At one time, people went to their nearest GP, regardless of their ailment. Today, we’re increasingly providing best care by targeting patients or clients with specific health needs through population-based programs.
During the week of November 26 to 30, Accreditation Canada will survey these population-based programs in a round-table discussion group. Surveyors will be looking at population standards rather than service standards, just as leadership of these programs plan at a population level.
Here are three examples of how we’re successfully reaching out to patient and client populations — it’s what we do every day — and we’re confident the surveyors will recognize the achievements of our friends and colleagues.
COPD Clinic & Outreach Team: helping patients return and stay home with the right supports
Since January 2012, patients admitted to VGH with an acute exacerbation of their chronic obstructive pulmonary disease (COPD) have had more support when they are discharged home from hospital through a COPD clinic/outreach team.
“Home is Best” for our VGH COPD Clinic & Outreach team (l to r): Carmen Rempel, certified respiratory educator; Erin Toplak, certified respiratory educator and Elizabeth Leonardis, nurse practitioner
The team communicates directly with the patient’s family physician to improve the coordination of care and support provided to clients as they transition home. Clients are offered follow-up visits at home and/or outpatient appointments, including consultation with respirologists and/or cardiologists.
The COPD team arranges referrals to various community service, including pulmonary rehabilitation programs like the six-week program offered by the Healthy Living Program. In this program, clients with chronic lung disease can access community-based support and education on self-management, exercise, nutrition and healthy lifestyle. They are encouraged to discuss their individual COPD action plan with their physicians and to learn to set goals and action plans to modify their lifestyles.
In addition, two community-based respiratory therapists provide COPD management to their specific populations, including the Downtown Eastside. Consultation and support are also offered to VCH care practitioners.
Among the first 84 clients referred to the COPD transition team, there was a 24 per cent decrease in average length of stay in acute care and a 28 per cent decrease in percentage of total days in hospital.
Heart Failure Strategy & Cardiac Function Clinic: facilitating self-management
Our Heart Failure Strategy, a joint program with Providence Health Care, has a strong educational component, establishing clinical practice guidelines for clients to learn ongoing management of heart failure and how to handle common co-morbidities. Web-based training is accessible to all. Sessions have also been held for residential care site staff, as many heart failure patients are frail and elderly.
The Cardiac Function Clinic at VGH offers a multidisciplinary approach to clients who have heart failure (reduced pumping function). Cardiologists, nurses, nurse practitioners, a pharmacist, dietitian and social worker are all available to provide evidence-based medical management as well as to help educate clients and their families on lifestyle issues, medications and more.
Clients are seen frequently in the clinic with the aim of optimizing medical care, providing self-management skills, linking to appropriate resources and specialists, and ultimately reducing hospital and ER admissions. On average clients are followed for approximately six to nine months before they transition back to their primary care physicians and cardiologists.
The Clinic currently follows 419 patients; it has had 964 referrals since it opened in January 2010.
STOP HIV/AIDS: supporting a highly marginalized population
Seek and Treat for Optimal Prevention of HIV/AIDS — STOP HIV/AIDS— is a Ministry of Health pilot project designed to expand access to HIV/AIDS medications among hard-to-reach and vulnerable populations in Vancouver and Prince George.
It’s different now: Eye-catching and stop-in-your tracks promotion supports STOP HIV/AIDS.
The STOP HIV/AIDS outreach team, a core component of the program, provides low-threshold, comprehensive testing and treatment services. Clients can access outreach HIV/ sexually transmitted infection (STI) testing, complex case management and HIV primary care.
The team offers testing in homeless shelters, bathhouses, an outreach van and drop-in centres. They performed more than 1,622 HIV tests from November 2010 to July 2012, and 33 new HIV positive clients were diagnosed and linked to care and treatment.
The same type of outreach extends to care: a nurse might meet a client in a park to assess care needs, or a physician might visit a client in a Downtown Eastside hotel if the person is unable to visit a traditional clinic. Staff reaches out to help connect people to the care they need, with an ultimate goal of supporting patient self-management and linking the patients back to existing primary care services in their community.
A total of 404 unique HIV-positive clients have been assessed and reached since November 2010; currently, 230 HIV-positive clients are receiving intensive case management and ARV adherence support.
The outreach team also provides contract tracing and partner notification services for newly diagnosed HIV patients, as well as HIV clinical education for VCH staff, physicians and community partners.
The team has successfully supported a highly marginalized group to receive care and treatment in their community, which has significantly reduced inappropriate usage of acute care resources, decreasing the average length of stay in acute care by 33 per cent and inappropriate use of emergency by 11 per cent.