Community Care Access Centre Quality Improvement Plan Work plan
This worksheet
aim has 3 major
measure
categories across row
change
5. Aim is the first
safetycategory
effectiveness
and it has 2access
sub-categories under it. Measureclient-centred
is the second category and it has 4 sub-categories under it. Change
2015/16
AIM
Quality
dimension
Safety
MEASURE
Objective
To reduce falls
among long-stay
home care patients
Measure/Indicator
Falls for Long-Stay Clients: Percentage
of adult long-stay home care patients
who record a fall on their follow-up RAIHC assessment
Current
performance
29.6% 13-14
33.2% 14-15
CHANGE
Target for 2014/15
Stretch target of
28.60% set by
NWCCAC
Target justification
Planned improvement initiatives (Change
Ideas)
Methods and process measures
Goal for change ideas (2015/16)
Comments
Provincial average
33.4% 2013-14
35.3% 2014-15
Create a comprehensive falls prevention
program involving providers and patients.
Review of best practices for falls has been
completed in 2014-15.
Engagement of providers to build the
To develop the outcome and
picture of patients who are at risk for falls. process measures locally for falls.
Mapping current state as it applies to CCAC
patients.
Gap identification.
Review results and identify change ideas
for testing.
Last year we completed the best practice
review and this year we are moving on to
identify gaps in our current system which
will result in change ideas to be acted
upon.
Provincial average
7.7% 2013-14
7.0 % 2014-15
Participate in a Palliative COPD/ CHF
program (PCCP) with TBRHSC. This clinic
began in 2014-15 and will be further
developed this year. Data analysis of the
metrics will begin this year to allow for more
trends to be identified and change ideas to
be created.
# ED visits
# Avoidable ED visits
# Hospital admissions per patient
# Avoidable Hospital admissions
Patient and provider satisfaction
Prevent clients with exacerbations
from going into ER or from being
admitted to hospital.
This clinic began in 2014-15 and will
develop further this coming year.
Health Links (HL) - The NWCCAC is the lead
organization for the Thunder Bay Health
Links and will participate in the 4 remaining
health links starting in our region. The HL
team for Thunder Bay will be developing
their program in this next year now that the
full team has been hired.
Develop an operational plan for Health
Links. Reduce unnecessary admission to
hospitals. Reduce the number of avoidable
ED visits for patients with conditions best
managed elsewhere.
Ensure the
development of co-ordinated care plans for
all complex patients.
Identify who the high users are and the
services they currently utilize and
determine the gaps.
To facilitate development of the HL
program and the ECTC clinic will
serve as initial learnings.
To further refine the HL role in the
ECTC clinic.
NWCCAC is the lead organization for the
Thunder Bay Health Link and is a
participant on the others. The NWCCAC
HL project team has been involved in the
planning and implementation of the ECTC
program, a precursor to HL. The
principles and systems guiding that
program will facilitate development of
the HL program and will serve as initial
learnings. HL team hired and ready to go
as at Feb 16, 2015.
Implementation of eNotification LHIN wide
allows us to track our patients ED visits and
reasons for visits which helps us check in
with patients to reassess their needs. We
will identify common reasons for the ED visit
and work with partners to fill gaps in
services.
# of hospitals with eNotification activated.
# of eNotifications per coordinator per
month.
# of alerts per care model
population and per program.
We will develop a process through which
to share trends in this data with our health
partners.
To have all of our coordinators
receiving eNotifications for their
patients accessing the ED and
making contact with patients.
eNotification is going live in as many
hospitals as possible (depends on if
they’ve signed the DSA and NSA) in the
North West on March 17, 2015. This will
allow us to monitor the number of
patients going to the ED, being admitted
to hospital, discharged from ED and
discharged from inpatient unit. We will
be able to start providing data for this at
some point in April 2015. We cannot
project the effect of the regional
hospitals data being added to our
sample. This year will be a baseline year
of data collection.
Space for additional indicators
Effectiveness
To reduce the
number of
unplanned ED visits
among home care
patients (TBRHSC
data only)
QIP Submission June 27, 2014
Unplanned Emergency Department
Visits: Percentage of home care patients
with an unplanned, less-urgent ED visit
within the first 30 days of discharge
from hospital
11.8% 2013-14
10.3 % 2014-15
10.8% 2014-15
9.3 % 2015-16
Copy of QIP final 15-16 in Excel. -ss
Community Care Access Centre Quality Improvement Plan Work plan
This worksheet
aim has 3 major
measure
categories across row
change
5. Aim is the first
safetycategory
effectiveness
and it has 2access
sub-categories under it. Measureclient-centred
is the second category and it has 4 sub-categories under it. Change
2015/16
AIM
Quality
dimension
Safety
MEASURE
Objective
Measure/Indicator
To reduce avoidable
hospital admissions
among home care
patients (TBRHSC
data only)
Hospital Readmissions: Percentage of
home care patients who experienced an
unplanned readmission to hospital
within 30 days of discharge from
hospital.
QIP Submission June 27, 2014
CHANGE
Current
performance
Target for 2014/15
Target justification
19.4% 13-14
18. 7% 14-15
2014-15 18.4%
2015-16 17.7%
Provincial average
2013-14 17.9%
2014-15 18.2%
Planned improvement initiatives (Change
Ideas)
Methods and process measures
Goal for change ideas (2015/16)
Comments
Development and spread of Telehomecare
program LHIN wide. Further develop the
Thunder Bay program and expand this
program to all of the regional communities.
#successful expansions sites.
To expand enrollment in the
# of people referred to the program.
program to regional patients with
# number of people who proceeded to join CHF and COPD.
the program.
Patient satisfaction.
Plans underway to expand to Nipigon,
Marathon and Dryden in Q1 and the rest
will follow this year. New Engagement
Lead position hired and will allow for
expansion and sustainability of program.
Palliative Nurse Practitioner (NP) program.
The NWCCAC has 5 NP positions whose role
is to provide primary care for home bound
people without a physician and help them to
be successful in managing their health in the
community. We want to improve our ability
to help the palliative patients remain at
home as long as possible. This year we will
have a full team and need to evaluate the
full program and review the metrics to
identify it's effect on the measures.
Hospital readmission visits by palliative NP
patient's.
Track the reasons for the readmissions.
# of palliative patients using the NP
program.
To reduce the number of Hospital
readmissions by palliative patients
by increasing their access to a NP in
the home.
We have 5 NP positions covering
Northwestern Ontario. Data is being
correlated to create reports for the
program to utilize. More time is needed
to analyse the data and look for change
idea opportunities.
Implementation of eNotifications LHIN wide
allows us to track our clients hospital
admissions/readmissions. We will identify
common reasons for the admission and
work with partners to fill gaps in services.
# of hospitals with eNotifications activated.
# of eNotifications per coordinator per
month.
Develop a process through
which to share trends in this data with our
health partners.
To have all of our coordinators
receiving eNotifications for their
patients readmitted to hospital and
making contact with patients.
eNotification is going live in as many
hospitals as possible (depends on if
they’ve signed the DSA and NSA) in the
North West on March 17/15. This will
allow us to monitor the number of
patients going to the ED, being admitted
to hospital, discharged from ED and
discharged from inpatient unit. We will
be able to start providing data for this at
some point in April 2015. We cannot
project the effect of the regional
hospitals data being added to our sample
. This year will be a baseline year of data
collection.
Copy of QIP final 15-16 in Excel. -ss
Community Care Access Centre Quality Improvement Plan Work plan
This worksheet
aim has 3 major
measure
categories across row
change
5. Aim is the first
safetycategory
effectiveness
and it has 2access
sub-categories under it. Measureclient-centred
is the second category and it has 4 sub-categories under it. Change
2015/16
AIM
Quality
dimension
MEASURE
Target for 2014/15
Target justification
Nursing Services
93.5% 13-14
90.1 % 14-15
94.5% unchanged
from 2014-15
Provincial average
93.9% 2013-14
94% 2014-15
Personal Support Services
81.3 % 13-14
78.7 % 14-15
83% unchanged
from 2014-15
82.7% 2013-14
84.8% 2014-15
Objective
Measure/Indicator
Safety
Space for additional indicators
Access
To reduce service
wait times.
QIP Submission June 27, 2014
CHANGE
Current
performance
Planned improvement initiatives (Change
Ideas)
Methods and process measures
Goal for change ideas (2015/16)
Comments
Review of referral process to identify nursing Quarterly data will continue to be
services that fall outside the target. The
monitored for any emerging trends based
measure is the time from service
on the reasons for delay in start of services.
authorization date to first visit date. There
are reasons for start dates to be delayed and
CCACs now record those reasons to see if
any patients truly waited for service past 5
days. The reasons are: Clinical need for
service to begin on a specific day; This
service is being preplanned; Patient has
chosen to delay service initiation.
To identify which patients are
waiting outside of the target and to
identify barriers to a timely visit. To
exceed the provincial average for
this target.
Provincial service scheduling reasons
codes have been implemented Nov. 19,
2014. These codes allow for the
coordinator to indicate why the service
start date is beyond 5 days. After
reviewing all the patients who's wait fell
after 5 days only 1 in Q3 2014-15 waited
for service. The service stat date is the
correct starting point for the 5 day wait.
We will continue to monitor the reasons for Quarterly data will continue to be
any delay of service for a patient that is
monitored for any emerging trends based
deemed ready for service. Currently none of on the reasons for delay in start of services.
our clients waited outside of the 5 day
period unless they were for one of the 4
acceptable reasons identified. The reasons
are: Clinical need for service to begin on a
specific day; This service is being
preplanned;. Patient has chosen to delay
service initiation.
To identify which patients are
waiting outside of the target and to
identify barriers to a timely visit. To
exceed the provincial average for
this target.
This measure is only for our complex
patients who have high needs. This
measure does not include people who
are on a waitlist. No patients in Q3 201415 waited past the 5 day period. This
indicator continues to need the starting
point changed as the service
authorization date creates the wrong
picture for patients waiting. The service
stat date is the correct starting point for
the 5 day wait.
Five-Day Wait Time for Home Care:
Copy of QIP final 15-16 in Excel. -ss
Community Care Access Centre Quality Improvement Plan Work plan
This worksheet
aim has 3 major
measure
categories across row
change
5. Aim is the first
safetycategory
effectiveness
and it has 2access
sub-categories under it. Measureclient-centred
is the second category and it has 4 sub-categories under it. Change
2015/16
AIM
Quality
dimension
Safety
Client-centred
MEASURE
Objective
Measure/Indicator
To improve client
experience
Client Experience: Percent of home care
clients who responded “Good”, “Very
Good”, or “Excellent” on a five-point
scale to any of the following client
experience survey questions:
1) Overall rating of CCAC Services.
2) Overall rating of management/
handling of care by Care Coordinator.
3) Overall rating of service provided by
service provider.
CHANGE
Current
performance
Target for 2014/15
92.8% 13-14
91.5 % 14-15
94% unchanged
from 2014-15
Target justification
Planned improvement initiatives (Change
Ideas)
CCAC provincial average Creation of a Patient/Family Centered Care
92.9% 2013-14
Model which will have our patients and their
92.4% 2014-15
caregivers at our committees and
improvement tables. It will also involve the
usage of focus groups to help us make our
service more patient and caregiver centered.
Methods and process measures
Goal for change ideas (2015/16)
Create the project charter.
To develop the program and have
Create new HR processes needed for
patients/caregivers participating on
managing a volunteer program.
committees by September 2015.
(recruitment/orientation/ participation and
evaluation).
To create a program evaluation and a
volunteer satisfaction measurement tool.
Improve transitions at discharge - implement # of discharged patients that received a
the post discharge phone calls by the CCAC post discharge phone call.
as part of the Model of Care Framework.
Comments
This is supported by our Board of
Directors and the NWCCAC Leadership
Team. We will be following best practice
examples such as TBRHSC and using
Accreditation Canada standards for
patient centered care.
80% of the identified populations
Team Assistant resources have been
receive their call in the time frame. allocated to complete the phone calls but
we continue to work on developing the
best process for identifying patients for
the post discharge phone call.
Space for additional indicators
QIP Submission June 27, 2014
Copy of QIP final 15-16 in Excel. -ss