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Waterloo Wellington SGS-BSO Redesign

Waterloo Wellington SGS-BSO Redesign. Waterloo Wellington Geriatric Services Network May 8, 2013. Redesign- Integration. “The best way to predict the future is to invent it” Allan Kay. Change Management. System of Changes. View from the Sector Health care.

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Waterloo Wellington SGS-BSO Redesign

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  1. Waterloo Wellington SGS-BSO Redesign Waterloo Wellington Geriatric Services Network May 8, 2013

  2. Redesign- Integration “The best way to predict the future is to invent it” Allan Kay

  3. Change Management System of Changes

  4. View from the Sector Health care Primary Care Community Care Acute Care LTC View from the Person and Family Health Care

  5. Four Quadrant Person and Family Directed care Challenge – ‘Frail Elderly’ • Cognitive/ Behavior • Function • Psychiatric/ mental health and addictions • Multiple medical Providers and services driven

  6. Thinking About Person Centered and Family Care and Transitions From a Stratified Population Perspective Primary / Community Care Self Management / Community The Many Faces of Person / Family Centered Care Tipping Point / Transition Tipping Point / Transition Community Care, Multiple Services High Risk Need

  7. What is an Authentic Partnership? An Authentic Partnership… • actively incorporates and values diverse perspectives and includes all stakeholders directly in decision making • means working with not for others

  8. Authentic Care---- Integration • Every Door is the right door • “integration=successful partnerships, transitions, access to service, quality and outcome based” • Clinical Intake and Triage to Access and Transition

  9. Transitional Components • Information Continuity • Management Continuity • Relationship Continuity Haggerty et al 2003 “One person, One Plan, One Person Team”

  10. Management – Operational 7 Sites SGS, – 10 Service Areas, 14+ providers

  11. Redesign - Integration System – Information, Management and Relationship • Simplified computer ‘fax’ referral method and Timebook infrastructure for SGS and CRBT clinical intake with access to partner agencies • SGS and CRBT service categories defined • Orientation complete to partner agencies

  12. Waterloo Wellington – Integrated Clinical Intake • video http://www.easyreferral.net • www.caredove.com/wwsgs

  13. Deliverables Achieved … • Service descriptions of SGS and CRBT service categories that can be used for training purposes with referral sources. • Develop ongoing case based learning approaches for clinical intake team and partner agencies. • Brochure, referral form, and online documents completed and rolled out

  14. Deliverables Achieved Continued… • Single referral form and brochure. • Online directory of services is created building on caredove service directory platform in use in WW.

  15. Pillars Alignment with WWLHIN Strategic Direction - Pillars • Enhancing Access to Primary Care • Experience a More Coordinated and Seamless Health Care System • Leading a Quality Health Care System Using Evidence Based Practice • Accelerating System Change

  16. Next Steps System Management Operational Management Structure √ Define, Organize, Outcome Measures • Sponsorship • Council • Lead

  17. Next Steps Continued… Inter-sectoral Interdisciplinary Service Delivery • Clinical Intake - in process √ • PDSA Cycles – • Measures to include: • Integrated service: information sharing, service providers, timely, accessible, • Impact on Senior and their Family • Transitions- successes and challenges • Impact on continuum of care Primary Care, Community, ED, Acute, Rehab/CC, Long Term Care • Role and function of Health Links

  18. Next Steps continued… Knowledge Care Team and Capacity Building Existing Resources – ‘Inventory’ • BSO Capacity Building Decision Tree • Capacity Building Roadmap • The Road Ahead • Behavioural Education and Training Supports Inventory (BETSI) • Person and Practice-Based Learning Tool (PerPLe) • http://akeresourcecentre.org/files/Person-Centred-Team-Based-Service-Learning/Person/Practice-Based/Learning/141112.pdf

  19. ‘Enablers’ in helping to design WW Geriatric Care System • RGPc – Access to Best Practice Information and Resource Support (2006 – present) • Integrated System of Care for Frail Elderly in Waterloo Wellington – Dr. George Heckman, (2011) • Behavioural Support Ontario (2011-2013) • Living Longer, Living Well, Senior Strategy – Dr. Samir Sinha (2013)

  20. Acknowledgements • Dr. Ken LeClair – (slides 4-7,9) “Opening the Doors to Quality Care Perspectives and Bridges Person and Family Care Transitions” Feb. 2013

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