Sustaining Improvement: Interior Health Authority Breathe Well Respiratory Liaison

Sustaining Improved Care: The Breathe Well Program

Respiratory Liaisons

Accelerate Funding Purpose

Accelerate the work being done by community integrated health services MOH looks at total health costs : Health Authority, Pharmacy and Physicians Care of People with COPD not just Disease Specific Interventions Summary Evaluation After 3 years Formative Evaluation Every Quarter

Breathe Well Case Management Model

Moderate to Severe COPD with 2 ED visits

AND/OR

One Hospital Admission related to COPD in the last 12 months

∗ level 3: Enhanced services for

complex COPD patients most at risk for hospital admission

∗ level 2: Build Capacity

∗ level 1: Triage to Avoid

Progression

Breathe Well Regions

Meet Ed

2/24/2014 5

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∗ Provide enhanced care and community resources to COPD clients who would otherwise return to acute care for service.

∗ A home based program that provides collaborative case management for moderate to severe COPD clients.

∗ Our goal is to reduce barriers and help change behavior to avoid acute care, or reduce a needed length of stay.

Purpose of Breathe Well

∗ Aims to preserve a low client to clinician ratio to enable the continuation of a case management model.

∗ Allows respiratory clients to be referred to appropriate respiratory or community services with the addition of a triage therapist.

∗ Allows for a better client experience and a fluid transition between acute and community services.

Respiratory Liaison

Breathe Well Physiotherapists

Mobility/home exercise for homebound BW Clients

Symptom control,

improved capacity for

improved QOL

Build access to Pulmonary Rehab in

regional hubs

Acute utilization data includes all ED visits and acute admissions regardless of CTAS or CMG codes.

Acute Care Utilization

Clinical Measures

12%

63%

68%

80%

81%

Have stopped smoking since being admitted to the program

Have medications attached to their COPD Action Plan

Have COPD Action Plan in place

Patient diagnoses confirmed by spirometry

Adhere to a CTS recommended inhaler regime

∗ “Having the RT as case manager has been very beneficial to my clients. As a team, we have been able to prevent clients from going to ER or being admitted to hospital.”

∗ “This program was a god send to us so that we could navigate the hospital and come home with more support.”

∗ “We are the glue that holds Respiratory services together – all services coordinated : Acute, Home Oxygen, Breathe Well, Community RT, Diagnostics and Rehabilitation.”

∗ Breathe Well is responsive to patients in a holistic manner and walks

clients through the process in a very focused way to increase their success to have optimal health outcomes and life they deserve.”

Patient & Provider Surveys: The Liaison Role

Patient Pathway

Together

We are enabling appropriate care, building capacity & sustaining the ability to

Breathe Well! Thank You