Hamilton Niagara Haldimand Brant Health Links Coordinated Care Planning Toolkit
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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