Putting Patients at the Heart: A Seamless Journey for Cardiac Surgery Patients 3M Health Care Quality Team Awards

Canadian College of Health Leaders National Awards Program 2018

2

Table of Contents

Section 1:Nomination form 3

Section 2:Executive summary 5

Section 3:Completed report template 6

Appendix: 17 A: PPATH Gain/Risk Sharing Model B: Coordination Along Continuum C: PPATH Performance Dashboard

3

Section 1To be submitted by February 1, 2018

3M Health Care Quality Team Awards – Nomination Form

Contact information for administrative purposes: Prefix: Ms. Name: Anne McKye Title: Project Manager Organization: Trillium Health Partners Address: 100 Queensway West, Mississauga, L5B 1B8 Phone: 647-287-3811Fax: 905-804-7791 Email: Anne.Mckye@thp.on.caProject title: Putting Patients at the Heart: A Seamless Journey for Cardiac Surgery PatientsStart date of the project: X This program was initiated within the past three years and has sustained itself for at least 18 months

Contact information for publication: Project title: Putting Patients at the Heart: A Seamless Journey for Cardiac Surgery Patients Name: Communications and Public Affairs Organization: Trillium Health Partners Address: 100 Queensway West, Mississauga ON, L5B 1B8 Phone: 905-848-7100 Email: Public.Affairs@thp.ca

4

Name Job Title Role as it relates to the project

1. Patti Cochrane Senior VP & Chief Innovation Officer, Trillium Health Partners (THP)

Executive Sponsor (recently re-tired, THP)

2. Stephanie Joyce VP Patient Care Services and Health Service Inte-gration, THP

Executive Sponsor

3. Michael Peters SVP, Business and Corporate Development, SE Executive Sponsor

4. Helene Lacroix VP Nursing and Innovations, SE Project Lead, SE

5. Shawn Kerr Associate VP, THP Associate Executive Sponsor

6. Adam Guy Project Director, THP Project Director

7. Anne McKye Project Manager, THP Project Manager

8. Michelle Fox VP Financial Operations, SE Project Lead, Finance SE

9. Madonna Gallo Head of Public Affairs, SE Communications

10. Roy French Chief Information Officer, SE Project Lead, IT/IS SE

11. Elizabeth Marinelli Senior Clinical Solutions Consultant Operational Leader, SE

12. Gary Spencer Director, Decision Support, THP

13. Carol Vinette-Hancharyk

Director and Deputy Chief Financial Officer, THP

14. Tim Young Director, Information Technology, THP

15. Dr. Charles Cutrara Head of Cardiac Surgery, THP

16. Chandra Presaud-Bacchus

Nurse Practitioner, Cardiac Program, THP

17. Dr. Amir Ginzberg Chief of Quality and Medical Director, Medical Ad-ministration, THP

18. Robin Horodyski Director, Cardiac Health System, THP

19. Tracy Renton Clinical Manager, Cardiac Inpatient, THP

20. Andrew Hartery Senior Advisor, Decision Support, THP

21. Janice Kwok Advisor, Decision Support, THP

22. Anthony Dial Consultant, Information Technology, THP

23. Reem Qurrain Senior Advisor, Finance, THP

24. Peggy Goff Process Improvement Consultant, THP

25. Alex Ward Manager, Information Services, SE IT/IS Leader, SE

26. Brenda Diduck Integrated Care Coordinator, THP

27. Kerry Glisic Integrated Care Coordinator, THP

28. Meglena Velkovska Integrated Care Coordinator, THP

29. Dr. Paul Holyoke Director SE Research Centre

30. Karen Tilemans Administration Assistant, THP

31. THP Clinical Team Health Professionals

32. SE Clinical Team Health Professionals

Please list project team members, with job titles, including anyone seconded or invited onto the team from other departments/groups. Include a separate page if necessary.

5

Executive SummaryIn 2015, Trillium Health Partners and Saint Elizabeth Health Care partnered with patients and families to redesign the journey for cardiac surgery patients from hospital to home. Responding to feedback about fragmented care on discharge, limited access to home care, demand for more hospital beds, and a need to reduce emergency department readmissions, we recreated the patient journey by seamlessly coordinating services around the needs of the patient through standardized post-operative care pathways, providing one team, 24/7 telephone line, community care and an integrated health record. “Putting Patients at the Heart” was funded by the MOH LTC along with five other Integrated Funding Models. It is now the standard of care at this regional cardiac surgical centre which has the second highest cardiac volumes in Ontario.

As a result of continuous quality improvement, in FY16/17 post-operative hospital length of stay was reduced 21%, readmission rates were reduced 28%, and ED visits were reduced 13%. Patient satisfaction with the PPATH program is very high at 98% and patient are more confident about their ability to care for themselves. Savings analysis for FY16/17 compared with FY14/15 showed a total health system savings of $1.4M through reduction of post-op LOS and readmissions.

This work is the result of meaningful patient engagement, courageous leadership and diligent team work across sectors, from senior executives to frontline staff, who eliminated silos of care and focused on what patients wanted. A deep and trusted partnership resulted in better continuity of care and increased patient satisfaction while lowering costs.

Michelle E. DiManuelePresident and CEO, Trillium Health Partners

Section 2

6

A. Issue Statement: Quality improvement initiative(s) across a health system� In 2015, Trillium Health Partners (THP) and Saint Elizabeth Health Care (SE) partnered with patients and

families to redesign the journey for cardiac surgery patients from hospital to home. The program was initiated in response to a variety of patient values and needs, and system challenges, for example:

◊ Surgery and the subsequent transition home was a stressful experience often described as disjointed. Patient and caregiver anxiety on discharge was high; patients and families needed improved support both in hospital and in the community following discharge to facilitate the transition to self-management.

◊ Communications among many providers were most challenged at points of transitions in care and created opportunities for gaps in service, errors in medication management as well as understanding and adherence to post discharge instructions and caregiver fatigue.

◊ In FY 2013/14, 25% of post-op cardiac surgery patients had an unscheduled visit to one of the three THP emergency departments within 30 days of discharge following cardiac surgery, 12% were readmitted.

◊ At THP, approximately 30% of patients post cardiac surgery received homecare services.� Responding to the demand for more hospital beds, patient feedback about the fragmented care

on discharge, limited access to home care and a need to reduce emergency department (ED) readmissions, we recreated the patient journey by seamlessly coordinating services around the needs of the patient through standardized post-operative care pathways.

� By providing “one team” from hospital to home, we improved communication and coordination of care across the hospital to home transition. Our thesis was that a focus on and improvement in the transition of care from hospital to home, would result in improved care outcomes for the patient and family, as well as for the system.

� This new model needed to overcome the system’s tendency for siloes of care between sectors by knitting the acute and community sectors together with shared responsibility for the patient outcomes from surgery until 30 days post discharge.

Section 2

7

� Challenges that were faced, and collaboratively overcome, included redesign of existing service authorization processes, funding mechanisms, and approaches.

� Transforming care in this way aligned perfectly with the vision of both THP and SE. By offering a new kind of health care, we were able to deliver improved quality care and exceptional patient experiences, better access and sustainability through allocation of resources.

B. Innovation in Healthcare Delivery & System InnovationThe “Putting Patients at the Heart” (PPATH) Program has achieved significant, sustained improvements in the patient experience and resulted in improved utilization and cost savings to the health care system. � 73% of post-cardiac surgery patients at THP now receive in-home nursing care within 24 hours of

transitioning home to reinforce discharge education and complete medication reconciliation (increased from 30% receiving some form of home care prior to PPATH); additional RN, PT, OT, PSW care is provided as needed.

� Improved options to access urgent care once transitioned to home has positively impacted ED utilization (13% reduction) and readmission rates (28% reduction); PPATH patients have access to a 24/7 telephone line, cardiac surgery follow-up clinic, and expedited access to integrated care coordinator, nurse practitioner and surgeon to support avoidance of ED visit and readmissions to hospital.

These improvements are possible as a result of both internal and external system monitoring, evaluation, and change. Particular innovations in health care delivery that have enabled the development and operation of “one-team” have provided a unique experience for patients. This was not possible without the following:

� MOH LTC awarded THP “approved agency” status under Home and Community Care Services Act, allowing delivery of community care — the first hospital to achieve such status.

� PPATH developed a transparent, flexible partnership that allowed us to nimbly respond to feedback and needs, and co-created new care pathways and joint ownership of successes and failures with shared responsibility for outcomes.

� Developed gain/risk sharing model where all partners share in the risks and can re-invest savings to innovate for better care. See Appendix A.

� Developed inter-professional education between THP and SE staff, including shadowing opportunities at partner organizations to develop “one team” knowledge, trust and cohesiveness.

8

� Implemented the Integrated Care Coordinator role to support transition from hospital to home playing a key role in connecting the in-home and acute care teams through a planned escalation process.

� IT procedural integration for seamless referral and data entry; single electronic health record in the community, accessible by all members of the PPATH program. See Appendix B.

� Real time electronic tracking log, virtual rounds and dashboard of key metrics developed.� “Iatrics” electronic medication record used with 100% completion of medication reconciliation

on discharge.� Virtual rounds with frontline staff across organizations to enhance circle of care communication and

collaboration.� Collaboration with LHIN Home and Community Care to halt duplication of service access for patients

receiving previous home care services; changing processes and systems.� Optimized patient and family involvement in the quality improvement process through robust

co-design methodologies.� Currently working with the MOHLTC to gain access to Ontario Drug Benefit Plan for patients under 65

who do not have health benefits; the Ministry has made regulation changes to ODB access for patients of “approved agency” — a change that will allow for additional holistic, innovative approaches to care.

C. Implementation � The Model for Improvement and LEAN

methodology were used to develop and implement a patient focused model of care. Stakeholders participating in continuous improvement throughout the project included: patients, caregivers, surgeons, clinical staff, decision-support, finance, information technology, health information management, project management, process improvement and senior leadership.

� LEAN Value Stream Mapping sessions were used to document care, care pathways, the flow of information, and capture patient experience prior to PPATH. Areas for improvement clearly emerged and were used to map our future state which directed our initial implementation.

� To guide implementation and change management, we established working teams focused on operations, clinical practice, IT/IS, quality and finance, with oversight provided by a steering committee; by keeping an open mind about the art of the possible, the team was able to make the required changes without getting too caught up in the limits of existing processes.

� Plan-Do-Study-Act (PDSA) cycles were utilized to test the processes initially on a subset of the total cardiac surgical population, and upon refinement, the program was expanded to include all eligible cardiac surgery patients. As we gained insight and experience with program implementation, adjustments were made to elements of the care pathway and patient teaching as needed.

� Best practices and learnings from other pilot organizations implementing IFMs and patient feedback from patient satisfaction surveys continue to be incorporated into this model.

9

� From the outset, the project team ensured a strong and ongoing focus on monitoring and evaluation over time; including the establishment of standard operating procedures and a real time dashboard of key metrics. These metrics are reviewed monthly by clinicians and leaders and change cycles are planned and implemented.

� Clinical Operations team continues to meet biweekly to review arising clinical or process issues, reflect on outcome and targets and develop strategies for improvements; monitoring of impact occurs at subsequent meetings.

� Actual volumes and costs are reviewed against bundle prices and planned volumes by Care Pathway on a monthly basis and presented quarterly to the steering committee. The monthly tracking process supports annual reconciliation for each Care Pathway, with respect to the actual costs. Adjustments for patient care resource intensity and associated costs are reviewed by finance and clinical representation from both organizations and changes agreed upon for implementation in the following year.

D. Team Leadership PPATH’s greatest strength has been its leadership and dedicated clinical and operations team that has included members from both organizations across departments/disciplines working collaboratively from inception. Even prior to PPATH, SE and THP leadership engaged in a process to confirm shared values and focus which paved the way for a successful start to our collaborative work.

Leadership for the PPATH program included setting up co-leads from both organizations for each committee and working group to reinforce shared accountability for the program. From the outset, we established eight principles that have guided our relationship: 1) Focus on patients, 2) Trust each other, 3) Be respectful, 4) Be transparent, 5) Be accountable, 6) Foster innovation, 7) Share in the potential gains and/or losses, 8) Be fiscally responsible.

Furthermore, the partners have worked together to better understand the roles and contributions of different healthcare providers in the hospital and the community. Team members participated in job-shadowing and shared orientation to the program to allow each partner to understand their daily work.

Key team member and contributions across both organizations:

� Senior leaders demonstrated courageous vision and action to address health system pressures in order to improve the quality of care and experience for patients. Our executives advocated with the MOHLTC to become the first ever hospital in Ontario beyond the CCACs to receive “approved agency” status to deliver home and community care services (required provincial legislation change); negotiated agreements with the LHINs to alter funding arrangements; engaged in tenacious pursuit of improved care by inspiring the team to work collaboratively for change.

� Decision support along with business intelligence and information technology teams developed business solutions for sharing sensitive patient information across the circle of care, as well as metrics and dashboards that allow real time review and analysis of processes and outcomes.

� Finance developed a gain/risk sharing model to manage cost and volume variances that allows cross organizational responsibility through a tight partnership. They have carefully and methodically shared data across organizations and created analyses of costs delineating pathways and sources of risk and gain. This thoughtful work has provided assistance to program decision-making that increases access for patients and challenges the team towards innovation for improved care/experience, while maintaining a focus on value for money in delivery of patient care.

10

� Clinical team courageously relinquished old methods of providing care and replaced it with new, creative, patient-centered approaches including: discharging patients home sooner, engaging patients in care pathway decisions, and surgeons maintaining most responsible provider status for patients post discharge to the community.

� Communications has been open and transparent, with regular meetings, minutes and correspondence, and joint celebrations to mark key milestones and achievements.

Team performance and process was optimized with:

� Strong physician leadership that acknowledged early on, the desire to work with the community to improve patient outcomes and ensured the unity of the physician group in taking on new expanded team roles.

� Regular face to face and virtual touch points and engagements. Governance and meeting structures have evolved to meet the demands of planning, implementing, and evaluating the project but a cross department/organization operations committee has continued to meet regularly every two weeks from inception.

� Clinical virtual rounding on a weekly basis has melded clinical teams together in problem solving patient care needs for best outcome.

� In spite of the challenges of working cross departments and cross organizations the teams have maintained focus primarily on improving patient care. This common patient focus has helped the relationship stay strong as we work through disagreements or barriers. It has encouraged the community health service providers to make autonomous decisions about care needs in light of best clinical judgment rather than contracts and logarithms.

� Courageous conversations that included transparency in data, methods and process sharing, as well as decision making to achieve the best for patients.

11

Understand who I am at the beginning and carry it through

Reduce sense of being overwhelmed

Support my caregiver(s) as they support my care and

recovery

Reduced sense of being

overwhelmed across my

experience of the PPATH program and

after ‘graduation’

Increase my understanding

of what supports and tools are

available to me and when

Support my understanding of the program

the way I need to hear/learn it and

include the person who will help me

E. Patients & Family Engagement Patient and caregiver feedback has shaped the development, design and ongoing optimization of the model of care from the outset:

� Patient stories told to clinicians over the years highlighting the gaps in community support post discharge were the basis for initial pathway development.

� Patients were included on our planning team – their feedback and ideas were explicitly solicited and used to confirm understanding and interpretation of patient needs as well as to drive improvements.

� Patient feedback has been elicited continuously through both a customized patient satisfaction phone survey, and the University of Toronto’s Health System Performance Research Network (HSPRN) eternal review. Results are reviewed at bi-weekly working group meetings and improvements based on feedback are identified, developed and incorporated into the PPATH processes as appropriate. Examples of changes resulting from patient feedback include: 24/7 telephone line added additional staff to ensure timely response, and the integrated care coordinator now asks patients preference for time of PSW visit.

� HSPRN has recently added a caregiver survey to help us understand the impact of caregiving on family and friends. We are looking forward to learning from this.

� Former patients participate as “Healing Heart Volunteers” where they are available daily to talk with patients and caregivers about the experience and recovery process, guiding them with a personal touch and encouragement.

� Though clinical outcomes and patient survey responses have been excellent, we wanted a deeper understanding of the core challenges related to the patient and caregiver experience and so worked with Saint Elizabeth Research Centre to initiate an in-depth co-design process with patients and their caregivers, as well as clinical, administration and leadership staff from both THP and SE to further improve the patient and caregiver focused nature of our program:

◊ Completed series of workshops/focus groups with patients/caregivers/providers (using co-design model) to understand their experience.

◊ From this work, we identified the following emergent themes: 1) Fear of the unknown, 2) Information overload, 3) What is going to happen? 4) Family physician role unclear, 5) Caregiver worry, 6) One size does not fit all.

◊ Emergent working statement:

12

◊ From the co-design collaboration we developed the “Healing Hearts Learning and Support Program” which includes four different approaches to learning: printed material, face to face, digital supports and telephone supports. Elements of this program were already in place (printed brochure, discharge class, 24/7 telephone hotline) but will expand to include: a pictorial experience map, caregiver learning section and short videos topics for home management. Patients and caregivers are working alongside us every step of the way to ensure these new learning and support tools are meeting their needs and positively affecting their overall experience with the program.

13

F. Data and Metrics Success of the PPATH model has been measured through key performance indicators (KPIs) that were developed in collaboration with THP, SE, and the Institute for Clinical and Evaluative Sciences (ICES) (the provincial evaluator for all six IFMs). The KPIs include process, outcome, service, partnership and value for money indicators. Benchmarks have been established for each indicator.

Key Performance Indicators for Cardiac Surgery Evidence-Based Integrated Funding Model

IndicatorExisting System

Improvement Opportunities

Existing System Improvement Opportunities

Best Practice (source)

Improvements Resulting from PPATH

LOS

• Availability of community resources

• Fear/concerns of patient/caregivers

Reduce 30% from 10.7 to 7.5 days

10.3 days

Average LOS for Ontario Hospitals: Top 5 CMGs for Cardiac Surgery (CIHI)

• Patient and caregiver education

• Timely home care services

ED visits within 30 days of

discharge

• Fear/uncertainty• SOB, chest pain,

fever, infection

Reduce 50% from 15% of population to 7.5%

8.9%

Rate of Return to the ED for Hospital Peer Groups for surgical patients (CIHI)

• Discharge education• Catch early through

ICC or home care providers

• 24/7 accessible support at home

• Diversion to hospital clinic for non-urgent issues

Readmission within 30 days of

discharge

• Wound infection• Myocardial infarction• Palpitation• Pneumonia• Pleural effusion

Reduce 50% from 8% to 4%

6.5%

30-Day All-Cause Unplanned Readmission Rates to Inpatient Acute Care for surgical patient (CIHI)

• Catch early through ICC or home care provider for non-urgent issues

• Diversion to hospital clinic for non-urgent issues

Patient satisfaction

• Patient & caregiver confidence/efficacy

• Fear• Involvement in care

plan• Interactions with

health care providers• Being hospitalized

Increase from 85.2% to 90%

70.2%

Ontario IP Community Hospital Average(NCR Picker)

• Patient and caregiver education

• Implement ICC role • Provision of care plan

prior to D/C• Access to 24/7 support

14

Other more detailed indicators that are measured throughout the program to monitor success, facilitate corrective measures in order to positively impact KPIs include:

1. Wait time from discharge to receiving home care 2. Post-operative length of stay 3. Number of visits and LOS in home care 4. Adverse events, including post op infections requiring readmission 5. Patient satisfaction for transition to home 6. Actual cost of care compared to integrated funding

Unique to this program are indicators measuring the joint partnership between THP and SE. The following are the partnership indicators:

1. Meetings held as per agreement 2. Partnership satisfaction (annually) 3. Dispute resolution escalation (frequency) 4. Comprehensive Service Level Agreement 5. Provider satisfaction 6. Virtual care rounds — actual vs expected

Sustainability of this program is measured in the following ways:

� Patient satisfaction is measured through an in-house telephone survey to all patients after discharge from community care, and through a standardized survey conducted by HSPRN at the University of Toronto.

� Provider satisfaction is measured informally through regular ongoing touch points with the cardiac surgeons, nursing and allied health staff and administrators, in hospital and the community.

� Patient safety is monitored through regular review of risks; and further demonstrated through the creation of a Quality Committee which reviews and reports on readmissions and program mortality up to 30 days post hospital discharge.

� Cost per patient and average cost per pathway are monitored by our finance team on a monthly basis to track actual costs against planned for each pathway. Monthly tracking is used to support annual reconciliations and recommended changes in annual planned resource intensities based on actual patients’ needs.

� A cost-benefit analysis is completed yearly for patients who have completed the bundled pathway. � Provincially, the six pilot projects are being monitored and evaluated by the MOHLTC via HSPRN,

who have an evaluation framework including: 1) interviews with key stakeholders, 2) patient experience survey, 3) common indicator reporting and 4) ICES data analyses. PPATH submits data to ICES on a quarterly basis. HSPRN has produced an interim report using this framework that indicates findings to date and direction for future analyses as program size increases.

Data and metrics are regularly monitored through the development of a real time electronic tracking log and dashboard and reviewed monthly by the operations team for ongoing process redesign and improvement. The Steering Committee reviews quarterly and holds responsibility for the overall program outcomes and impact. See Appendix C for sample of dashboard.

15

G. Analysis and Evaluation During 18 months of clinical operations (Feb 2016 to Sept 2017), PPATH has enrolled 1414 patients and realized significant benefits in quality, access and sustainability:

� Average length of stay post-op for cardiac surgery under PPATH was 6 days, compared to 8 day overall average for cardiac surgeries in FY14/15 at Trillium.

� Readmission rates within 30 days have been reduced from 7% (14/15) to 5% of patients returning back to Trillium.

� The number of patients who came back to the one of the three Trillium emergency/ urgent care departments within 30 days was reduced from 15% to 13%.

� 0% of patients on PPATH are ALC vs 2% in 14/15. � There was a 230% increase in patients receiving community support services.� Overall health system costs were reduced by 17%, or 1.4 million dollars.� 93% of patients said the PPATH program helped them feel confident about their ability to care for

their own health.� 96% of patients said members of their health care team were available when they needed them in the

community.� Other metrics reported on our scorecard to help maintain quality are: ◊ Medication reconciliation completed at hospital and home. ◊ % and # of patients returning to cardiac follow-up clinic post discharge from hospital. ◊ Mortality rate in hospital. ◊ Average home care visits per pathway.

16

� Patients have timely access to their surgeon in the cardiac follow up clinic whereas previously they visited the ED for urgent follow-up.

� Quality Review Committee reports no evidence that PPATH activities/model of care in first full year (e.g. early discharge) have resulted in potential/actual harm to cardiac surgery patients.

� Savings analysis of FY16/17 IFM compared with FY14/15 baseline showed that by investing an extra $331K into community support reduced post-op LOS by 2% equivalent to 4 annualized post-op beds. When comparing to FY14/15 Trillium Cardiac Surgery and resulting home care for those patients, there is annualized savings of $1.4 million to hospital and community health combined care.

� Results of the patient and caregiver engagement co-design process has resulted in development a learning and support program that will address the high levels of anxiety through multi-modal ways of delivering education, further strengthening patient engagement and satisfaction.

� Anecdotal responses from patients have been very positive. One patient experienced shortness of breath a few weeks after surgery. “I called the helpline and the woman said, ‘I can hear it in your voice, can you come in?’ I went in to the clinic and they took two and a half litres of fluid from around my lungs. Without that helpline, what would I have done?”

� Another patient developed an infection in her arm. “I called the 1-800 number and a nurse came out within an hour. It worked perfectly for me. Knowing that care was just a phone call away was the best part.”

� Results from “Preliminary Comparative Effectiveness Evaluation of the Integrated Funding Models using ICES Data – Interim Results” has been circulated. Their findings found a significant decrease for LOS, readmissions and ED visits when compared to Trillium’s “Pre Bundle” populations. Relative to changes over time for patients from comparator facilities, patients from Trillium’s IFM Bundle have a significantly larger decreased in the number of ED visits. While the LOS and readmissions did show a decrease, they were found not to be significant. HSPRN expects more significant findings to arise between comparators in the future with greater enrollment and statistical power.

Putting Patients at the Heart has redesigned the regional cardiac surgical program at Trillium Health Partners to provide more affordable, integrated and quality care across the health system together with our community partner, Saint Elizabeth Health Care. This model is in full alignment with the strategic and visionary priorities of both organizations. It has reduced acute care service utilization and increased community care, as per patients’ choice, while increasing patients’ confident to take care of themselves in the community. This model has provided better care to more patients, at the right place and at a reduced cost while concurrently addressing health system capacity pressures. It is a prototype that is being used for scale and spread to other surgical programs within THP and across the province.

17

Appendix: