Connecting the Dots'to Coordinated Care

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Connecting the Dots.to Coordinated Care

• Catherine ODonnell, MBA, CHRP
• Improvement Facilitator
• Chinook Primary Care Network

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• Issues
• Delays in service provision and multiple visits
  for the patients
• Disconnect between CH programs and primary care
  in their approaches to patient care and
  coordination of services provided to patients.
• Suboptimal clinical outcomes, lower patient
  satisfaction, increased work cost for the
  system.

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• Process
• Clinical Office Practice Redesign
  principles/processes adopted by Programs

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• Formal process
• Service Agreement
• - Developed to support the delivery of high
  quality, high capacity, comprehensive care that
  is timely and efficient

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• Our wish list for service agreement

Consistent Care between primary and specialty
Seamless Care
Use of clinical guides
Access
Consistent information
Positive Outcomes
Planned care
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• Service Agreement Steps
• Bring all Stakeholders to the table
• Examine the volume, reason source for referrals
• Compare the current state with the ideal
• Evaluate the referral process (Flow Map)
• Prepare draft Service Agreement
• Distribute the final agreement to all providers

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• Outcomes
• Service Agreement
• Identify areas of overlap, Increase efficiency,
  cost effective and productive
• Registries
• Reducing overlaps in the service
• Chronic Care Manual
• Consistency for assessing and managing chronic
  disease

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• Linkages creates Success

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• Success Story
• Mary, Age 23
• Type 1 Diabetes non compliant
• Social/Family Issues/Depression
• Wants to start a family
• Linkages with BHL
• Pre-conception Group, Diabetes Management, bridge
  to clinicians, communicate via email

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• Lessons Learned
• Silos are counterproductive to patient centered
  planning and efficient service
• Registries can contribute to improved
  organization of patient care
• Flow mapping a multiagency process puts the
  patient in the centre of the process
• Program services can be successfully delivered in
  primary care sites with the right planning and
  patient-centred approach