1 north west toronto health links. 2 1.primary care attachment 2.coordinated care planning 3.7-day...

1 North West Toronto Health Links

Upload: kenneth-hancock

Post on 14-Dec-2015

212 views

Category:

Documents

0 download

Report

Download

Embed Size (px):

TRANSCRIPT

North West Toronto Health Links

1. Primary care attachment 2. Coordinated care

planning3. 7-Day post-discharge

primary care follow-up4. Reduce avoidable ED

visits5. Reduce admissions to

hospitals6. Reduce primary care to

specialist wait times

1. Health Link Program Aims

7. Reduce 30 day readmission to hospital

8. Reduce the time from referral to home care visits

9. Enhance patient experience10. Reduced ALC11. Reduce costs

Page 3: 1 North West Toronto Health Links. 2 1.Primary care attachment 2.Coordinated care planning 3.7-Day post-discharge primary care follow-up 4.Reduce avoidable

Page 4: 1 North West Toronto Health Links. 2 1.Primary care attachment 2.Coordinated care planning 3.7-Day post-discharge primary care follow-up 4.Reduce avoidable

NWTHL: Year 1 Critical Path

February 5, 2015 Partners Council Convened

February- March 2015Advisory Councils & Working Groups Established:-CCP -Primary Care -Patient and Family

March 2015-March 2016 - Planning, implementation and evaluation of initiatives and projects completed

April 2016-Spread and Sustainability Strategy developed

Page 5: 1 North West Toronto Health Links. 2 1.Primary care attachment 2.Coordinated care planning 3.7-Day post-discharge primary care follow-up 4.Reduce avoidable

Partners Council

Primary Care Advisory

Engagement & Attachment

7 Day Post Discharge Follow

Transitional Aged Youth, MH Focus

Coordinated Care Planning Advisory

Acute (Better Care

System)

Primary Care (ICCT)

Seniors Housing, MH Focus

(Bracondale)

Primary Care (ICCT)

Patient/Client Advisory

Community Agency

Notification (CAN)

Long Term Care (ED transfers)

Health Human Resources

*Patients/Clients/Families are included in Partners Council and Initiative Working Group activities

Executive SupportCommittee Support

Project Management

•General Oversight•Meets quarterlyPartners

Council

•Responsible for planning and initiative portfolio

•Meets bi-monthly

Advisory Councils

•Meet as needed•Responsible for implementing specific initiatives

Action Teams

Page 6: 1 North West Toronto Health Links. 2 1.Primary care attachment 2.Coordinated care planning 3.7-Day post-discharge primary care follow-up 4.Reduce avoidable

Planning for 1-5% populations

ID clients (Hospital, Primary Care,

Community)

Attach to Primary Care (Health Care Connect)

Coordinated Care Planning Process

(Tool, Principles, Conference)

Ongoing Monitoring & Tracking Process and Outcome Measures

SFHN Primary Care Update...Primary Care Director of Population Health and Quality SFHN Primary Care Update July 12, 2017. Vision for SFHN Primary Care 1st Choice for Health Care

Primary Cancer Care - Patient Centered Primary Care ... Care and Cancer... · Primary Cancer Care The Important Role of Primary Care Providers at the Beginning of the Cancer Journey

2017 Primary Care Symposium Doctor Registration Materials WOA Primary Care... · FROM: Christine Renner, O.D. - WOA Primary Care Symposium Chair RE: 2017 WOA Primary Care Symposium

The Primary Care Trigger Tool - NES Care... · The Primary Care Trigger Tool: Practical Guidance for GP Teams Reviewing electronic patient records to detect avoidable harm Index Content

SITUATIONANALYSIS: EYESITUATION ANALYSIS: EYE CARE …. Khin_AP.pdf · Rapid assessment of avoidable BlindnessRapid assessment of avoidable Blindness-conducted at three district in

Primary Health Care PCN - Mosaic Primary Care Network · Alberta Health Primary Care Network (PCN) Profiles Mosaic Primary Care Network 2nd edition, March 2018

Think Kidneys And what?? - Patient Safety Oxford...Think Kidneys … And then what?? ... primary care? Avoidable harm ... Referral rate to secondary care, Medication Appropriateness

Primary Care Commissioning Committee , Part 1 … Care...South East London Primary Care Team Nora Simon (NS) NHS England Assistant Head of Primary Care, South East London Primary Care

Primary care and avoidable hospitalization for diabetes

DISCOVERY PRIMARY CARE › assets › discoverycoza › ...4 DISCOVERY PRIMARY CARE You can choose between Discovery Primary Care Advanced or Discovery Primary Care Activate. The cover

Primary Care Challenges: Data, Teams and Primary … Care Challenges: Data, Teams and Primary Care. ... JAP. $0 $500 $1,000 $1,500 ... Primary Care Challenges: Data, Teams and Primary

Mid-Point Assessment Report · the health care delivery system to achieve the primary goal of reducing avoidable hospital use by 25% over 5 years. More than 100 organizations including

Malnutrition In The UK – An Avoidable Problem? Andrew Williams - Care Homes

Pressure Ulcers: Avoidable or Unavoidable? Results of · PDF filePressure Ulcers: Avoidable or Unavoidable? ... considered an indicator for quality of care, ... a difference exists

NoCVA North Carolina Preventing Avoidable Readmissions ... · NoCVA North Carolina Preventing Avoidable Readmissions Collaborative ... Lean Health Care How Do We Define Value?

Primary Solutions for Primary Care

Strengthening Primary Health Care through Primary …neltoolkit.rnao.ca/sites/default/files/Strengthening Primary Health... · Strengthening Primary Health Care through Primary Care

Integrated primary care needs integrated research infrastructure: The Netherlands Primary Care Database Robert Verheij, NIVEL Primary Care Information

Primary Care Spending 2020 - Primary Care Collaborative

Primary Palliative Care in Ireland · PRIMARY PALLIATIVE CARE IN IRELAND Primary Palliative Care in Ireland Identifying improvements in primary care to support the care of those in

Webinar: Comprehensive Primary Care Initiative - For Primary Care Physicians

Health Systems Development Primary Health Care Primary Health Care Resources

MANAGING CHANGE IN PRIMARY CARE: THE CONTRIBUTION OF … · emphasis towards primary care, primary health care organisations, comprehensive primary health care clinics and improved

CPC Primary Care Practice Solicitation · Primary Care Practice Solicitation . Contents. ... Eligibility Criteria for Primary Care Practices .....8 VIII. Primary Care Practice Selection

Strengthening primary care in weak primary care systems

Hand Hygiene: Preventing avoidable harm in our care - … · Hand Hygiene: Preventing avoidable harm in our care ... also known as microorganisms 9 . ... Gloves are the worst enemy

Primary Health Networks...health care system for patients in the PHN, facilitating effective primary health care provision to reduce avoidable hospital presentations and admissions

primary care

Reducing avoidable hospital based care: re-thinking out of

Primary care networks: critical thinking in developing an ... · 08 | PRIMARY CARE LANDSCAPE 2. Primary care landscape Background to primary care networks NHS Chief Executive Sir

Primary Care: The Opportunities and You (Primary Care Progress)

Transforming Primary Care Primary Care Networks … Care...Transforming Primary Care Primary Care Networks (PCN) Development Support 30 July 2019 Cover Sheet Action Required Decision

primary care strategy - hammersmithfulhamccg.nhs.uk€¦ · care home’ concept to become ‘Primary Care Networks’ The ‘primary care home’ concept preserves and improves the

Integrating Primary Care & Behavioral Health: … Primary... · Certificate Program in Primary Care Behavioral Health© The Center for Integrated Primary Care Integrating Primary

Measuring Avoidable Variation Following the patient Care ...wennbergcollaborative.org/uploads/documents/Nuti.pdf · Oxford 11-13 September 2017 Measuring Avoidable Variation Following