Theme 2. Optimizing capacity of interprofessional teams
Presentation Materials (members only)
Presentation Slides: Telemedicine Impact Plus
(I) Telemedicine IMPACT PLUS (TIP): Bringing Inter-Disciplinary Team Resources to the Community
Learning Objectives
- Demonstrate how Telemedicine complex care clinic can provide high-quality comprehensive care for medically complex patients and support community primary care
- Model how to leverage FHT inter-professional skills to promote working to full scope of practice
- Outline the efficiencies needed to offer this service via protected video-conferencing
- Describe the opportunities and risks in extending FHT resources to community primary care
- Demonstrate the value of this approach in coordinated care planning.
Summary
Telemedicine IMPACT PLUS is an innovative, proactive interdisciplinary model of care for serving complex patients and supporting their solo primary care providers (PCPs). TIP has been implemented across the Toronto Central LHIN offering clinics since 2013. Through TIP, both the complex patient and family physician are connected to an interdisciplinary care team over a one-hour consultation via secure videoconferencing technology. The teams leverage inter-disciplinary support from FHTs to focus on critical issues identified by patient, family and PCP. A dedicated TIP nurse facilitator, as care coordinator, provides pre- and post-clinic follow-up supports to all stakeholders. The model recognizes the “perfect storm” created by an aging demographic within a health care system founded on treating acute illness. Currently, disconnected serial consultations based on single disease entities do not reduce the burden of chronic illness for these patients nor provide coordinated care planning for their PCPs. TIP built upon the success of IMPACT PLUS, a Bridges evaluated inter-professional care model. By marrying the power of a skilled inter-professional team, including general internist and psychiatrist, to telemedicine technology, TIP provides one stop coordinated real-time care planning in the PCP office or at home. Evidence from the literature found that intensive inter-professional care succeeds in reducing health care costs with at least equivalent outcomes for complex populations. Preliminary results demonstrate high patient, provider and caregiver satisfaction with this model of care. Already the model has shown itself to be scalable with plans to spread TIP to 2 other teams within the Toronto Central LHIN.
Presenters
- Taddle Creek FHT:
- Pauline Pariser, Co-lead; Lead, Mid-West Toronto Health LInk
- Sherry Kennedy, Executive Director
- one of Shazmah Hussein, Victoria Charkow or Karen Finch, Registered Nurse
- Jessica Lam, Pharmacist
- one of Jocelyn Charles, Chief of Family Medicine, Sunnybrook FHT, or Tia Pham, Physician Lead, South East Toronto FHT
(II) Blitzing Integrated Care for the Super Complex Patients
Learning Objectives
- Recognizing the need for an inter-professional and primary care led team to address patients' medical and social complexities.
- The importance of starting a coordinated care plan with the patient physically present at the case conference with the inter-professional team.
- The importance of having primary care, community agencies (CCAC and CSS), and specialists such as Psychiatrists working collaboratively towards patient's care coordination and follow-up, and for the patient to have an individualized care team.
- The impact of using Hospitalization Admission Risk Monitoring System (HARMS-8) to identify complex patients in primary care, and who are then recipients of an electronic coordinated care plan. 5. Share results of patient/caregiver experiences via patient/caregiver stories.
Summary
East Toronto Health Link has developed an innovative approach to address the needs of 1-5% complex patients who have significant social and medical concerns. ETHeL is trying to demonstrate that high risk hospitalization (using HARMS-8) justifies increased use of resources such as Complex Care Plan Management (intensive care management with dedicated follow-up and requiring an inter-professional team approach maximizing scopes of practice, and integration of multiple sectors) . CCT is composed of a small core team of hospital based programs currently operating within ETHeL (Virtual Ward, Geriatric Emergency Medicine (GEM) Nurse, Telemedicine Impact Plus (TIP)-RN, Primary Care Physicians, specialists, as well as a CCAC care coordinator), AND a community-based team consisting of multiple sectors including community support services, mental health, addictions, housing, and Toronto Paramedics. Primary target population for CCT intervention is the frail elderly with complex medical/social needs residing in ETHeL’s catchment area; however, any individual identified by CCT members as complex and in need of coordinated care planning, is supported, though a case conference might not be the desired or effective mechanism in all cases. Some of the key primary characteristics that qualify an individual as ‘complex’ and who would require care coordination via CCT’s case conference are as follows:
- At least one (preventable) hospital inpatient admission and/or multiple (preventable) emergency department visits in the last 12 months (mandatory requirement) and at least two of the following:
- 55 years and older (65 years old and over is ideal except when individuals have conditions that deem them to be frail and elderly)
- Unattached to primary care or ‘poorly’ attached to primary care
- Physical immobility including staying upright, maintaining balance and walking resulting in falls, immobility or delirium
- Multiple/chronic co-morbidities including dementia
- Mental health and addiction complexities leading to barriers to access care
- Polypharmacy
- High caregiver burden and stress
Presenters
- Thuy-Nga (Tia) Pham, MD, Physician Lead, South East Toronto FHT and Toronto East General Hospital; Assistant Professor, University of Toronto DFCM
- Richard Doan, MD, FRCPC, Psychiatrist, South East Toronto FHT and East Toronto Health Link