Thamesview, Tilbury District and Chatham-Kent Family Health Teams, working together with the local Health Link, adopted an integrated case management (ICM) model that improved the healthcare experience for frequent users of the healthcare system, simultaneously reducing ER visits and hospital admissions.
In recognition of this work, the three FHTs were the 2017 recipients of the Association of Family Health Teams of Ontario’s (AFHTO) Bright Lights award for the category Using Data to Demonstrate Value and Improve Quality of Care.
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From left to right: Julie Shaw (staff simulating a patient receiving ICM) Sonia Teeuwen, Intensive Case Manager, Dr. Don Hastings, Family Physician
The FHTs employed an intensive and integrated case management approach to connect patients with complex needs to community care. The case managers followed a cohort of these complex patients and collaborated with patients/families and healthcare teams to develop a care plan that supported each patient within the community. As soon as a frequent user of the system arrived in the emergency department or was admitted to hospital, the case manager initiated ICM services to support his or her needs post-hospitalization.
We asked Denise Waddick (Thamesview FHT), Kelly Griffiths (Thamesview FHT) and Laura Johnson (Chatham-Kent FHT) about their experience implementing this program.
Can you describe the data you collected to demonstrate the impact of integrated case management?
Approximately 2600 patients in the Chatham-Kent area qualify for an integrated case management (ICM) approach, however, based on resources available, only 230 patients are receiving ICM. Of these 230 patients, we were able to track about half because patients needed to have had ICM services for at least 6 months to demonstrate impact of these services.
Our analysis demonstrated that 6 months after ICM was initiated with patients, there was:
- A 78% reduction in ER visits
- An 81% reduction in hospital re-admissions
- An 81% reduction in hospital bed days
Our data also revealed that there is approximately a 6 month waiting period before patients are contacted and offered ICM, which means we needed a triage process to improve access to ICM. This drove decision making to prioritize patients based on their need for care and support.
What advice do you have for other organizations looking to reduce ED visits and hospital readmissions?
We believe strong partnerships are key to success. Working with hospitals, primary care providers and case managers made the difference. We focused on establishing trust, openness and transparency with these partners. We were willing to be vulnerable and share information, knowing that we could all learn a great deal if we were open to doing so.
We specifically worked on evolving our Health Link approach whereby primary care providers take on a larger role in identifying complex patients that would benefit from integrated case management, versus identifying these patients post ED visit or hospital admission. Primary care providers can be the voice for the patient and these providers should lead how the patient is supported. We have found that an ongoing relationship with primary care helps complex patients rely less on the emergency room and learn better self-management.
What are your next steps?
Currently, the three FHTs are working with Erie St. Clair LHIN to explore ways to sustain the program and access the additional resources that would be needed to implement a program of this type within their primary care teams.
We are also continuing to collect data via EMRs to demonstrate the need for integrated case management, drive advocacy and decision-making.
Read more about Thamesview, Tilbury District and Chatham Kent Family Health Team’s Project: Primary Care Impact on an Integrated Case Management Model for the Frequent User on the AFHTO website.
Do you have questions about Integrated Case Management Models? Reach out to Denise Waddick, on Quorum.