1. health and fitness

Excellent Care for All
Mississauga Halton CCAC
Quality Improvement Plans (QIP): Progress Report for 2014/15 QIP
The Progress Report is a tool that will help organizations make linkages between change ideas and improvement, and gain insight into how their change ideas
might be refined in the future. The new Progress Report is mostly automated, so very little data entry is required, freeing up time for reflection and quality
improvement activities.
Health Quality Ontario (HQO) will use the updated Progress Reports to share effective change initiatives, spread successful change ideas, and inform robust
curriculum for future educational sessions.
ID
Measure/Indicator
from 2014/2015
1 Falls
%
Adult long stay home
care clients
2012/13
HCD, RAI-HC via
LSAS
Current
Target as
Current
Performance as
stated on
Performance
stated on QIP14/15 QIP 14/15
2015
36.70
34.50
37.20
Comments
For the 2014/15 QIP - Mississauga Halton CCAC
stated its current performance numbers and set its
target based on FY 2013/14 data (the most recent
complete fiscal year reporting period).
UPDATED REPORTING PERIOD for Current
Performance 2015 (Oct. 1, 2013 – Sep. 30, 2014).
Realizing that the QIP is a living document and the change ideas may fluctuate as you test and implement throughout the year, we want
you to reflect on which change ideas had an impact and which ones you were able to adopt, adapt or abandon. This learning will help
build capacity across the province.
Was this change idea
Lessons Learned: (Some Questions to Consider) What was your
implemented as
experience with this indicator? What were your key learnings? Did the
intended? (Y/N button)
change ideas make an impact? What advice would you give to others?
Development of Program for No
Medication Management was put on hold in August 2014 while in the initiation
Chronic/Complex Patient
stage of the project cycle. The organization made the decision to reprioritize onPopulations
going initiatives/work due to various competing pressures it was facing at the
time. This planned improvement initiative (change idea) will be carried over into
the 2015/16 QIP as we work towards a continued strategy of preventing falls of
our complex patient population.
Change Ideas from Last
Years QIP (QIP 2014/15)
Implement Home
Independence Program
No
This change idea initiative was put on hold in August 2014 and subsequently
has been discontinued as a planned improvement initiative. MH CCAC
refocused its rehabilitation patient programming service delivery strategy with
other improvement initiatives that were not included in the 2014/15 QIP. These
Mississauga Halton CCAC 2014/15 Quality Improvement Plan – Progress Report (March 2015)
Page 1 of 12
Change Ideas from Last
Years QIP (QIP 2014/15)
(1) Rapid Recovery
Program and (2)
Physiotherapy Delivery
Model
Was this change idea
implemented as
intended? (Y/N button)
Lessons Learned: (Some Questions to Consider) What was your
experience with this indicator? What were your key learnings? Did the
change ideas make an impact? What advice would you give to others?
other initiatives included the Rapid Recovery Program and the Physiotherapy
Delivery Model.
Yes
MH CCAC and the community care sector has a greater awareness to falls
especially with having a greater complex population, and striving to serve those
with more complex needs. MH CCAC experience with this falls indicator over
the last five quarters (Q3 2013/14 to Q3 2014/15) demonstrates a downward
trend approaching to our 2014/15 QIP target. As well, we are performing below
the provincial CCAC sector average which has increased during the last two
quarters of reported data.
(1) Rapid Recovery Program services are provided to rehabilitative patients
where a personalized care plan and ideal level of rehabilitation services are
provided to recover at home for a two week period starting within 24 hours after
they leave hospital so that they can recover at home within one of the three
treatment streams (Rehabilitate to Independence, Restore to Optimal Function,
and Prevent & Maintain Decline). This initiative was fully implemented at all our
hospital sites since Jan. 2014. Refinement of the program's eligibility criteria is
currently underway and discussions with the Mississauga Halton LHIN are
underway to ensure the continuation of this programming option for patients.
(2) Physiotherapy Delivery Model provides the patient an opportunity to
improve, develop, restore or maintain physical function (neuromuscular,
musculoskeletal and cardio-respiratory) and promote mobility lost or impaired as
a result of de-conditioning, disease, pain, injury or surgical procedure and/or to
prevent a decline in functional/clinical status. There are 3 PT Streams
(Rehabilitate to Independence, Restore to Optimal Function, and Maintain &
Prevent) that have been designed and operationalized. Currently, this work is
undergoing its second phase of evaluation to see if further improvements are
warranted as we work towards better assisting patients in attaining and
progressing towards self-management strategies of their care delivery plan at
home.
Mississauga Halton CCAC 2014/15 Quality Improvement Plan – Progress Report (March 2015)
Page 2 of 12
ID
Measure/Indicator
from 2014/2015
2 5 Day NUR
%
Home Care Clients
2013/14
Ministry of Health
Portal
Current
Target as
Current
Performance as
stated on
Performance
stated on QIP14/15 QIP 14/15
2015
93.90
93.90
96.2
Comments
For the 2014/15 QIP - Mississauga Halton CCAC
stated its current performance numbers and set its
target based on FY 2013/14 data (the most recent
complete fiscal year reporting period).
UPDATED REPORTING PERIOD for Current
Performance 2015 (Oct. 1, 2013 – Sep. 30, 2014).
Realizing that the QIP is a living document and the change ideas may fluctuate as you test and implement throughout the year, we want
you to reflect on which change ideas had an impact and which ones you were able to adopt, adapt or abandon. This learning will help
build capacity across the province.
Was this change idea
Lessons Learned: (Some Questions to Consider) What was your
implemented as
experience with this indicator? What were your key learnings? Did the
intended? (Y/N button) change ideas make an impact? What advice would you give to others?
Use technology to better
Yes
The One Clinician model refers to 3 technology systems: IAR, Reach and
share patient information with
cGTA (Connecting GTA). These systems can provide Mississauga Halton
health system partners (One
CCAC users with timely access to patient information from across participating
Clinician Model)
Health Service Partners in order to support coordinated, timely care planning
for its patients. MH CCAC continues to work with our service provider
organizations to increase uptake/utilization of these information technology
portals as a means to assist in getting patient services going even quicker.
Change Ideas from Last
Years QIP (QIP 2014/15)
INTEGRATED ASSESSMENT RECORD (IAR) NOTE: Implementation and
roll-out of the IAR as a means of sharing patient assessments that different
health care providers perform to determine patient needs and care plans) was
completed as of March 2014. The result, we are not dealing with as many
faxes and have 35 identified IAR partners reducing the amount of time it takes
to access patient information entered by other health care providers or sharing
information from our organization.
CONNECTING GTA (cGTA) NOTE: The cGTA project (when operational later
this year) will allow us to view and share patient information with hospitals and
CCACs across the five Toronto area LHINs. Connectivity testing is complete
and Limited Production Release has started. Use of this portal by Care
Coordinators is expected to be initiated in the Spring of 2015 (timing to be
Mississauga Halton CCAC 2014/15 Quality Improvement Plan – Progress Report (March 2015)
Page 3 of 12
Change Ideas from Last
Years QIP (QIP 2014/15)
Was this change idea
implemented as
intended? (Y/N button)
Lessons Learned: (Some Questions to Consider) What was your
experience with this indicator? What were your key learnings? Did the
change ideas make an impact? What advice would you give to others?
confirmed).
This QIP priority indicator performance measure was incorporated into the
organization balance scorecard in FY 2014/15 Q1 to ensure monitoring is ongoing.
Mississauga Halton CCAC 2014/15 Quality Improvement Plan – Progress Report (March 2015)
Page 4 of 12
Current
Target as
Current
Performance as
stated on
Performance
stated on QIP14/15 QIP 14/15
2015
3 5 Day PSW (Complex) 91.10
91.10
91.3
%
Home Care Clients
2013/14
Ministry of Health
Portal
ID
Measure/Indicator
from 2014/2015
Comments
For the 2014/15 QIP - Mississauga Halton CCAC
stated its current performance numbers and set its
target based on FY 2013/14 data (the most recent
complete fiscal year reporting period).
UPDATED REPORTING PERIOD for Current
Performance 2015 (Oct. 1, 2013 – Sep. 30, 2014).
Realizing that the QIP is a living document and the change ideas may fluctuate as you test and implement throughout the year, we want
you to reflect on which change ideas had an impact and which ones you were able to adopt, adapt or abandon. This learning will help
build capacity across the province.
Change Ideas from Last
Years QIP (QIP 2014/15)
Redesign Assessment at
Intake Process (part of
Core Business Redesign
work)
Was this change idea
Lessons Learned: (Some Questions to Consider) What was your
implemented as
experience with this indicator? What were your key learnings? Did the
intended? (Y/N button)
change ideas make an impact? What advice would you give to others?
Yes
Core Business Redesign is a strategic plan project that helps us change and
evolve the way we provide care to meet the growing and changing needs of our
patients, families and our new role within the health care system. Core Business
Redesign work (Assessment at Intake Process) develops an efficient, patient
centered intake process that helps deliver on our patient pledge to anticipate
and meet their needs from the first call regardless of intake point.
Core Business Redesign work (Assessment at Intake Process) is on track to be
completed by the end of the fiscal year. The new intake and assessment
processes began in July 2014 at the Credit Valley hospital site, with further rollout occurring at Oakville Trafalgar Memorial Hospital and Trillium Health
Partners (Mississauga and Queensway sites) in November 2014 via the Access
Care Team (ACT).
ACT data results demonstrate expected productivity based on early
implementation results. Data demonstrates an increase in volumes from 1870
referrals in Nov to 2283 referrals in Dec. As well, there was a noted decrease of
daily referral backlogs from 130-150 to approximately 40 over the first PDSA
cycle. This patient flow streamline has meant an enabling of consistency in
patient referrals, and has provided our in-hospital care coordination team with
more time to support patients with complex care needs.
Mississauga Halton CCAC 2014/15 Quality Improvement Plan – Progress Report (March 2015)
Page 5 of 12
Change Ideas from Last
Years QIP (QIP 2014/15)
Was this change idea
implemented as
intended? (Y/N button)
Lessons Learned: (Some Questions to Consider) What was your
experience with this indicator? What were your key learnings? Did the
change ideas make an impact? What advice would you give to others?
This QIP priority indicator performance measure was incorporated into the
organization balance scorecard in FY 2014/15 Q1 to ensure monitoring is ongoing.
Mississauga Halton CCAC 2014/15 Quality Improvement Plan – Progress Report (March 2015)
Page 6 of 12
ID
Measure/Indicator
from 2014/2015
4 Client Experience
%
Home Care Clients
FY 2012/13
OACCAC
Current
Target as
Current
Performance as
stated on
Performance
stated on QIP14/15 QIP 14/15
2015
91.50
93.00
90.90
Comments
For the 2014/15 QIP - Mississauga Halton CCAC
stated its current performance numbers and set its
target based on FY 2013/14 data (the most recent
complete fiscal year reporting period).
UPDATED REPORTING PERIOD for Current
Performance 2015 (Apr. 1, 2013 – Mar. 31, 2014).
Realizing that the QIP is a living document and the change ideas may fluctuate as you test and implement throughout the year, we want
you to reflect on which change ideas had an impact and which ones you were able to adopt, adapt or abandon. This learning will help
build capacity across the province.
Was this change idea
Lessons Learned: (Some Questions to Consider) What was your
implemented as
experience with this indicator? What were your key learnings? Did the
intended? (Y/N button)
change ideas make an impact? What advice would you give to others?
Share Care Council Yes
While MH CCAC has experienced challenges in achieving our overall Client
Providing patients with a
Satisfaction target, indicator results may be influenced by a variety of factors
direct voice in our programs
and thus further research on root causes is key to making improvements.
and services
Patient and caregiver engagement through the Share Care Council is one
important route to take to gain a direct understanding of how to improve client
experience. With this new collection of knowledge, MH CCAC expects it will
lead to better outcomes in the upcoming year and going forward as we learn
how to best use the Share Care Council in improvement efforts.
Change Ideas from Last
Years QIP (QIP 2014/15)
Redesign System
Navigation at Intake
process (part of Core
Business Redesign work)
Yes
Redesign Care Planning
and Monitoring process
(part of Core Business
Redesign work)
Yes
MH CCAC experience with overall Client Satisfaction scoring has revealed that
the ability for MH CCAC to link clients to other services is influential in improving
overall client satisfaction. With the change idea of implementing the Information
and referral specialist role that works with an up-to-date "single source of truth",
this is expected to improve MH CCAC's ability to link patients to other services,
and thus in the near future, improve overall patient satisfaction scores.
With the challenges experienced in achieving overall Client Satisfaction targets,
further analysis revealed that the Care Coordination component question was
the one requiring the most attention. The Care Planning and Monitoring portion
of Core Business Redesign work - implemented new Patient Service Report
(PSR) guidelines in Oct. 2014. This on-going work to improve timeliness and
consistency in responses to changes in patients' needs is expected to improve
in the upcoming year, patients' experience with care coordination.
Mississauga Halton CCAC 2014/15 Quality Improvement Plan – Progress Report (March 2015)
Page 7 of 12
ID
Measure/Indicator
from 2014/2015
5 Hospital Readmits
%
Home Care Clients
2012/13
HCD, DAD, NACRS
Current
Target as
Current
Performance as
stated on
Performance
stated on QIP14/15 QIP 14/15
2015
14.90
14.90
15.70
Comments
For the 2014/15 QIP - Mississauga Halton CCAC
stated its current performance numbers and set its
target based on FY 2013/14 data (the most recent
complete fiscal year reporting period).
UPDATED REPORTING PERIOD for Current
Performance 2015 (Jul. 1, 2013 – Jun. 30, 2014).
Realizing that the QIP is a living document and the change ideas may fluctuate as you test and implement throughout the year, we want
you to reflect on which change ideas had an impact and which ones you were able to adopt, adapt or abandon. This learning will help
build capacity across the province.
Was this change
Lessons Learned: (Some Questions to Consider)
idea implemented What was your experience with this indicator? What
Change Ideas from Last Years QIP (QIP 2014/15)
as intended? (Y/N were your key learnings? Did the change ideas make
button)
an impact? What advice would you give to others?
Improvement initiatives will be identified for the
Yes
MH CCAC has experienced that this readmission
2015/16 Quality Improvement Plan, once complete
indicator is impacted by hospital and primary care partner
data on current performance is reviewed and analyzed.
organization activity and as such, the relevant change
In the meantime, Mississauga Halton CCAC will
ideas identified involve work with these partner
continue to work with Service Providers, Hospitals and
organizations. MH CCAC has learned that with this
other partner organizations to ensure appropriate care
indicator relying on data from both hospital and
planning and interventions are in place for individual
community care databases, it is not very current because
clients to minimize emergency department visits and
of the required integration time and thus assessing
hospital admissions for our patients. Initiatives
whether change ideas make an impact on the indicator is
currently underway to support this work include:challenging.
Health Links partnerships to coordinate care for
seniors and others with complex conditions, involving
HEALTH LINKS NOTES: The Health Links change idea
family health teams, hospitals, CCACs, community
is designed to develop a process that improves
support services agencies and others- Continued
partnerships among health service providers, primary
improvement of our Client Care Model and Standards
care physicians and other providers to provide effective,
of Care to ensure regular patient follow-up, regular
coordinated care (by geographical area) for complex
reassessment of care needs and helping patients
patients that would otherwise require hospital
navigate the health system- Continuing our work to
readmission. The 7 identified Health Links within our MH
adopt and implement evidence based pathways to
LHIN area are in various states of development with six
guide patient care (e.g. Wound Care, Hips and Knees,
having completed their business planning process and
Mississauga Halton CCAC 2014/15 Quality Improvement Plan – Progress Report (March 2015)
Page 8 of 12
Change Ideas from Last Years QIP (QIP 2014/15)
Palliative Care)- Primary Care Integration work to
connect our Care Coordinators more closely with
Family Physicians and Family Health Teams
Was this change
idea implemented
as intended? (Y/N
button)
Lessons Learned: (Some Questions to Consider)
What was your experience with this indicator? What
were your key learnings? Did the change ideas make
an impact? What advice would you give to others?
East Mississauga identified as an early adopter and
seeing patients since 2013.
The South West Mississauga Health Link is led directly
by MH CCAC and is in the planning phase. The East
Mississauga Health Link is led by one of our key hospital
partners (Trillium Health Partners) and their progress
report has demonstrated some quality improvement
results.
For patients enrolled in this Health Link from October
2013 to March 2014: a) There was a 37% decrease in
emergency room usage, as 29 of 48 patients had fewer
visits; b) there was a 29% decrease in admissions, as 26
of 48 patients had fewer admissions.
In another report from Trillium, for East Mississauga
Health Link patients having ED visits/Admissions from
April 2014 to June 2014: a) there was a 34% decrease in
emergency room usage, as 49 of 80 patients had fewer
visits; b) there was a 32% decrease in admissions, as 43
of 80 patients had fewer admissions.
With this demonstration of positive preliminary results,
MH CCAC looks forward to partnering through Health
Links to improve provision of care coordination for
complex patients, and providing the required leadership
for the Southwest Mississauga Health Link and the
Health Link Secretariat to ensure the successful
implementation of Health Links within the MH LHIN.
CLIENT CARE MODEL NOTES: Mississauga Halton
CCAC's Client Care Model has been operationalized.
Mississauga Halton CCAC 2014/15 Quality Improvement Plan – Progress Report (March 2015)
Page 9 of 12
Change Ideas from Last Years QIP (QIP 2014/15)
Was this change
idea implemented
as intended? (Y/N
button)
Lessons Learned: (Some Questions to Consider)
What was your experience with this indicator? What
were your key learnings? Did the change ideas make
an impact? What advice would you give to others?
Existing Guidelines of Care are being implemented and
merged within the Primary Care standards of care by Feb
2015. A planned outcome is a robust process to reassess
and monitor patients in conjunction with primary care to
avoid unplanned emergency department visits.
EVIDENCE BASED PATHWAYS NOTES: Outcome
based pathways are in place for both Wound Care
patients (short stay) and for Hip & Knee replacement
patients. These pathways and supporting processes are
monitored and refined on an on-going basis. The
palliative pathway was put on hold as we are awaiting
provincial direction.
PRIMARY CARE INTEGRATION: Integration of Care
Coordinators with Family Physicians and Family Health
Teams is scheduled to begin in January 2015 along with
the completion of Primary Care Standards of Care
Provider's guidelines.
This QIP priority indicator performance measure was
incorporated into the organization balance scorecard in
FY 2014/15 Q1 to ensure monitoring is on-going.
Mississauga Halton CCAC 2014/15 Quality Improvement Plan – Progress Report (March 2015)
Page 10 of 12
ID
Measure/Indicator
from 2014/2015
6 ED Visits
%
Home Care Clients
2012/13
HCD, DAD, NACRS
Current
Target as
Current
Performance as
stated on
Performance
stated on QIP14/15 QIP 14/15
2015
5.10
5.10
4.40
Comments
For the 2014/15 QIP - Mississauga Halton CCAC
stated its current performance numbers and set its
target based on FY 2013/14 data (the most recent
complete fiscal year reporting period).
UPDATED REPORTING PERIOD for Current
Performance 2015 (Jul. 1, 2013 – Jun. 30, 2014).
Realizing that the QIP is a living document and the change ideas may fluctuate as you test and implement throughout the year, we want
you to reflect on which change ideas had an impact and which ones you were able to adopt, adapt or abandon. This learning will help
build capacity across the province.
Change Ideas from Last Years QIP (QIP 2014/15)
Improvement initiatives will be identified for the 2015/16 Quality
Improvement Plan, once complete data on current performance
is reviewed and analyzed. In the meantime, Mississauga Halton
CCAC will continue to work with Service Providers, Hospitals and
other partner organizations to ensure appropriate care planning
and interventions are in place for individual clients to minimize
emergency department visits and hospital admissions for our
patients. Initiatives currently underway to support this work
include: Health Links partnerships to coordinate care for seniors
and others with complex conditions, involving family health
teams, hospitals, CCACs, community support services agencies
and others; Continued improvement of our Client Care Model and
Standards of Care to ensure regular patient follow-up, regular
reassessment of care needs and helping patients navigate the
health system; Continuing our work to adopt and implement
evidence based pathways to guide patient care (e.g. Wound
Care, Hips and Knees, Palliative Care) - Primary Care Integration
work to connect our Care Coordinators more closely with Family
Physicians and Family Health Teams
Was this
change idea
implemented as
intended? (Y/N
button)
Yes
Mississauga Halton CCAC 2014/15 Quality Improvement Plan – Progress Report (March 2015)
Lessons Learned: (Some Questions to
Consider) What was your experience with this
indicator? What were your key learnings? Did
the change ideas make an impact? What advice
would you give to others?
See notes above from Hospital Readmissions
initiatives.
This QIP priority indicator performance measure
was incorporated into the organization balance
scorecard in FY 2014/15 Q1 to ensure monitoring
is on-going.
Page 11 of 12
Mississauga Halton CCAC 2014/15 Quality Improvement Plan – Progress Report (March 2015)
Page 12 of 12