A collaborative approach between the Georgian Bay General Hospital (GBGH) and the North Simcoe Community Health Link (NSCHL) have successfully improved outcomes and reduced costs for the Health Links population that represent the highest users of the hospital inpatient emergency department (ED). A cross jurisdictional partnership was formalized, focused on high user Quality Based Procedure (QBP) patients with COPD and CHF. The aim was to establish a system partnership that would improve health care experiences and reduce costs evidenced by improved outcomes and quality of care by April 2016. To achieve this, a collaborative strategy was established to optimize QBP performance, integrate Primary Care into the process, and engage First Nation/Metis/ Inuit communities. Relationships and processes were developed enabling improved access to the right care, at the right time, in the right place, and a measurement plan to understand the impact of coordinated care.
A system navigation model was created that wrapped care around clients, and tools developed to better inform decision making and system change. GBGH and NSCHL meet monthly to identify clients who access the ED or have high inpatient stays. Navigators from the NSCHL approach the client to understand the gaps, and navigate the care to reduce ED visits and inpatient stays, and reduce costs to the system. Outcome measures included: number of ED visits, length of stay, readmission rates, and cost saving to the system. Balancing measures included patient satisfaction survey results, access to Primary Care physicians for the navigator and patients, and access to specialists.
Results in 59 patients demonstrated that in just over a year they were able to establish system change with ED visits reduced by 31%, inpatient admissions reduced by 45%, length of stay reduced by 33.6%, and improved quality of life for patients/clients.
Next steps include an ED flagging process, the availability of care plans in the ED and activation of the system navigator to guide admission processes, as well as partnering with the NSM LHIN to encourage spread. Please see supporting video: https://drive.google.com/open?id=0B1Vf5WhFOIWgYlk5bk9WSFNIdjA
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