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Transition Improvement for Continuity of Care

an overview of the initiative

Shelley Sharp

on 26 March 2014

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Transcript of Transition Improvement for Continuity of Care

An Innovative Approach for Improving Continuity of Care in Stroke Recovery
What does our prototype for improved transitions of care look like?
Continuity of Care is the concern with the quality of care over time. It may be viewed from the perspective of the patient or provider.
The experience of Continuity of Care relates to the
of care and the
of that care.
Focus is on
new models
of care delivery and improved patient
through integration, coordination and the sharing of information between different providers
A full consideration of continuity of care should
of these
perspectives, exploring
how these come together
to enhance the
of care.
Health care providers said...
Persons with stroke & caregivers said....
Turning Points in
Means deepening relationships across the system and with people living with stroke/caregivers, creating formal communication processes and unplanned interactions that enable a broader picture of stroke trajectories and system possibilities.

In relational strength, we lift our heads from our own pieces to see the whole, know what kind of experience people will have with other parts of the system, and collaborate on care, in the abstract and individually.
Care Helix
How t

3 Constructs
Optimistic Care
Recognizing stroke care not as a linear continuum but as more flexible and fluid, opportunities to provide resources when needed
Doesn’t mean conveying the most optimistic view of an evidence-based trajectory – Means working with people with stroke/caregivers to set goals that are meaningful to them and which will give them hope.

Shifting from “managing expectations” to co-creating a narrative that enables people living with stroke/ caregivers to reach for the best possible outcome.

Framing stroke as complex and building comfort with not knowing.
Relational Strength
My Stroke Passport
Peer Support
Peers are experienced caregivers and persons with stroke who are well into their recovery and are trained in visiting people who have just had a stroke and their caregivers. This will help with recovery by providing hope, optimism, encouragement, and concrete support.
Knowing Each Other's Work
designed to provide a meaningful & in-depth learning experience for all health care providers

opportunity to learn about the system, each other’s practice environment & about each other

learning about each other's practices and building respectful relationships contributes to collaboration; a key component for successful, seamless transfers
Stroke Care Observerships
designed to foster verbal exchange among health care providers

serve as a supplement to written information across the system

also represent a vital opportunity to enable learning about the patient and about each other’s work.

a key component for successful, seamless transfers
Essential Professional Conversations for Seamless Care
Key opportunity to further knowledge exchange about TICC / stroke care, foster new ideas, continue to build relationships & facilitate effective problem solving

Toronto Stroke CoP website: www.strokecommunity.ca
(Virtual) Community of Practice
Turning points in the work: contributes to clarity and momentum
Transition Improvement for
Continuity of Care
1.Collaborative Change Leadership -
leadership engagement/validation
aligned to organization/system (and MOH) priorities
2. emergent with Stroke Flow work
Focus Groups with organizations
7 organizations
Interviews with:

Persons with stroke
Healthcare providers
Thought leaders
Core Team Conversations
What is needed for seamless care?
Peer support
Individualized hopeful care
HCP knowledge of the system
Flexibility in care provision
Navigation support
Understanding the needs
of the system
Collaborative Change Leadership Course
3 Project teams
Broader engagement
13 pilot sites
Change Leadership Approach
- Complexity Science
- Appreciative Inquiry
- Developmental Evaluation

Key Methodological elements
Community development
Foundational Project Development
Implementation, Learning & Evaluation
Adaptation, Spread,
This is all new!
navigation support
peer support
individualized hopeful care
Relationships create community conversations
Iterative process and prototyping
Feb ‘09 – 2013
Design & Implementation
…our network partners and form a core team
We engage…
Their expertise guide the process needed to create an interconnected, adaptive community in the stroke care system
On our climb we find…
Nothing worthwhile
is without risk.
Holding the space
Expertise Required
RFP Process
Oct ‘09 – Feb ‘09
Adapting to emerging needs of:
The team
The system
The need to continually adapt to emerging needs.

Sensing and adapting new perspectives that reshape thinking and allow a “cultural shift”
Jul ‘09 – Dec ‘09
Road to Discovery
We suspend our voices of judgement and become learners in the process
Mar ‘09 – June ‘09
Need a shared vision (dream) to build a shared future (engagement)
Stakeholder engagement – inter/intra team collaboration

Building where
the energy is.
Initiative Re-design &
New Learning
We decide to abandon the traditional process and “break through” new ground using an Appreciative Inquiry approach
And with many turns and directions to take…
With the fork in the road…
We discovered the need to suspend our process and embrace Emergent Change
Feb ‘09
We hit the road thinking we knew where we were going and how we’d get there
Sept ‘08 – Jan ‘09
“Standardize the communication between health care providers and patients/families at transition points to enable/enhance continuity of care.”
Through regional engagement forums, what did the voices in the system tell us?
Sep ‘08
What is the most important thing we can do as a Network that will improve the quality of stroke care for patients and families?

And so our journey
We thank you for making the climb and traveling down this road with us
We hit the road and
map out a workplan

Transition Improvement for Continuity of Care (TICC) Initiative
Toronto West Stroke Network
By capturing those conversations we…
Leverage and learn from them to create a sustainable foundation for seamless care
More than 50 contributors designed an innovative 2 part patient mediated resource that can be introduced anywhere along the care continuum.

To be shared as they move from one health care provider to the next.
*promote enhanced conversations
*collaboration between HCP's
*support stroke knowledge and self management
*enable person centred & meaningful care
photographs & stories

'peel and stick' pictures of pills

name of pharmacy

colour coded charts to plot progress on risk factor control

map of their journey

business card holder

top 10 things to consider when going home

+ more
a NAVIGATION tool to:
support self management of recovery & community re-engagement
15 areas of concern
1. communication
2. pain
3. fatigue
4. sleep
5. depression
6. return to work
7. social support & activity
8. sexuality
9. caregiver support
10. where I live
11. getting around
12. driving
13. travelling
14. money matters
15.advance care planning
What to Expect
Your health care team
personal journal space
Provincial and local priorities in health care are driving change that focuses on better management of chronic conditions; matching services to patient needs and enhancing coordination of care across the continuum.

Excellent Care for All Act 2010

The Change Foundation, 2010-2013

Drummond Report, Feb 2012

Ontario Action Plan for Health, Feb 2012

Toronto Central LHIN strategic plan 2012-14
Complexity Science: (change theory)
>health care is a complex adaptive system
-interactions difficult to control
-conditions and knowledge are changing
-multiple perspectives and relationships
-path of change can not be predicted

>provides a new way of understanding, adapting and working with and within systems that need attention to process as well as structures.

>allows us to be cohesive across the system/ populations while its application is adaptable and flexible to varying local needs.
Appreciative Inquiry: (organizational change methodology)

>generates new ideas and ways of doing things

>focus on the most positive image of the system

> respects perspectives, engages generative dialgoue, collaboration, creative thinking and innovative solutions.

>builds relationship capital in relationship dependent systems.
Developmental Evaluation: (a process to guide action toward outcomes seeking)

> works best in a complex environment, where
• a number of inter-dependent elements interact
• there can be no central control or cause/effect
relationships identified

> is a “learn by doing” process.

> requires ongoing conversations that involve continual
reflection on what is shifting and changing in the
system to inform action.

> It allows us to accept unanticipated consequences and
•capacity for adaptability
•connections/relational strength across initiatives
•innovative and transformative processes.
Community Engagement
& Development (KT)
Capacity Building
Sustainable Change
Chronological Timeline
Environmental Priorities:
Ministry of Health
Healthcare organizations
capacity building
Goal of TICC:
to improve the life experience of the persons with stroke/caregiver by creating and implementing sustainable foundations of a new person centred model of care through the development of an adaptive community of care providers in the Networks.

to create a sustainable interconnected system of seamless, equitable planning and consistent care processes

paradigm shift!
Getting Started
Next Steps
Thank you!
HSFO/OSN Collaborative October 15th, 2012

Shelley Sharp BSc.PT, M.Sc.
Jocelyne McKellar M.SW, RSW
Gail Avinoam, BSc. Nutritional Science, M.Ed.

Peer Reference Guide

This guide was designed to help peers understand:
the purpose of peer support
their role as a peer
the effects of a stroke
how to offer hope and support through conversations
how to conduct a visit with a person affected by stroke
Peers Fostering Hope
obtain further perspectives
from primary care
St. John's Rehab
Toronto Rehab
The Potential Group
Aphasia Institute
Bridgepoint Health
Mount Sinai FHT
Thompson House
Bellwoods Centre
Persons with Stroke
Downsview Services for Seniors
VHA Rehab Solutions
Centre for Effective Practice
Winnipeg Regional Health Authority
Runnymede Health Care
The Scarborough Hospital
NEGTA SN regional team
SET SN regional team
March of Dimes
Needs change over time
More optimistic, hopeful care
Full transcript