COORDINATED CARE PLAN USER GUIDE 14
v1.0.0
Examples (red) & Information field What it tries to capture Paper form / CCT Format probing questions (blue) The level of danger in regards to the substance allergy or Drop down (Refer to list below) Severity intolerance as perceived by the care team Option Description Mild Symptoms could be ignored by client/patient with minimal effort Moderate Symptoms cannot be ignored by client, but do not limit his/her daily activities Severe Symptoms cannot be ignored by client, limit his/her daily activities, and require extensive treatment Life-threatening Symptoms endanger client/patient’s life without treatment Decline to answer The client/patient declined to answer Current medications Date of last medication The date on which the most recent medication reconciliation Free text / Date picker YYYY-MM-DD 2014-10-14 reconciliation was performed by a qualified member of the care team The names of all the care team members who directly Free text / Drop down – select from care Performed by Sayid Jarrah contributed to the care plan team A plain language description of the most recent change My last medication (addition, deletion, modification, etc.) to the client/patient’s Free text Increase ibuprofen change was medication A plain language description of how that change made the Drop down (Refer to list below) It made me feel client/patient feel Option Description Better The medication change made the client/patient feel better Worse The medication change made the client/patient feel worse About the same The medication change did not produce an effect that could be detected by the client/patient Other The medication change made the client/patient feel other than the ones listed; free text (specify) Decline to answer The client/patient declined to answer
MY KNOWN, CURRENT ALLERGIES AND MEDICATIONS — COORDINATED CARE PLAN USER GUIDE 15
v1.0.0
Examples (red) & Information field What it tries to capture Paper form / CCT Format probing questions (blue) A description of the aids that the client/patient uses to take Drop down (Refer to list below) Aids I use to take my his/her medications medications Option Description Dosette A container intended for the storage and organization of a client/patient’s medication Blister packs Packaging used for storing and protecting a client/patient’s medication Someone administers medications Someone other than the client/patient administers the client/patient’s medication None The client/patient does not use any aids to take his/her medication Other Any aids other than the ones listed; free text (specify) Decline to answer The client/patient declined to answer Challenges I have taking A plain language description of the challenges the I have difficulty remembering to Free text medications client/patient has in taking his/her medications take my medication The generic name of the particular medication that the Drug name Free text Ibuprofen client/patient is currently taking The quantity of the particular medication that the client/patient Dose Free text Number + unit of measurement 20 mg is currently taking
The route by which the client/patient takes the particular Drop down / Type ahead Route Oral medication (Refer to list in appendix B) The prescribed method or frequency at which the Direction Free text Daily client/patient takes the particular medication The reason that the client/patient was prescribed/directed to Reason Free text Pain/arthritis take the particular medication The pharmacy from which the client/patient acquired this Pharmacy name Free text Rexall, Oak St. 613-555-9999 particular medication The date that the client/patient started taking this particular Start date Free text / Date picker YYYY-MM-DD 2013-10-26 medication
MY KNOWN, CURRENT ALLERGIES AND MEDICATIONS — COORDINATED CARE PLAN USER GUIDE 16
v1.0.0
Examples (red) & Information field What it tries to capture Paper form / CCT Format probing questions (blue) The date of the most recent change to any aspect of this Change date Free text / Date picker YYYY-MM-DD 2013-11-14 particular medication
The care team member who prescribed/directed the Free text / Drop down – select from care Prescriber Jack Shephard client/patient to take this particular medication team (includes ‘Other’ free text) Do not take with aspirin or Special notes or Any other notes that do not fall into previous categories Free text alcohol, reviewed by Kate instructions pertaining to the client/patient’s medications and their use Austen at patient’s home
MY KNOWN, CURRENT ALLERGIES AND MEDICATIONS — COORDINATED CARE PLAN USER GUIDE 17
v1.0.0
My plan to achieve my goals for care This section describes the analysis of the current situation and the “care plan” for the client/patient. The client/patient informs the plan generally by communicating his or her priorities and concerns about his or her health. More specific goals are articulated below which should represent the agreed upon goals for the client/patient and care team. Several specific actions to achieve the goals are listed, each with a person responsible for ensuring the completion of the goal identified. The “Plan for future situations” subsection describes what the client/patient should do in certain situations, such as a sudden decline in health or function. Finally, there is a sub-section to provide process-related information about the client/patient’s advance care planning.
Information field What it tries to capture Paper form / CCT Format Examples (red) & probing questions (blue) Care team members The names of all the care team members who Free text / Drop down – select one or who contributed to Jack Shephard, Kate Austen, James Ford directly contributed to the care plan more members from care team this plan Enjoying time with my family What is most The single highest priority of the client/patient What parts of your day do you look forward to the important to me right both within and outside the context of their Free text most? What is really important to you and your now health family?
What concerns me Being able to afford my prescription medication The single greatest concern of the most about my Free text What is most concerning about the state of your client/patient within the context of their health healthcare right now healthcare? Walk my daughter down the aisle at her wedding on The client/patient’s articulation of his/her key What I hope to June 30 goals (not limited to medicine or healthcare), Free text achieve What are the top 3 things you want to be able to do? considering the advice of the care team What do you want to improve or work on?
Who suggested the goal Drop down (Refer to list below) Suggested by Option Description Me The client/patient suggested the goal Formal caregiver A formal caregiver (e.g., physician) suggested the goal Informal caregiver An informal caregiver (e.g., client/patient’s daughter) suggested the goal Decline to answer The client/patient declined to answer
MY PLAN TO ACHIEVE MY GOALS FOR CARE — COORDINATED CARE PLAN USER GUIDE 18
v1.0.0
Information field What it tries to capture Paper form / CCT Format Examples (red) & probing questions (blue) Make an appointment with the physiotherapist and What we can do to The actions that the care team will take to follow exercise regimen Free text achieve it accomplish those goals (i.e., the “follow-up”) What are some steps we can take to work toward this goal? The names of care team members who will be Who will be Free text / Drop down – select one or Jack Shephard, Kate Austen, Me responsible for completing the actions more members from care team (includes responsible Who do you want to help you do this? described ‘Other’ free text, and ‘Me’)
A measurable articulation of the client/patient’s Weigh 80 kg Expected outcome Free text goal How will you know when you’ve achieved your goal?
Those barriers or challenges, identified by any Spouse unwilling to modify diet with me Barriers and care team member that could prevent the Free text How confident are you that we can do this? What challenges client/patient from reaching his/her goals do you think might stop you from getting there? Lost 3 kg since March 2013 Results achieved so A description of the client/patient’s progress Free text What progress have you made toward far towards completing the goal accomplishing this goal? A future date on which progress on the Review date client/patient’s goals will be assessed by the Free text / Date picker YYYY-MM-DD 2014-10-14 care team and the client/patient
My plan for future situations
A situation that the client/patient may be faced Severe chest pain Future situations with, based on their current situation, in the Free text What are some future situations that we should plan near future for? Actions that the care team has agreed the What I will do Free text Call 911 client/patient should do in this situation Actions that the care team has agreed the What I will not do Free text Do not bathe independently or take Tylenol client/patient should not do in this situation
MY PLAN TO ACHIEVE MY GOALS FOR CARE — COORDINATED CARE PLAN USER GUIDE 19
v1.0.0
Information field What it tries to capture Paper form / CCT Format Examples (red) & probing questions (blue)
Those people who will help the client/patient in John Locke Who will help me this situation and are aware of their inclusion Free text Who are some care team members who will be in the plan ready to help you if these things happen? The primary telephone number(s) for the Telephone # persons listed to help the client/patient in this Free text XXX-XXX-XXXX 613-555-0000 situation A future date on which the client/patient’s plan Review date for future situations will be reviewed by the Free text / Date picker YYYY-MM-DD 2013-10-26 care team and the client/patient
The client/patient has been informed by a (Refer to list below) I have received member of their care team about advance Drop down Is there someone whom you trust to care out your information about care planning wishes if you are unable to speak for yourself? advance care Option Description planning Yes The client/patient has received information about advance care planning No The client/patient has not received information about advance care planning Decline to answer The client/patient declined to answer Not applicable This field is not relevant to the client/patient I do not know what this is The client/patient does not know what advance care planning is I would like more information The client/patient would like more information about advance care planning (Refer to list below) Affirmation of whether the client/patient has an I have a completed Drop down Does your attorney for Personal Care know your oral or written advance care plan advance care plan healthcare wishes? Option Description Yes The client/patient has a completed advance care plan No The client/patient does not have an advance care plan Decline to answer The client/patient declined to answer
MY PLAN TO ACHIEVE MY GOALS FOR CARE — COORDINATED CARE PLAN USER GUIDE 20
v1.0.0
Information field What it tries to capture Paper form / CCT Format Examples (red) & probing questions (blue) My ACP is located The physical location of the client/patient’s I have a copy in my jewelry box and my daughter Free text here advance care plan has a copy too I want my life to be prolonged and that I am As I understand it, The client/patient’s plain speak interpretation provided with all life-sustaining treatments my advance care Free text of what his/her advance care plan entails applicable to my condition. plan says What is your advance care plan? The client/patient has a legal document that I have a Power of gives someone else the right to act on their Drop down (Refer to list below) Attorney (POA) for behalf for care and medical treatment personal care Option Description Yes The client/patient has an attorney for Personal Care No The client/patient does not have an attorney for Personal Care Decline to answer The client/patient declined to answer My POA document is The physical location of the client/patient’s Free text In a drawer at home located here POA document The name of the attorney for the Name of POA client/patient’s personal care POA (note: it can Free text Walt Lloyd attorney be a family member or personal friend)
The relationship of the attorney for Personal Drop down (Refer to list below) Relationship to me Care to the client/patient Options Brother Daughter Friend Grandparent Sister Spouse / Partner Caregiver Extended family Grandchild Parent / Guardian Son Other – free text (specify) The primary telephone number(s) for the Telephone # Free text XXX-XXX-XXXX 613-555-9999 Power of Attorney
MY PLAN TO ACHIEVE MY GOALS FOR CARE — COORDINATED CARE PLAN USER GUIDE 21
v1.0.0
My situation and lifestyle This section begins to capture some of the social determinants of health about the client/patient that will likely impact health and care. Where possible, the impact of the information on the client/patient’s health and care is the focus of the data, rather than the information itself (e.g., impact of income, rather than the magnitude of income).
Examples (red) & Information field What it tries to capture Paper form / CCT Format probing questions (blue)
A description of the client/patient’s involvement with the labour force Drop down (Refer to list below) How I work Option Description Student Client/patient is enrolled in a school or college full-time, or is home-schooled Self-employed Client/patient’s income comes directly from own profession or business Full-time Client/patient has a formal employer and works 30 hours or more per week Part-time/seasonal Client/patient has a formal employer and works less than 30 hours per week or only for part of the year Volunteer/unpaid Client/patient is performing services willingly and without pay Unemployed Client/patient is without a job either by choice or by circumstance, excepting retirement Retired Client/patient has left/ceased to work; reasons may include age, personal choice, or legal reasons Other Client/patient is in a work situation other than the ones listed, free text (specify) Decline to answer The client/patient declined to answer A measure of the client/patient’s sense of whether or not his/her income Drop down (Refer to list below) How adequate impacts his/her health – up to client/patient’s discretion my income is for Option Description my health More than adequate The client/patient feels living and health related expenses are easily covered by his/her income Adequate The client/patient feels living and health related expenses are covered by his/her income Less than adequate The client/patient feels living and health related expenses are close to being met by his/her income Much less than adequate The client/patient feels living and health related expenses are not being met by his/her income Decline to answer The client/patient declined to answer
MY SITUATION AND LIFESTYLE — COORDINATED CARE PLAN USER GUIDE 22
v1.0.0
Examples (red) & Information field What it tries to capture Paper form / CCT Format probing questions (blue)
Identifies the supplementary benefits that the client/patient receives Drop down (Refer to list below) Supplementary Option Description benefits that I Private insurance Insurance plans that are arranged between the client/patient and a third-party receive Canada Pension Plan (CPP) Provides pensions and benefits when contributors retire, become disabled, or die Available to people who have contributed to the CPP and who are not able to work regularly at Canada Pension Plan Disability (CPPD) any job because of a disability Guaranteed Income Supplement (GIS) A federal government supplement for individuals with low income Ontario Disability Support Program (OSDP) Provides financial support for qualifying disabled persons in financial need Ontario Drug Benefits Pays most of the cost of prescription drugs for qualifying clients/patients Ontario Guaranteed Income Supplement (GAINS) Provides financial aid to qualifying seniors Ontario Works Provides financial aid & services for qualifying persons in temporary financial need Special Service at Home (SSAH) Provides services and financial aid to families caring for a disabled child Veteran’s benefits Various benefits provided to qualifying military veterans Other Supplementary benefit other than the ones listed; free text (specify) Decline to answer The client/patient declined to answer An indication of the client/patient’s sense of compliance with his/her Drop down (Refer to list below) I follow my recommended diet recommended Option Description diet Yes The client/patient follows his/her recommended diet No The client/patient does not follow his/her recommended diet I don’t have one The client/patient does not possess a diet recommended by a medical authority The client/patient does not know if he/she possesses a recommended diet or, if he/she I don’t know possesses one, whether he/she follows the recommended diet Decline to answer The client/patient declined to answer
MY SITUATION AND LIFESTYLE — COORDINATED CARE PLAN USER GUIDE 23
v1.0.0
Examples (red) & Information field What it tries to capture Paper form / CCT Format probing questions (blue) A measure of the client/patient’s sense of how his/her food source impacts Drop down (Refer to list below) How adequate his/her health my food is for Option Description my health More than adequate The client/patient feels his/her nutrition requirements are being easily met Adequate The client/patient feels his/her nutrition requirements are being met Less than adequate The clients/patient feels his/her nutrition requirements are close to being met Much less than adequate The client/patient feels his/her nutrition requirements are not being met at all Decline to answer The client/patient declined to answer A description of the primary day to day mode of transportation for the Drop down (Refer to list below) How I travel client/patient Option Description Independently The client/patient is able to travel independently without the aid of another person Dependently on friends or family The client/patient is able to travel with the help of friends or family Dependently on public transit The client/patient is able to travel with the help of public transportation services (or a taxi) Dependently on accessible transit The client/patient is able to travel with the help of accessible transit (e.g., Wheel Trans) Decline to answer The client/patient declined to answer A measure of the client/patient’s sense of how difficult it is for him/her to Drop down (Refer to list below) How difficult it is travel (e.g., to appointments) to travel Option Description Not at all difficult The client/patient feels he/she has no difficulty travelling Somewhat difficult The client/patient feels he/she has some difficulty travelling but it does not affect his/her independence The client/patient feels he/she has much difficulty travelling and this negatively affects his/her Very difficult independence Homebound The client/patient is unable to travel outside of his/her home Bedbound The client/patient is unable to get out of his/her bed Decline to answer The client/patient declined to answer
MY SITUATION AND LIFESTYLE — COORDINATED CARE PLAN USER GUIDE 24
v1.0.0
Examples (red) & Information field What it tries to capture Paper form / CCT Format probing questions (blue) A measure of the client/patient’s sense of how difficult it is for him/her to Drop down (Refer to list below) How difficult it understand written information about their health and/or treatments is to read and Option Description understand Not at all difficult The client/patient has no difficulty in understanding information about his/her health information Somewhat difficult The client/patient has some difficulty in understanding information about his/her health, but is able to cope about my health Very difficult The client/patient is extremely limited in his/her capability to understand information about his/her health Decline to answer The client/patient declined to answer A measure of the client/patient’s sense of how his/her housing impacts Drop down (Refer to list below) How adequate his/her health my housing is Option Description for my health More than adequate The client/patient feels his/her housing requirements are being easily met Adequate The client/patient feels his/her housing requirements are being met Less than adequate The clients/patient feels his/her housing requirements are close to being met Much less than adequate The client/patient feels his/her housing requirements are not being met at all Decline to answer The client/patient declined to answer An indication of whether or not the client/patient currently smokes products Drop down (Refer to list below) I smoke tobacco containing tobacco Option Description Yes The client/patient smokes products containing tobacco No The client/patient does not smoke products containing tobacco Decline to answer The client/patient declined to answer # of The client/patient’s estimate of the number of cigarettes per day he/she Number 5 cigarettes/day smokes The client/patient’s estimate of the number of pack-years he/she has smoked; pack years = number of packs smoked per day multiplied by the # of pack years Number 3 number of years spent smoking (e.g., half a pack per day X 20 years = 10 pack years)
MY SITUATION AND LIFESTYLE — COORDINATED CARE PLAN USER GUIDE 25
v1.0.0
Examples (red) & Information field What it tries to capture Paper form / CCT Format probing questions (blue) If applicable, the date that the client/patient quit smoking, or the date of the Quit date Free text / Date picker YYYY-MM-DD 2014-10-14 most recent quit attempt
An indication of whether or not the client/patient currently uses alcohol Drop down (Refer to list below) I drink alcohol Option Description Yes The client/patient consumes products containing alcohol No The client/patient does not consume products containing alcohol Decline to answer The client/patient declined to answer The client/patient’s estimate of the highest number of drinks he/she has had # of drinks in in one sitting in the last 14 days (beer: 341ml/drink, wine: 148ml/drink, Number 3 one sitting spirits: 44ml/drink) The client/patient’s estimate of the number of drinks he/she typically has in # of drinks/week Number 5 one week An indication of whether the client/patient has ever used other substances Drop down (Refer to list below) I have used beyond alcohol, tobacco, and medications prescribed to him/her other Option Description substances Yes The client/patient has used the above described substances No The client/patient has not used the above described substances Decline to answer The client/patient declined to answer A description of the other substances that the client/patient has used in the Drop down (Refer to list below) Substance past Option Description The client/patient has used marijuana, a plant that produces the psychoactive THC, which may distort perception, disrupt Marijuana cognitive functions and cause loss of motor function Cocaine The client/patient has used cocaine, a stimulant commonly used in powdered and freebase (crack) forms The client/patient has used a hallucinogen, a drug belonging to a class of psychoactive substances that include LSD, ketamine, Hallucinogens etc., which may cause hallucinations Stimulants The client/patient has used a stimulant, a drug belonging to a class of substances that increase alertness, attention, and energy
MY SITUATION AND LIFESTYLE — COORDINATED CARE PLAN USER GUIDE 26
v1.0.0
Examples (red) & Information field What it tries to capture Paper form / CCT Format probing questions (blue) Opiates The client/patient has used an opiate, a drug belonging to a class of depressant painkillers derived from the opium poppy The client/patient has used a sedative, a drug belonging to a class of substances that induces sedation by reducing irritability or Sedatives excitement The client/patient has used a solvent, a drug belonging to a class of substances that are inhaled by people for their psychoactive Solvents effects The client/patient has used any substances other than the ones listed (e.g., non-prescribed use of prescription drugs, other Other people’s prescription drugs); free text (specify) Decline to answer The client/patient declined to answer An indication of how recently the client/patient has used each of the Drop down (Refer to list below) How recently substances he or she indicated he or she has used in the past Option Description More than 6 months ago The client/patient has used the above indicated substance at some point in time more than 6 months ago Within the last 6 months The client/patient has used the above indicated substance within the last 6 months Decline to answer The client/patient declined to answer An indication of how frequently the client/patient has used each of the Drop down (Refer to list below) How frequently substances he or she indicated he or she has used in the past Option Description Daily The client/patient uses the above indicated substance on a daily basis Weekly The client/patient uses the above indicated substance 1-2 times a week Monthly The client/patient uses the above indicated substance 1-2 times a month Less than monthly The client/patient uses the above indicated substance less than once a month Other The client/patient uses the above indicated substance on a frequency other than the ones listed Decline to answer The client/patient declined to answer An indication of whether the client/patient, in his or her opinion, has Drop down (Refer to list below) I gamble responsible gambling practices responsibly Option Description The client/patient believes he or she is gambling responsibly Yes (see, for example, the Short Problem Gambling Screener available at www.problemgambling.ca)
MY SITUATION AND LIFESTYLE — COORDINATED CARE PLAN USER GUIDE 27
v1.0.0
Examples (red) & Information field What it tries to capture Paper form / CCT Format probing questions (blue) No The client/patient acknowledges that they do not gamble responsibly Unsure The client/patient is unsure whether they gamble responsibly Decline to answer The client/patient declined to answer Most recent date The most recent date that the client/patient has gambled Free text / Date picker YYYY-MM-DD 2013-05-13 I gambled # of days in last The client/patient’s estimate of how many days in the last 90 days on which Number 4 90 days he gambled at least once The client/patient’s estimate of whether or not he/she gets the indicated Drop down (Refer to list below) I get 30 minutes amount of physical activity of physical Option Description activity 5x/week Always The client/patient always gets the above described amount of exercise Sometimes The client/patient sometimes gets the above described amount of exercise Never – I am unable to The client/patient never gets the above described amount of exercise because they’re unable to Never – I don’t want to The client/patient never gets the above described amount of exercise because of lack of motivation Decline to answer The client/patient declined to answer The client/patient’s estimate of whether or not he/she has had social Drop down (Refer to list below) I have had social interaction in the last 7 days interaction in the Option Description last 7 days Yes The client/patient has had social interaction within the last week No The client/patient has not had social interaction within the last week Other Specific details as to the client/patient’s social interaction within the last week; free text (specify) Decline to answer The client/patient declined to answer Other considerations Any issues that should be brought to the attention of the care team that have Only able to get four hours of Free text (e.g., sleep not been covered by any of the previous fields sleep a day habits)
MY SITUATION AND LIFESTYLE — COORDINATED CARE PLAN USER GUIDE 28
v1.0.0
My recent health assessments This section lists the health needs that have been identified by the client/patient’s providers. This section attempts to capture a more quantitative assessment of the client/patient’s health using the results obtained by various health assessments. Refer to appendix A for assessment type details.
Examples (red) & Information field What it tries to capture Paper form / CCT Format probing questions (blue) The assessment type that was conducted for the Assessment type N/A / Drop down (Refer to appendix A) client/patient The name of the particular assessment that was Assessment name Free text LACE (for Hospital re-admission risk) conducted for the client/patient An indication of whether or not said assessment has Drop down (Refer to list below) Completed ever been completed for the client/patient Option Description Yes Said assessment has been performed for the client/patient No Said assessment has not been performed for the client/patient The date that the most recent instance of Date completed Free text / Date picker YYYY-MM-DD 2013-04-13 said assessment was completed Where applicable, the numerical outcome of 11 (major or minor depressive Score Free text / Number said assessment; may include the score description disorder) Where applicable, the actions that were taken by the Actions taken Free text None care team in response to said assessment
MY RECENT HEALTH ASSESSMENTS — COORDINATED CARE PLAN USER GUIDE 29
v1.0.0
My most recent hospital visit This section provides some information about the client/patient’s most recent hospital admission or ED visit. The section tries to capture details about the visit such as any complications that may have arisen during the visit, the attending physician at the time, and any follow-up appointments or advice that may have occurred or been given out respectively.
Examples (red) & Information field What it tries to capture Paper form / CCT Format probing questions (blue)
The name of the hospital where the client/patient most The Ottawa Hospital Hospital name recently visited the ED or was admitted (not meant to Free text / Type ahead Have you been to a hospital or an capture out-patient visits) ED in the past 6 months?
The type of hospital visit (e.g., ED visit, admission) Drop down (Refer to list below) Type of visit Option Description ED visit only The client/patient only visit the ED Scheduled admission The client/patient was directly admitted into the hospital ED visit then admission The client/patient visited the ED and then was admitted to the hospital Visit date The date that the visit started Free text / Date picker YYYY-MM-DD 2013-04-13
Date of discharge The date that the client/patient left the hospital Free text / Date picker YYYY-MM-DD 2013-04-18 (if applicable)
Reason for visit A plain language description of the reason for the visit Free text Severe shoulder pain
A plain language description of the complicating issues that Complications Free text I couldn’t move my arm may have exacerbated the visit Hospital physician The name of the physician most responsible for the Free text John Locke name client/patient during the visit Hospital physician The telephone number for said physician Free text XXX-XXX-XXXX 613-555-9999 telephone #
Key advice from A plain language description of the key advice from said Increase ibuprofen to 400 mg, 3x Free text hospital physician physician or a summary of the discharge order daily and start physiotherapy
MY MOST RECENT HOSPITAL VISIT — COORDINATED CARE PLAN USER GUIDE 30
v1.0.0
Examples (red) & Information field What it tries to capture Paper form / CCT Format probing questions (blue) Follow-up The name of the primary care provider with whom a follow- Free text / Drop down – select from care team appointment Kate Austen up appointment has been made (includes ‘Other’ free text) made with Date of follow-up The date on which said follow-up appointment is scheduled Free text / Date picker YYYY-MM-DD 2013-05-21 appointment
MY MOST RECENT HOSPITAL VISIT — COORDINATED CARE PLAN USER GUIDE 31
v1.0.0
My other treatments This section lists common interventions that are related to or may influence the client/patient’s current health status. This section includes information about the use of equipment, current self-monitoring, any coaching received and other interventions. It is intended to capture primarily medical or clinical activities, whereas the subsequent section is intended to capture activities more related to social health and well-being.
Examples (red) & Information field What it tries to capture Paper form / CCT Format probing questions (blue) Significant surgeries and/or implanted A list of surgical devices the client/patient Pacemaker, Peritoneal Free text devices (e.g., pacemaker, transplant, stent) depends on or significant surgical changes dialysis catheter Health education or counselling (e.g., A list of the counselling or education services Diabetes education Free text group counselling) that the client/patient is currently receiving program The date of the next planned health education or Next planned date Free text / Date picker YYYY-MM-DD 2014-01-13 counselling session Assistive devices (e.g., oxygen cylinder, A list of the assistive devices that the Uses a walker, CPAP Free text wheelchair) client/patient uses machine Self-monitoring routines (e.g. daily home A brief description of the self-monitoring that the Free text Blood glucose monitoring blood pressure readings) client/patient conducts A brief description of any treatments or Other treatments (e.g., traditional healer) interventions that the client/patient is undertaking Free text Acupuncture or exposed to other than the ones listed
MY OTHER TREATMENTS — COORDINATED CARE PLAN USER GUIDE 32
v1.0.0
My current supports and services This section describes all the formal and informal supports and services provided to the client/patient that are more related to the client/patient’s social health and well-being, as opposed to the preceding section which was focused on medical or clinical activities. This section includes basic information about who the primary contact is and contact information for each support or service, and what and when services were provided.
Examples (red) & Information field What it tries to capture Paper form / CCT Format probing questions (blue) The name of the client/patient`s primary contact or support/ Contact name Free text Benjamin Linus service provider for a particular support/service If applicable, the name of the organization with which said person Organization name Free text YMCA is affiliated
Services provided If applicable, a description of the services provided Free text Aerobics class
Telephone # The primary telephone number for the contact Free text XXX-XXX-XXXX 613-555-9999
Email address The primary email address for the contact Free text [email protected]
The date on which the client/patient started using the particular Start date Free text / Date picker YYYY-MM-DD 2012-09-21 support/service
MY CURRENT SUPPORTS AND SERVICES — COORDINATED CARE PLAN USER GUIDE 33
v1.0.0
My appointments and referrals The “Appointments and referrals” section lists the basic information on upcoming health-related appointments. These could include visits to or from formal or informal supports or services or visits to or from care team members.
Examples (red) & Information field What it tries to capture Paper form / CCT Format probing questions (blue) The date of an upcoming appointment with a member of the Date Free text / Date picker YYYY-MM-DD 2013-10-24 care team
Time The time of said upcoming appointment Free text 24 hour time HH:MM 14:15
Free text / Drop down, select from care Provider name The name of said member of the care team Jack Shephard team (includes ‘Other’ free text)
Purpose A brief description of the purpose of said appointment Free text Weight loss follow up
A brief description of any other important context related to Notes Free text Delilah here at 0900 said appointment (e.g., information to bring, travel plans)
MY APPOINTMENTS AND REFERRALS — COORDINATED CARE PLAN USER GUIDE 34
v1.0.0
Appendix A: Assessment types and examples
Assessment type Description Example
A measure of the client/patient’s capability of recovering after stress Frailty Rockwood Frailty Scale events
A measure of the client/patient’s desire and ability to make use of Test of Function Health Literacy in Adults (TOFHLA) Health literacy information that promotes and maintains good health Rapid Estimate of Adult Literacy in Medicine (REALM-SF) A measure of the client/patient’s ability to perform basic tasks of ADL InterRAI ADL Hierarchy Scale everyday living like dressing and eating A measure of the client/patient’s ability to perform activities related to IADL InterRAI IADL Involvement Scale independent living like housework and shopping
Pain A measure of the amount of pain felt by the client/patient InterRAI Pain Scale
A measure of the possibility that client/patient will be readmitted into LACE Hospital re-admission risk a hospital within a specified time interval after hospital discharge MAPLe InterRAI Cognitive Performance Scale (CPS) Cognition A measure of the client/patient’s cognitive ability or impairment General Practitioner Assessment of Cognition (GPCOG) A measure of the client/patient’s propensity for causing physical or Aggressive behaviour Aggressive Behaviour Risk Assessment Tool (ABRAT) emotional harm to others InterRAI Severity of Self-harm (SOS) Risk of self-harm A measure of the client/patient’s likelihood of hurting him or herself OCAN Safety to Self InterRAI Depression Rating Scale (DRS) Mood A measure of the client/patient’s emotional state Positive and Negative Affect Schedule (PANAS)
Risk of falls A measure of the client/patient’s risk of falling FRAT (Falls Risk Assessment Tool)
APPENDIX A: ASSESSMENT TYPES AND EXAMPLES — COORDINATED CARE PLAN USER GUIDE 35
v1.0.0
Appendix B: Field options for care coordination tool
The table below lists the options available for some of the “type ahead” fields in the CCT.
Field / Options My identifiers – Ethnicity / culture Abyssinians (Amharas) Brazilian Indians Gypsy Metis Slovakian African American Bruneians Hawaiians Mexican Indians Somalis Afro-Caribbean Bulgarian Hungarian Micronesians South Asian Afro-Caucasian Canadian Hututu Mixed ethnic group South East Asian Amerind Caucasian Icelandic Mongoloid Spanish Arab Chinese Inca Mozambiquans Sudanese Armenians Congolese Indian (East Indian) New Zealand European Swedish Asian Czech Indian (Hindi-speaking) New Zealand Maori Swiss Australian aborigine Danish Indonesians Nigerians Syrian Austrian Dutch Inuit Norwegian Taiwanese Aztec Egyptian Irani Oceanic Tamils Bangladeshi English Iraqi Oriental Tatars Basque Estonian Italian Other Asian ethnic group Thais Belgian European Japanese Other ethnic non-mixed group Turks Bhutanese Fijian Javanese Other white British ethnic group Tutsi Black Filipinos Kenyans Pakistani Ugandans Black - other African country Finnish Kirghiz Polish Venezuelan Indians Black - other Asian First Nation - Non-status Koreans Polynesians Vietnamese Black Arab First Nation - Status Lapps Portuguese Welsh Black Caribbean French Liberians Russian West Africans Black East African Gambians Madagascans Samoan West Indian Black Indian sub-continent Georgian Malayans Senegalese White Black North African German Maori Senoy Consumer Declined to Answer Black West Indian Ghanaians Maya Serbian Unknown Black, other, non-mixed origin Greek Melanesian Siamese
APPENDIX B: FIELD OPTIONS FOR CARE COORDINATION TOOL — COORDINATED CARE PLAN USER GUIDE 36
v1.0.0
Field / Options My identifiers – Religion Agnostic Christian: Christian Reformed Christian: Lutheran Missouri Synod Christian: United Church of Christ Jewish: Renewal Atheist Christian: Christian Science Christian: Mennonite Christian: United Methodist Muslim Baha'i Christian: Church of Christ Christian: Methodist Christian: Wesleyan Muslim: Other Buddhist Christian: Church of God Christian: Orthodox Christian: Wesleyan Methodist Muslim: Shiite Buddhist: Mahayana Christian: Church of God in Christ Christian: Other Confucian Muslim: Sunni Buddhist: Other Christian: Church of the Nazarene Christian: Other Pentecostal Ethnic Religionist Native American Buddhist: Tantrayana Christian: Community Christian: Other Protestant Hindu New Religionist Buddhist: Theravada Christian: Congregational Christian: Pentecostal Hindu: Other Nonreligious Chinese Folk Religionist Christian: Eastern Orthodox Christian: Presbyterian Hindu: Shaivites Other Christian Christian: Episcopalian Christian: Protestant Hindu: Vaishnavites Shintoist Christian: African Methodist Episcopal Christian: Evangelical Church Christian: Reformed Church Jain Sikh Christian: African Methodist Episcopal Zion Christian: Free Will Baptist Christian: Roman Catholic Jewish Spiritist Christian: American Baptist Church Christian: Friends Christian: Salvation Army Jewish: Conservative Unknown Christian: Anglican Christian: Greek Orthodox Christian: Seventh Day Adventist Jewish: Orthodox Decline to answer Christian: Assembly of God Christian: Jehovah's Witness Christian: Southern Baptist Jewish: Other Christian: Baptist Christian: Latter-day Saints Christian: Unitarian Jewish: Reconstructionist Christian: Christian Missionary Alliance Christian: Lutheran Christian: Unitarian Universalist Jewish: Reform My known current allergies and medications – Route Apply Externally Intrabursal Intrathecal Oral Tracheostomy Buccal Intracardiac Intrauterine Other Transdermal Dental Intracervical (uterus) Intravenous Otic Translingual Endotrachial Tube Intradermal Mouth/Throat Perfusion Urethral Epidural Intrahepatic Artery Mucous Membrane Rebreather Mask Vaginal Gastrostomy Tube Intramuscular Nasal Rectal Ventimask GU Irrigant Intranasal Nasal Prongs Soaked Dressing Wound Immerse (Soak) Body Part Intraocular Nasogastric Subcutaneous Inhalation Intraperitoneal Nasotrachial Tube Sublingual Intra-arterial Intrasynovial Ophthalmic Topical
APPENDIX B: FIELD OPTIONS FOR CARE COORDINATION TOOL — COORDINATED CARE PLAN USER GUIDE 37
v1.0.0
Field / Options My care team – Role or relationship Acupuncturist Nutritionist Physician - Gastroenterology Physician - Paediatric Cardiology Audiologist Occupational Therapist Physician - General Internal Medicine Physician - Paediatric Emergency Medicine Brother Optometrist Physician - General Pathology Physician - Paediatric Haematology/Oncology Cardio-Pulmonary Technologist Other Physician - General Practitioner Physician - Paediatric Radiology Care Coordinator Parent / Guardian Physician - General Surgery Physician - Paediatric Surgery Caregiver Pharmacist Physician - General Surgical Oncology Physician - Pain Medicine Case Manager Physician Physician - Geriatric Medicine Physician - Pathology and Bacteriology Chiropodist Physician - Adolescent Medicine Physician - Geriatric Psychiatry Physician - Pediatric General Surgery Chiropractor Physician - Anatomical Pathology Physician - Gynecologic Oncology Physician - Pediatrics Clinical Perfusionist Physician - Anesthesiology Physician - Gynecologic Reproductive Endocrinology & Infertility Physician - Physical Medicine and Rehabilitation Community Worker Physician - Bacteriology Physician - Hematological Pathology Physician - Plastic Surgery Counsellor Physician - Cardiac Surgery Physician - Hematology Physician - Psychiatry Daughter Physician - Cardiology Physician - Infectious Diseases Physician - Public Health Dental Hygienist Physician - Cardiothoracic Surgery Physician - Internal Medicine Physician - Public Health & Preventive Medicine Dental Therapist Physician - Cardiovascular and Thoracic Surgery Physician - Laboratory Medicine Physician - Radiation Oncology Dentist Physician - Child and Adolescent Psychiatry Physician - Maternal Fetal Medicine Physician - Respirology Denturist Physician - Clinical Immunology Physician - Medical Biochemistry Physician - Rheumatology Dietician Physician - Clinical Immunology and Allergy Physician - Medical Genetics Physician - Specialist Dietician - Registered Physician - Clinical Pharmacology Physician - Medical Microbiology Physician - Thoracic Surgery Employment Counsellor Physician - Clinical Pharmacology and Toxicology Physician - Medical Oncology Physician - Transfusion Medicine Extended family Physician - Colorectal Surgery Physician - Neonatal-Perinatal Medicine Physician - Urology Friend Physician - Community Medicine Physician - Nephrology Physician - Vascular Surgery Grandchild Physician - Critical Care Medicine Physician - Neurology Physician Assistant Grandparent Physician - Dermatology Physician - Neurology and Psychiatry Physiotherapist Homeopath Physician - Developmental Paediatrics Physician - Neuropathology Podiatrist Kinesiologist Physician - Diagnostic and Therapeutic Radiology Physician - Neuroradiology Psychologist Massage Therapist Physician - Diagnostic Radiology Physician - Neurosurgery Psychotherapist Mental Health Case Manager Physician - Emergency Medicine Physician - Nuclear Medicine Respiratory Therapist Midwive Physician - Endocrinology and Metabolism Physician - Obstetrics Sister Naturopath Physician - Family Physician - Obstetrics and Gynecology Social Service Worker Nurse Physician - Family Medicine Physician - Occupational Medicine Son Nurse - Practical Nurse Physician - Family Medicine (Emergency Medicine) Physician - Ophthalmology Speech-Language Pathologist Nurse - Registered Nurse Physician - Forensic Pathology Physician - Orthopedic Surgery Spouse / Partner Nurse Practitioner Physician - Forensic Psychiatry Physician - Otolaryngology - Head and Neck Surgery
APPENDIX B: FIELD OPTIONS FOR CARE COORDINATION TOOL — COORDINATED CARE PLAN USER GUIDE 38
Insert Your Health Link Name Here
Health Link Model of Care Introduction – For the Patient
Know your audience. Personalize the message. Keep it simple.
Identifying patients who would benefit from a Coordinated Care Plan utilizing the Health Link Model of Care - Health care professionals who have identified a patient that meets the Health Link criteria will need to give the “mini intro” as well as obtain consent to proceed with the referral process. The following is a suggested script.
We know coordinating health care and navigating the system can be difficult, especially when you’re living with significant health issues that affect you, and when there are multiple people involved in your care.
Developing a Coordinated Care Plan is one option that is available to patients and their caregivers, to help make it easier to keep everyone up to date on what’s happening with a person’s health and a way for those in your care team to work together to reach your specific health care goals.
We know better communication and coordination between your doctor and other health care providers has improved care for many individuals.
By creating one Coordinated Care Plan that works for you and is shared by all your health providers there is less chance of confusion and will result in better care for you.
The development of the Coordinated Care Plan starts with you and your goals, then a discussion with your family doctor followed by a discussion with all your care providers about what your goals are and what actions are required to achieve each of your goals. The plan includes information such as:
Your goal (s) A list of people that support you, such as your Doctor, your family etc. Your health history The medications that you’re taking Daily routine and how you manage your everyday tasks
Having this information all together in on documented plan will help you to:
Not have to share your story every time you meet someone new, or your health changes Keep your whole care team updated about changes in your life or your health Make sure that everyone is working together toward the same goals Who to contact
Would you be interested in having a Coordinated Care Plan developed specifically for you?
If yes,
I will connect you with {insert name}. They will meet with you to help guide you through the process of developing the Coordinated Care Plan.
April 1, 2016
Health Link Model of Care: For the Integrated Care Lead (ICL) Interview
Integrated Care Lead initial patient contact - “Guided Conversation”
Hello, my name is {______} and I am a {insert title} with the {______}. I have been contacted by {______} to review with you how a Coordinated Care Plan may benefit you /or to review with you how we can help to improve the coordination of your care. I am wondering if we can have a conversation about your experiences accessing health care services/or can you tell me a little bit about your most recent emergency room visit, hospital visit or healthcare experience.
Engage Have you ever felt that there is a break down or disconnect in your care? (Use the lists of prompts below carefully assessing what resonates with your client, or attending to their conversation as you probe. You do not need to use all of the examples, they are prompts) Was communication difficult for you or you felt unheard? Have you found you have to repeat yourself over and over? Do you find yourself wondering “why isn’t anyone talking to each other?” Do you feel like the people who care for you don’t understand what is most important to you? Do you know who to call when you have questions or who can help coordinate your care? Do you forget who you have seen and for what? Were you ever provided a copy of your care plan? Inform We realize that the health system is complicated and confusing for some and care providers are rarely in the same room or fully know what the other is doing. We believe we could do a better job coordinating your care by working more closely with you If you agree, my role will be to bring together all the people that are a part of your healthcare team (provide personal examples: family members, Doctor, Physiotherapist, care providers) to develop a Coordinated Care Plan that focuses on what is most important to you and what concerns you about your health. This care plan can be shared with the team so that everyone is on the same page and using the care plan you feel will best address your needs. Empower We would like to work together on this with you so we can make it better for you. Would you work with us to improve your care? If yes we will need your verbal or written consent. Here is the consent form that will allow your care team to communicate with each other and to support you in your care (record consent obtained). Let’s chat about who is involved in your care so we can begin to figure out the next steps to help you in your wellness.
Questions: Why me? Who qualifies? Initially, we are assisting those people who have a number of health conditions happening at the same time and who may find themselves having to come to the hospital often. Those who are identified as having frequent visits to the Emergency Room or admissions to Hospital are offered the option of having a Coordinated Care Plan developed. However, most people would benefit from having a coordinated care plan, so eventually it may be an option to everyone.
Is there a fee? How much will this cost? The development of a Coordinated Care Plan and the services that you receive are all covered with your Ontario Health Care, so there is no fee to you.
2
Insert Your Health Link Name Here
Brief Semi-Structured Engagement Conversation
Purpose: This document outlines a semi-structured process to inform, engage and empower potential clients to participate in Coordinated Care Planning. This tool includes some key messages about the Health Links Model of Care and some conversation openers to identify the value of a Coordinated Care Plan.
Engage: Finding the right care to meet your needs can be difficult especially if you have more than one healthcare issue – how has this been for you? Could communication between your healthcare providers be improved? Have you found you have had to repeat your story over and over again? Are you confused about the next step in your care but it seems that providers are rushed or do not have a holistic view of your health and the values you hold? Have you found that sometimes you have been asked to repeat a medical test or you were asked to take a medication but you did not know why? Do you find yourself wondering if providers are talking to each other and have an overall plan of care to meet your needs and goals- not just to treat one aspect of your health? Do you feel that the people who help you to take care of your health don’t understand what is most important to you? Do you know who to call when you have questions or who can help to coordinate your care? Do you forget who you have seen and for what?
Inform: We realize that we can do a better job coordinating your care If you agree to work with us, we will contact all of the members of your healthcare team and any individual you identify as an important personal support, to create an individualized master plan for your healthcare. This plan will be shared with you, and all of the people in your care, focusing on what matters most to you.
…/2
April 1, 2016
Through this process we hope to learn more about your values, priorities, and unmet needs. We may identify additional services or programs for which you qualify now or in the future. We may also identify questions you have about your health which we have not adequately addressed in the past. As your needs change, this plan can change with you. We will identify someone who will take on the role of revisiting this plan with you when a change is needed. Our goal is safe, high quality care for every patient. We are working towards a better system that can give you the care that you need when and where you need it.
Empower: (If yes) Do you have time now to discuss next steps or would you prefer to schedule a time to meet again?
Benefits of Coordinated Care Planning: There is one master care plan for everyone who helps me in my care with everything in one place. If I have a problem, I will have a list of who to contact and action steps. With an accurate and complete history I will be asked to repeat my story fewer times. My history is accurate and it makes sense to me and my team. Focuses on goals which are important to me. Thanks to the planning, I can get the services I need when I need them by the right people I need to see.
Costs or Burden of Coordinated Care Planning: I will have to share my information with the entire care team or take care to identify my preference for who sees this information. I will need to spend the time to make this successful. I need to be clear about what I am going to do to meet my goals. If I am not capable, my family or caregivers will need to be involved.
2
Insert Your Health Link Name Here
[Insert Health Link Name] Health Link - Referral Form Fax: [insert] Health Service Provider Referring Name: ______Source:
□ Emergency Department □ CCAC
□ Urgent Care Centre □ Community Partner/Agency
□ Primary Care Provider □ Other ______
Referring/Contact Person: ______Referral Source Phone: ______Referral Date (dd/mm/yyyy):______/______/______Patient Name: ______Health Card#: ______LHIN ID #______Patient Organizational #______DOB (dd/mm/yyyy): ______/______/______Patient Address: ______Patient Phone #: ______Alt. Contact: ______Primary Care Provider/MRP Name:______Patient/caregiver has been informed of this referral by (required): ______
Briefly summarize reason for referral below:
April 1, 2016
Hospital Referral Process to CCAC for Health Link Patients
Effective April 1, 2016
As per the Health Link Key Process and Key Requirements document the LHIN is looking at real time identification of patients appropriate for the Health Link Model from hospital. In order to ensure timely access to care for patients who are appropriate for the Health Link model across the HNHB region, all hospitals are requested to please include the following information in their referrals (meditech, RM & R and/or paper CCAC Request for Service forms) to CCAC for patients who are identified as appropriate for the Health Link Model of care.
1. “Health Link” included in on the referral. 2. Health Link ICL identified (i.e. CCAC) 3. Number of ED visits AND Admissions in the last 366 days (See clinical connect) 4. Reasons for ED visits/Admissions (i.e. COPD, hypoglycemia, falls) 5. Primary Diagnosis
Please note: HNHB CCAC’s goal is to ensure patients who require the Health Link Model of Care are contacted within 2 business days once discharged from hospital. Patients will experience delays in access to appropriate care in the absence of the required criteria.
HNHB CCAC will accept referrals for ALL patients who meet the LHIN criteria: 5+ ED visits and multiple chronic conditions in the last 366 days. A clinical assessment is an important consideration when identifying those appropriate for the model. HNHB CCAC’s hospital care coordinator would be pleased to discuss other referrals for access to care including community support services and other home and community care options. Patients with a primary diagnosis of mental health or addiction disorders are best managed by mental health & addiction agencies that have expertise in working with this patient population. Please refer those patients to an appropriate Mental Health Agency and the CCAC will be able to collaborate as a partner agency when appropriate.
HNHB CCAC is available to support patients across the region, 7 days per week, 365 days per year, from 8:30 am to 8:30 pm at 1-800-810-0000.
April 1, 2016
Insert Your Health Link Name Here
[Insert HL Name] Health Link Consent Form
This is [Insert HL Name] Health Link’s coordinated care plan multi-agency consent form for the collection, use, and disclosure of personal health information.
I, (print full name of patient or substitute decision maker*) ______of (insert address) ______, hereby authorize the agencies listed below to collect, use and disclose the personal health information of (patient name) ______, (date of birth) ______, with one another for the purpose of completing a coordinated care plan and connect providers to improve care**.
Box on left is to collect (gather) information – box on right is to give (disclose) information Consent Given (initial beside Gather Organization/Agency/Service provider Disclose each agency for which consent is given)
…/2
April 1, 2016
I have been advised and I understand that I can withdraw my consent to the collection, use and/or disclosure of my personal health information at any time to some or all of the organization/agencies/Service Providers listed above by contacting:
I have read and understood the information above, and the purpose for the information sharing. I have had all my questions answered to my satisfaction and fully understand that specific providers will either collect, user and or disclose my personal health information. I have initialed the boxes above to indicate my consent with respect to the collection, use and/or disclosure of my personal health information to/from the following providers.
______Signature of Patient or Substitute Decision Maker Date
______Signature of Witness Date
*A substitute decision maker is a person authorized under PHIPA to consent, on behalf of the individual to the collection, use, or disclose of personal health information about the individual.
**Health Links will complete a coordinated care plan and connect providers to improve care. The care plan will become part of your health record and will be accessible and available to individuals who are providing you with health care services unrelated to Health Links.
2
CIRCLE OF CARE
Sharing Personal Health Information for Health-Care Purposes
Ann Cavoukian, Ph.D. Information and Privacy Commissioner, Ontario, Canada THE Information and Privacy Commissioner of Ontario, canada would like to thank the following organizations for their participation in this brochure:
College of Physicians and Surgeons of Ontario Ontario Association of Community Care Access Centres Ontario Association of Non-Profit Homes and Services for Seniors Ontario Hospital Association Ontario Long Term Care Association Ontario Medical Association Ontario Ministry of Health and Long-Term Care
The term “circle of care” is not a defined term in the Personal Health Information Protection Act, 2004 (PHIPA). It is a term commonly used to describe the ability of certain health information custodians to assume an individual’s implied consent to collect, use or disclose personal health information for the purpose of providing health care, in circumstances defined inPHIPA .
The purpose of this brochure is to clarify the circumstances in which a health information custodian may assume implied consent and the options available to a health information custodian where consent cannot be assumed to be implied. Throughout the brochure, appropriate application of the assumed implied consent provisions of PHIPA will be illustrated using a variety of health-care scenarios involving a fictional 61-year-old gentleman named David Mann. It should be noted that the assumed implied consent provisions of PHIPA apply equally to paper-based and electronic records of personal health information.
In an appointment with his family physician, David Mann complains of memory loss, disorientation, speech problems and mood swings. The family physician examines David and asks him a series of questions relating to his medications, his health history and the health history of his family. The family physician also conducts a mini-mental state examination and provides David with a requisition for blood and urine testing and for magnetic resonance imaging. The family physician indicates that she will refer David to both a neurologist and geriatrician for further assessments. Circumstances When you may assume Consent to be Implied A health information custodian may only assume an individual’s implied consent to collect, use or disclose personal health information if all of the following six (6) conditions are satisfied. 1
1
The health information custodian must fall within a category of health information custodians that are entitled to rely on assumed implied consent.
Most health information custodians may rely on assumed implied consent to collect, use and disclose personal health information for the purpose of providing health care or assisting in the provision of health care to an individual.
A health information custodian is a person or organization described in PHIPA with custody or control of personal health information as a result of, or in connection with, the performance of its powers, duties or work. For example, health information custodians include:
✚ health care practitioners ✚ long-term care homes ✚ community care access centres ✚ hospitals, including psychiatric facilities ✚ specimen collection centres, laboratories, independent health facilities ✚ pharmacies ✚ ambulance services ✚ Ontario Agency for Health Protection and Promotion
However, it is important to note that some health information custodians are not entitled to rely on assumed implied consent. For example, these include:
✚ an evaluator within the meaning of the Health Care Consent Act, 1996 ✚ an assessor within the meaning of the Substitute Decisions Act, 1992 ✚ the Minister or Ministry of Health and Long-Term Care ✚ the Minister or Ministry of Health Promotion ✚ the Canadian Blood Services
2 2
The personal health information to be collected, used or disclosed by the health information custodian must have been received from the individual, his or her substitute decision-maker or another health information custodian.
The personal health information to be collected, used or disclosed must have been received from the individual to whom the personal health information relates, from his or her substitute decision-maker or from another health information custodian.
Personal health information is defined in PHIPA as identifying information relating to the physical or mental health of an individual, the provision of health care to an individual, the identification of the substitute decision-maker for the individual and the payments or eligibility of an individual for health care or coverage for health care, including the individual’s health number.
A substitute decision-maker is a person authorized under PHIPA to consent on behalf of an individual to the collection, use or disclosure of personal health information.
If the personal health information to be collected, used or disclosed was received from a third party, other than the substitute decision-maker for the individual or another health information custodian, consent cannot be assumed to be implied. For example, a health information custodian may not rely on assumed implied consent if the personal health information was received from an employer, insurer or educational institution. David’s family physician provides the neurologist and geriatrician with a referral letter summarizing David’s symptoms, health history, and family health history, along with the results of his examination. Can the family physician disclose and can the neurologist and geriatrician collect this personal health information based on assumed implied consent? Yes. The family physician, neurologist and geriatrician may assume implied consent. The family physician received the personal health information directly from David and the neurologist and geriatrician received the information directly from another health information custodian, the family physician, for the purpose of providing health care to David. 3
The health information custodian must have received the
personal health information that is being collected, used 3 or disclosed for the purpose of providing or assisting in the provision of health care to the individual.
The personal health information to be collected, used or disclosed must have been received for the purpose of providing health care or assisting in the provision of health care to the individual to whom it relates. A health information custodian may not rely on assumed implied consent if the personal health information was received for other purposes, such as research, fundraising, marketing or providing health care or assisting in providing health care to another individual or group of individuals.
The geriatrician to whom the referral is made is a co-investigator in a research study involving familial predisposition to Alzheimer’s disease. In the course of the research study, while reviewing the list of study participants, the geriatrician notices the name “David Mann.” The geriatrician reviews the research file of David Mann and determines, based on a comparison with the information contained in the referral letter, that it is the same David Mann. The geriatrician photocopies the records of personal health information contained in the research file and places them in the clinical file for use at an appointment with David scheduled for November 13. Can the geriatrician use the personal health information in this way based on assumed implied consent? No. The geriatrician may not assume implied consent because the personal health information in the research file was not received for the purpose of providing health care or assisting in the provision of health care to David, but rather, for research purposes.
Following the appointment with David on November 13, the geriatrician would like to contact the laboratory for the results of the blood and urine testing ordered by David’s family physician. The geriatrician would also like to contact the pharmacy where David indicated he routinely fills his prescriptions in order to obtain a list of all current medications. Can the laboratory and pharmacy disclose and can the geriatrician collect this personal health information based on assumed implied consent? Yes. The laboratory, pharmacy and geriatrician may assume implied consent. The personal health information was received by the laboratory and pharmacy, and will be received by the geriatrician, for the purpose of providing health care to David.
4
The purpose of the collection, use or disclosure of personal health information by the health information custodian must be for the provision of health care or assisting in the provision of health care to the individual.
The collection, use or disclosure must be for the purposes of providing health care or 4 assisting in the provision of health care to the individual to whom the personal health information relates. A health information custodian may not rely on assumed implied consent if the collection, use or disclosure is for other purposes, such as research, fundraising, marketing or providing health care or assisting in the provision of health care to another individual or group of individuals. Several years pass and David’s cognitive abilities continue to decline. Based on a diagnosis of probable Alzheimer’s disease and the growing loss of David’s functional abilities, David’s geriatrician makes a referral to the local Community Care Access Centre. For purposes of assessing David’s eligibility and service levels, the case manager at the local Community Care Access Centre contacts David’s family physician to obtain further information about David’s health history, current medications and treatment. Can the Community Care Access Centre collect and can the family physician disclose this personal health information based on assumed implied consent? Yes. The Community Care Access Centre is collecting this personal health information and the family physician is disclosing this personal health information for the purpose of providing health care or assisting in the provision of health care to David. Ultimately, the local Community Care Access Centre facilitates the placement of David into a long-term care home. One morning, following breakfast at the long-term care home, David falls and is transferred to the hospital by ambulance with a suspected hip fracture. The next day David’s former spouse, a nurse in the labour and delivery unit of the hospital, is advised by their son that David was admitted. The nurse looks at David’s electronic health record to determine the reason for admission. The nurse signed a confidentiality agreement with the hospital. Can the nurse use the personal health information in this way based on assumed implied consent? No. The nurse may not assume implied consent to use the personal health information because she is not providing health care or assisting in the provision of health care to David. Following a physical examination and X-ray, it is confirmed that David has a hip fracture and David undergoes a surgical procedure. A week later, David is discharged from hospital and returns to the long-term care home. Two days following discharge, a nurse at the long-term care home notices small red, swollen and pus-filled bumps on David’s skin. David also complains of fever, chills and shortness of breath. Following laboratory testing, David is diagnosed with MRSA infection. Since the infection may have been acquired at the hospital, the nurse would like to disclose the fact that David has MRSA to the hospital to prevent or reduce the risk of a possible outbreak. Can this personal health information be disclosed to the hospital by the nurse at the long-term care home? Yes. PHIPA permits a health information custodian to disclose personal health information without consent if there are reasonable grounds to believe that it is necessary to eliminate or reduce a significant risk of serious bodily harm to a person or group of persons. The nurse, however, may not rely on assumed implied consent because the disclosure is not for the purposes of providing health care or assisting in providing health care to David.
5
In the context of disclosure, the disclosure of personal health information by the health information custodian must be to another health information custodian.
A health information custodian may not assume an individual’s implied consent in disclosing personal health information to a person or organization that is not a health information custodian, regardless of the purpose of the disclosure.
David is planning to attend an outing away from the long-term care home and will be accompanied by his cousin and the spouse of his cousin. 5 On the Wednesday prior to the outing, the spouse of David’s cousin contacts the long-term care home. She would like information about the medications David is currently taking, including the frequency and dose, and “any other information about his condition” that will assist her in “helping David.” Can the long-term care home disclose this personal health information based on assumed implied consent? No. The long-term care home may not assume implied consent because the spouse of David’s cousin is not a health information custodian within the meaning of PHIPA.
6
The health information custodian that receives the personal health information must not be aware that the individual has expressly withheld or withdrawn his or her consent to the collection, use or disclosure.
PHIPA permits an individual to expressly withhold or withdraw consent to the collection, use or disclosure of his or her personal health information, unless the collection, use or disclosure is permitted or required by PHIPA to be made without consent. In most circumstances, if an individual decides to withhold or withdraw consent, PHIPA requires the receiving health information custodians or their agents to be notified if the disclosing health information custodian is prevented from disclosing all of the information that is considered to be reasonably necessary for the provision of health care.
For further information about the ability of an individual to expressly withhold or withdraw consent to the collection, use or disclosure of personal health information for health-care purposes, and the obligations on health information custodians in this context, please refer to the Lock-box Fact Sheet produced by the Information and
Privacy Commissioner of Ontario, which is available at www.ipc.on.ca. 6 David must visit the orthopedic clinic of the hospital for follow up related to his hip fracture. The orthopedic clinic is staffed by physiotherapists, occupational therapists, physicians and nurses. David’s current spouse, who is his substitute decision-maker, learns that his former spouse, who was a nurse in the labour and delivery unit of the hospital, now works as a nurse in the orthopedic clinic. David’s current spouse wants to ensure that the former spouse and her colleagues do not view David’s electronic health record. David’s current spouse requests the hospital to ensure that only the orthopedic surgeon and the physiotherapist providing health care to David are permitted to view his electronic health record. Can David’s current spouse make this request? Yes. David has been determined to be incapable of consenting to the collection, use and disclosure of personal health information and his current spouse is his substitute decision-maker for these purposes. As the substitute decision- maker, David’s current spouse may expressly withhold or withdraw consent to the collection, use and disclosure of David’s personal health information. The hospital, as a health information custodian, must comply with this decision unless the collection, use or disclosure is required or permitted by PHIPA to be made without consent. 7
Factors to be Considered in Relying on Assumed Implied Consent In general, a health information custodian must not collect, use or disclose personal health information if other information will serve the purpose and must not collect, use or disclose more personal health information than is reasonably necessary for that purpose. These general limiting principles apply even where a health information custodian is entitled to rely on an individual’s assumed implied consent.
Options Available When you Cannot Assume consent to be Implied When consent cannot be assumed to be implied, health information custodians should consider other options. Depending on the circumstances, a health information custodian may be permitted to collect, use or disclose personal health information without consent, with the implied consent of the individual to whom the personal health information relates or with the express consent of that individual. PHIPA distinguishes between implied consent and assumed implied consent. In the case of implied consent, health information custodians must ensure that all of the elements of consent are fulfilled; whereas in the case of assumed implied consent, health information custodians may assume that all of the elements of consent are fulfilled, unless it is not reasonable to do so in the circumstances.
Without Consent Health information custodians may collect, use or disclose personal health information without consent if the collection, use or disclosure is permitted or required by PHIPA to be made without consent1. For example, health information custodians are permitted to disclose personal health information without consent to a medical officer of health if the disclosure is made for purposes of the Health Protection and Promotion Act. In addition, in certain circumstances set out in sections 37(1)(a), 38(1)(a) and 50(1)(e) of
1 Sections 36 and 37 of PHIPA, respectively, set out the circumstances in which personal health information 7 may be collected and used without consent and sections 38 - 48 and section 50 set out the circumstances in which personal health information is permitted or required to be disclosed without consent.
PHIPA, health information custodians may use or disclose personal health information without consent where it is reasonably necessary for the provision of health care and the individual has not expressly instructed otherwise.
Implied Consent Health information custodians may imply an individual’s consent to collect and use personal health information for most purposes. They may also imply consent to disclose personal health information to another health information custodian for the purpose of providing or assisting in the provision of health care to the individual. However, subject to limited exceptions, health information custodians cannot rely on implied consent when disclosing personal health information to a person or organization that is not a health information custodian. This exception applies regardless of the purpose of the disclosure.
In order to rely on implied consent, health information custodians must be satisfied that all the required elements of consent are fulfilled.
Express Consent In all other circumstances, health information custodians may only collect, use or disclose personal health information with the express consent, (i.e., verbal or written consent) of the individual to whom the personal health information relates or his or her substitute decision-maker.
In order to rely on express consent, health information custodians must be satisfied that all of the required elements of consent are fulfilled. Elements of Consent The consent of an individual for the collection, use or disclosure of personal health information by a health information custodian:
✚ Must be a consent of the individual or his or her substitute decision- maker; ✚ Must be knowledgeable; ✚ Must relate to the information that will be collected, used or disclosed; and ✚ Must not be obtained through deception or coercion.
For consent to be knowledgeable, it must be reasonable to believe that the individual knows the purpose of the collection, use or disclosure and knows that he or she may give or withhold consent.
It is reasonable to believe that an individual knows the purpose of the collection, use or disclosure if the health information custodian posts or makes readily available a notice describing these purposes where it is likely to come to the individual’s attention or provides the individual with such a notice. Although health information custodians are not required to provide notice in those circumstances where consent may be assumed to be implied, health information custodians are encouraged to do so as a best practice. The Commissioner would like to gratefully acknowledge the excellent contribution of Manuela Di Re, Health Law Legal Counsel and Debra Grant, Senior Health Specialist, Office of the Information and Privacy Commissioner of Ontario, Canada, inthe preparation of this paper.
Information and Privacy Commissioner, Ontario, Canada 2 Bloor Street East, Suite 1400 Toronto, Ontario M4W 1A8 Tel: 416 326 3333 1 800 387 0073 Fax: 416 325 9195 TTY: 416 325 7539 www.ipc.on.ca
Clockwork Productions Inc. Productions Clockwork PRI N T: www.busstopdesign.com Design + Communications d es i gn : Bus Stop September 2, 2009
Insert Your Health Link Name Here
Dear Physician:
The Ministry of Health and Long Term Care’s Patients First plans focus on the commitment to put people and patients first by improving the health care experience, reducing gaps in care and strengthening patient-centred care. This includes supporting the advancement of Health Links, a new Model of Care to improve care for patients living with complex chronic conditions. See Health Links video with Mike Evans: https://www.youtube.com/watch?v=gYT7P5Or1as
Within the Hamilton Niagara Haldimand Brant (HNHB) Local Health Integration Network (LHIN) [Insert] Health Link is one of many Health Links. Health Links across the HNHB LHIN have created standardized tools and strategies which will aid in communicating the standard approach to coordinated care planning. The HNHB Health Links Model of Care Process and Key Requirements document is one of these. The 5% cohort are large consumers who consume the largest share of healthcare resources.
Who would benefit from the Health Links Model of Care?
Patients living with 4+ chronic conditions as a priority for care planning where there is high acute healthcare utilization (5+ Emergency Room/Urgent Care Centre or having several admissions in the last 12 months) People living with mental health and /or addiction issues; people who are frail/living with complex health conditions and people who are palliative
What is involved for my Patient?
The Integrated Care Lead (ICL), care professional will visit with the patient, and facilitate the development of a Coordinated Care Plan, in collaboration with yourself and other health or social service providers, with a focus on patient goals and most importantly what matters to them. The ICL will take the lead at coordinating care to improve both the person’s health outcomes and their experience navigating the health care system including a coordinated care conference attended by all those who are involved in the patient’s care.
What is the role of Primary Care?
The role of the Primary Care Practitioner is pivotal to the success in a collaborative approach to patient-centred care. The ICL will contact you to gather pertinent information about your patient and elicit your opinion on how we, individually and/or collectively, can address the goals identified by the patient You have several ways to participate in the care conference: in person, in your office, by phone or through a home visit.
For more information on the Health Links Model of Care, or how to refer a patient to the
Sincerely,
______
April 1, 2016
Insert Your Health Link Name Here \
Date:
Dear:
Regarding Patient: ______HCN:______
LHIN ID #:______
Your patient has consented to participate in the
Contacting your office to request your preferred method of input in the care planning process. Conducting a home assessment with the aim of better informing the Coordinated Care Plan with a more holistic understanding of patient needs and circumstances. Updating you with any changes regarding your patients Coordinated Care Plan.
Your engagement as the Primary Care Provider is pivotal in providing the best care for your patient. {Insert name} Health Link in collaboration with community partnering agencies look forward to working with you in providing patient-centred care. Please find attached for your reference Physician billing codes which may be used.
Should you have any questions or would like more information regarding Health Links Model of Care please contact me at
Sincerely,
attach
April 1, 2016
2
3
4
5
6
7
8
9
10
Insert Your Health Link Name Here
Goal Setting: Tips and Pitfalls for Clinicians
Coordinated care planning first seeks to understand what matters most to our patients and then to ensure provider efforts are aligned to this end. This shift works to put patients identified needs, values and priorities as the centre of the care plan and focus of attention. For some this will mean we ensure basic needs (housing, food security) are in place prior to addressing symptom management. In fact, if we do not work to support our patients to have their priority goals addressed, we are unlikely to succeed in addressing more long term healthcare management goals.
When a patient verbalizes agreement to a plan, but does not follow through with required actions, it may be that goals have been set prematurely. Patients living with complex needs, because of previous healthcare experiences, may come to anticipate provider goals and focus on what they expect we want to hear. Providers have shared that it can take time for patients to believe we do want to take a more holistic view of their health.
A useful tool to help patients resolve the ambivalence that often accompanies a significant change is a simple Pro/Con worksheet which explores the benefits and losses on each side of the change. This tool has been shown to be very helpful to help identify unanticipated barriers to making behaviour changes and it can lead to important problem-solving to address the barriers to change which may derail their plans.
Give some consideration to how you frame your questions. Most of us do not think in terms of goals – this is healthcare provider language. Asking open-ended questions and listening attentively can quickly lead to areas of need and focus for Coordinated Care Planning: “what would be one or two things that would improve your health or quality of life?” Be ready to take a number of approaches to this question as some individuals have lost hope and may have no idea what could improve their life.
Some of the time there will be a mismatch between provider and client goals. For example a client might ask for a procedure which is against current evidence or they might seek a service for which they are not eligible. Alternately when discussing goals one HL patient indicated she hoped to “continue to visit the hospital everyday as this is where all my friends are”. The willingness to explore what hospital admission provides can lead to useful information about the unmet needs in the patient’s current life. This conversation can lead to meaningful client goals. …/2
When you hear a client identify change opportunities, seek clarification and permission to focus on this as a goal: “So it sounds like you would like to eliminate or minimize your physical pain, could I put this as a goal for us to work on together with your care team?”
April 1, 2016
Work with the client to prioritize the goals which have the most importance to them and start with a manageable focus. Helping your client to build on small successes is much more reliable than creating an ambitious plan which can quickly become overwhelming.
Ensure goals are SMART (Specific, Measurable, Attainable, Relevant and Timely) and that anyone who is involved in helping a patient to meet a goal is clear about their role in the plan.
2
Insert Your Health Link Name Here
Use of Motivational Interviewing for Clinicians: *Created, Developed, and Distributed by CAMH/TEACH, 2014 Spirit of Motivational Interviewing:
Partnership Acceptance Compassion Evocation
Core Foundations of Motivational Interviewing: MI is an evidence-based respectful, goal directed conversation that works to help an individual identify what they would like to do to change by getting them to examine where they want to be and their current behavior.
Open Questions Affirmations Reflections Summary Statements Roll with resistance – avoid confrontations which can further entrench someone in their position Agenda Mapping Recognizing/Responding to Change/Sustain Talk
What is client “change talk”?
There are two categories of change talk:
Preparatory change talk is reflected in statements expressing a person’s Desire, Ability, Reasons, or Need for change. Commitment language is reflected in statements expressing Commitment, Action, or Taking steps toward change.
…/2
April 1, 2016
Motivational Interviewing Targets:
Two reflective statements for each question asked At least 50% complex (vs. simple) reflections No more than 50% of therapist talk time
Simple and Complex Reflections:
*Forum on Public Policy, 2009
Simple reflections are statements made by the counselor which echo, repeat, rephrase, or reword what the client has just said. Complex reflections are also statements made by the counselor but they require more skill and practice. They are statements in which the counselor paraphrases or reflects the deeper meaning or feeling of what the client has just said.
2
Insert Your Health Link Name Here
Care Conference Request
Dear______Organization______,
The < HL Name> is requesting your participation in a care conference to discuss the health care needs for the following patient:
NAME: ______
D.O.B. : ______
HCN: ______
Care Conference Details
Date: ______/______/______Time: ______:______Alternate date/time:______
Location: ______
Teleconference details: ______
The outcome of this meeting will be the development of a Coordinated Care Plan (CCP) that addresses the following priority issues identified by the patient: ______
______
______
______
…/2
April 1, 2016
Please indicate whether you will be able to attend and fax/email your reply to:
□ Yes I will attend this case conference □ I cannot attend, but would like a copy of the CCP, and a:
□ follow up call, or □ written summary
Comments:______
This care conference request was completed by:
Name/Organization:______
Contact Number:______
2
Insert Your Health Link Name Here
Care Conference Facilitator Quick Guide
Pre-Conference
□ Meet with the patient to understand their strengths, priorities and unmet needs. Work with the patient to identify key supports (current or proposed) and potential goals.
□ In partnership with the patient determine the care conference modality required (virtual or face to face as well as the location) and clarify areas of focus for the care conference.
□ Talk with the Primary Care Provider (PCP) and review the Health Links Model of Care, roles and responsibilities, the patient’s health status and issues discussed with the patient. Gather information about the PCP’s perspective. Request their preferred method of input into the care planning process (discuss care conference options-telephone, teleconference, face to face and various places in which this meeting may take place such as the patient’s home or the physician’s office).
□ Set a time and place for a care conference which best meets the needs of various parties including the patient, family, PCP and others as appropriate.
□ Call other members of the care team individually to review the need for a collaborative care plan and conference. Outline the goals of the meeting and the reason their input is requested.
During the Conference
□ Welcome participants, introduce yourself and describe your role.
□ Invite all participants to introduce themselves and their role.
□ Explain the purpose of the conference and briefly describe the process which will be followed.
□ Discuss the patient’s overall medical history and their current challenges. Invite further comment or clarification from the patient/family.
□ Summarize comments into specific actionable goals. …/2
With each specific goal, invite participants to share their perspectives on how, given their individual expertise, the patient can achieve these goals and the resources which can be provided to support success. Document points of agreement and/or disagreement.
April 1, 2016
□ Once each goal has been discussed, summarize the discussion and check for accuracy/understanding, noting the agreed upon actions.
□ For each action item identify the individual who take the lead responsibility and the timeline for implementation of actions.
□ Invite patient/family to provide feedback about the conference outcomes and discuss the next steps related to the completion and sharing of the coordinated care plan (CCP).
□ Provide contact information and encourage participants to circle back to the Integrated Care Lead, the single point of care if any concerns arise.
Post Care Conference
□ Document conference, complete CCP and send a copy to each conference participant.
□ Meet with patient to review the CCP, including action items, and provide them with a copy.
□ Share the CCP and document its completion. Proceed to monitoring the success of the CCP.
2
Insert Your Health Link Name Here
How to Arrange a Lync Meeting
Use Outlook 2013 or Outlook Web App, to schedule a Lync meeting.
Use Outlook 2013 or Outlook Web App, to schedule a Lync meeting similar to the way you use Outlook to schedule regular meetings. When you add a Lync meeting, a link used to join the online meeting is automatically added to your meeting request. And, if your account is configured for dial-in conferencing, the meeting request will include call-in information (phone number and conference ID).
Tip: For an interactive guide to setting up Lync Meetings—including troubleshooting tips—see Scheduling and preparing for a Lync Meeting.
If you don’t use an Outlook program (or Windows), you can arrange new meetings by using Lync Web Scheduler through the following link https://sched.lync.com, or learn more at Lync Web Scheduler.
Schedule a Lync Meeting by using Outlook 2013
To schedule a Lync Meeting, you need a sign-in address and password from an organization that uses Lync Server.
Watch this video or follow the steps in this section to learn how to schedule a Lync 2013 meeting by using Outlook 2013.
To set up a Lync Meeting by using Outlook 2013
1. Open Outlook, and go to your calendar. 2. On the Home tab, on the Lync Meeting ribbon, click New Lync Meeting.
Note If Lync is installed on your computer, and you don’t see the New Lync Meeting button, follow the steps in the Lync Meeting control is not displayed on the Outlook 2013 ribbon article to resolve the issue.
…/2
April 1, 2016
3. Set up the meeting as you typically would, that is: o In the To box, type the email address of each person you’re inviting, separated by semicolons. o In the Subject box, type a name for the meeting. o If you’ll have in-person attendees, either click Room Finder, in the Options ribbon of the Meeting tab, and then find a room or, in the Location box, type a meeting location, such as a conference room.
o Select a start time and end time.
Notes To look for a time that works for everyone, click Scheduling Assistant, in the Show ribbon of the Meeting tab.
4. In the meeting area, type an agenda. Be careful not to change any of the Lync meeting information.
Important Scheduling a meeting with the default options, like we just did, is suitable for small, internal meetings, such as casual meetings with a few coworkers. If you have a meeting with people outside your company, or you’re scheduling a large event, change the meeting options before sending the invites to better fit your meeting requirements. In the meeting request, on the Lync Meeting ribbon of the Meeting tab, click Meeting Options, and then select the appropriate options.
For details about what options are available and when you should chose them, see Set options for Lync Meetings.
5. (Optional) On the Show group of the Meeting tab, click Scheduling Assistant to make sure you have the best time for the meeting.
2
6. You're almost done. Just double-check the information and click Send.
Set up an online meeting by using Outlook Web App
To create a Lync Meeting request in Outlook Web App, you have to:
Be using a browser that supports the full version of Outlook Web App. Have a user name and a password from an organization that has a business or enterprise subscription to Office 365.
To set up an online meeting by using Outlook Web App
1. In the Office 365 portal, do one of the following: o To set up a meeting by date, click the Calendar tab, select the date, and then in the upper-left corner, click New Event. o To set up a meeting by the people you want to invite, click the People tab, click a contact or group in your Contacts list, and then, under the person or group’s name, click Schedule meeting.
Tip If you get a message from you popup blocker asking if you want to allow this, select Always Allow.
Tip To add a contact or group, on the People tab, in the upper-left corner, click New, and either click Create Contact and type in the requested information, or click Create Group, type a group name, click the Members text box, and then type the email address of the person you want to add. As you type, the Search contacts and directory link appears to offer suggestions; if you see the contact’s name there, click it. When you're finished adding users, click Save.
2. In the middle of the meeting window, above the message area, click Online meeting.
Call-in details, such as a Join online meeting link appears in the message area. If your account is configured for dial-in conferencing, you’ll also see a Find a local number link.
3
Notes If you don't see the Online Meeting link, it could be for one of the following reasons:
o You’re not using a browser that supports the full version of Outlook Web App. o Your Office 365 subscription does not include Lync. o You’re logged in as a user who hasn’t been granted a license for Lync. 3. Set up the meeting as you typically would, that is, by giving the event a name, adding or removing attendees, choosing a start time and duration, and so on. If you’ll have in-person attendees, in Location, type a location for the meeting, such as a conference room, or click Add Room for help finding a conference room.
Tip To look for a time that works for everyone, click Scheduling Assistant, at the top of the meeting window.
Tips To view settings for who has access to the online meeting, who has to wait for you to admit them into the meeting, and who can present during the meeting, click Online meeting settings (just above the message area.
4. (Optional) In the meeting area, you can type an agenda. Be careful not to change any of the online meeting information. 5. (Optional) To add a picture or attachment with the agenda, at the top of the meeting window, click the More actions icon (…), click Insert, and then click Attachments or OneDrive files or Pictures inline.
6. At the top of the meeting window, click Send.
Applies To: Office 365 End User, Lync 2013 for Office 365
4
Insert Your Health Link Name Here
Care Coordination Helpful Resources:
Video Links for Care Coordination Planning:
https://www.youtube.com/watch?v=OAQ-V1nQu4w
https://www.youtube.com/watch?v=ILTyTVKCvlo
Useful Documents:
Cancer Care Ontario Person-Centred Care Guideline
Cancer Care Ontario Person-Centred Care Report
April 1, 2016 Who Would Benefit from This Making Healthy Change New Model of Care? For Information and Referrals, People with multiple complex needs who: Contact Haldimand Health Link at: Happen
Frequently visit the emergency department. Haldimand Health Link Frequently are admitted and readmitted to Wendy Renault: Care Coordinator hospital. Telephone: 905-229-2261 Fax: 905-774-6776 Need additional support to get the care they Email: [email protected] need for complex issues.
Have trouble managing their lives, even with current support. Harriet Ekperigin: Haldimand Health Link Lead When you make a referral, the team works with Telephone: 905-229-2261 primary care providers and the patient to devel- Fax: 905-774-6776 op and implement a care plan. Everyone will be Coordination and Care for Patients kept informed about the patient’s progress and with Complex Needs activity. Participation is confidential and volun- tary, patients may withdraw at any time. Team members will develop a connection be- Serving Haldimand County tween primary care, the home, and other appro- priate services. Together, we will deliver coordi- nated care to improve health outcomes. What is Haldimand Health Link? Live with mental health and psy- In our community, five percent of patients ac- chosocial challenges such as count for nearly two-thirds of the total health depression, anxiety, social isola- Health Links: Community and Primary Care tion or substance abuse and care usage. There can be many reasons for Working Together need help . this; complex medical and social issues, or When the hospital, the primary care provider, the mental health challenges. Sometimes these long-term care home, community organizations and patients simply cannot coordinate everything others work as a team, the patient experiences that is going on in their lives. Health Links is a more coordinated care, leading to improved out- model of care that can help. comes. The best way to support these patients is for all Home Visits the organizations that touch their lives to work together with existing primary care providers Improving in-home support is a vital step to im- to give them the coordinated care they need. proving the lives of patients with complex needs. By working with primary care, this level of support Haldimand Health Link will see that people who can help patients avoid hospitalization and emer- need coordinated support: gency room visits. Health Link Staff will visit pa-
Will have individual care plans. tients at home who:
Will have caregivers who frequently check Have multiple chronic conditions such as COPD, heart failure and dementia. in to help and to adjust and evaluate care.
Will have access to new approaches of care Are frail and experience falls at home.
in their community. Frequently visit the hospital and the emergency department.
Burlington Health Link “Integrating and improving 440 Elizabeth Street Burlington L7R2M1 health care for those who Phone: 905.639.8794 Fax: 905.639.0129 need it most is one of the
Dr. Shailesh Nadkarni ext 3884 ways we'll improve our Health Link Lead ability to provide the best
Elizabeth Davis ext 3869 care possible to patients Health Link Manager and help to identify
efficiencies in our health care system.” Dr. Doug Weir, President,
Ontario Medical HNHB Burlington Association Let’s Make Healthy Change Happen
"Family physicians in Ontario are always looking for ways to improve care for complex needs patients. Health Links is an opportunity to foster better working relationships with other local health care providers which will result in better outcomes for patients."
What matters to you? It’s easy to get started.
Health Link teams have been You will meet with the Health created across the province of Link Team and anyone you Do all the members of your Ontario to help improve your choose to be there at your side health care team talk to each care, and make the health care (e.g.: family, friends) other? system work for you. We will talk about your health care- what’s working for you, Health Link Care Coordinators what isn’t. The Health Link Let's join hands with everyone will bring everyone together and team will then work with involved, and make a plan! assist you in creating a plan of care that everyone will follow and members of your circle of care. have access to. We want to work with you to ensure you are receiving timely
access to the most appropriate YOU are in the driver's seat! People who see many health care care in the most appropriate place providers, people who access a from the most appropriate range of health care services, and providers. people who find it hard to navigate the health system will You will receive your own care benefit from Health Link . plan that you can share with anyone you wish.
It’s easy to become involved.