CFHI Interview with Mary Woodman, Project Lead, Quinte HealthLink
Quinte HealthLink Sponsor: Belleville and Quinte West Community Health Centre (Belleville, ON)

March 2015

Mary-Woodman-Interview

Mary Woodman, at right, with patient Colette.

In a new, occasional feature, we interview leads of CFHI-supported projects currently underway. This month, Mary Woodman, project manager for Quinte HealthLink's work in the Institute for Healthcare Improvement's Better Health at Lower Cost Triple Aim collaborative, describes its progress with the area's top 5% of patients with a history of high-cost healthcare use.


Could you please describe your Triple Aim work?

We set out two years ago on our HealthLink project, an Ontario-wide QI initiative, to improve the lives of complex-needs patients. We were already aware of the Triple Aim framework and trying to apply it to our work, but enrolling in 2014 in IHI’s Better Health at Lower Cost (BHLC) program has taught us so much more regarding the Triple Aim approach and population management. The Triple Aim framework provided a rigorous overlay to existing work.

Describe your defined population for the Triple Aim work.

Our macro population is community-wide, covering 128,000 residents within the Quinte region. These include the communities of Prince Edward County, Brighton, Belleville and Quinte West. Our target population is the top 5% (6,400) who have a history of high-cost healthcare utilization or those whom we believe are headed in that direction.

That population has been segmented into 3 sub-populations and this has been done not according to disease, but rather according to needs. They include advanced and chronic co-morbidities; end of life needs; and addictions and mental health. For the BHLC work, we concentrated initially on just five frail elderly patients with advanced, chronic conditions and, in some cases, end of life needs. We are now working with 25 patients.

What are their most pressing healthcare issues?

These individuals have many complex needs – both social and medical.

A surprisingly common finding is that while they may be attached to a primary care provider, they often report a non-therapeutic relationship with that provider. While attachment implies access to care, the patient often tells us they either have much difficulty getting an appointment, or they do not feel heard or respected at the visit.

There are also polypharmacy issues; lack of access to specialty services, especially because we are a rural community and these patients cannot easily get to the closest academic centre. Most - despite having several seriously advanced diseases - have not had any advanced care planning completed. So this has become a focus in our project.

Many have great difficulty navigating the “complex system” and they are very grateful to have just one person / one phone number to call when they become frustrated and confused. In this HealthLink re-design of care that person is their “care coordinator.”

We are learning how important the social determinants of health are as many patients live in poverty and/or are socially isolated. Transportation is often an issue.

What other sectors outside of healthcare are you engaging with to further your Triple Aim goals?

Our HealthLink and BHLC Triple Aim projects are led by the primary care sector in the SouthEast LHIN. However, we are collaborating with many key partners including:

  • Community hospital/ Quinte Healthcare
  • CCAC/ home care
  • LTC homes
  • Addictions & Mental Health agencies
  • Community & Social Service agencies
  • Community paramedics
  • Palliative care
  • Community Care for Seniors
  • Victoria Order of Nurses

What are the barriers to patients accessing existing services?

They don’t know what services exist – and even if they do know they exist, they don’t know how to access them or can’t get to them. They tell us that they are afraid to push too hard and advocate for themselves for fear that they will be provided with even less. For example, I recently spent two hours on the phone trying to arrange Meals on Wheels for a cancer patient. The patient didn’t realize this service existed and who provided it; she certainly wouldn’t have had the energy to sit on the phone for two hours.

Describe your results to date. How have patients benefited from your work?

We have just taken an in-depth look at the first 85 patients who have had the benefit of six months of a coordinated care approach. Hospital admissions are down 74.5%, readmissions are down 85.7% while emergency room (ER) visit rates have dropped by 40.4%. 

How do you plan to sustain the Triple Aim work with these patients?

We have a model of “spread and sustain” for our care coordination work. Amongst our eight primary health care organizations, we have about 45 providers who are skilled in care coordination and patient engagement.

Are you able to take a holistic approach, i.e. ensuring your patients’ spiritual, mental and economic needs are also met (i.e. that the social determinants of their health are improved)?

Absolutely! It is often where we make the biggest difference. To better understand patient needs, we engaged an expert “lived experience” coordinator who will guide us in our efforts. We strive to engage every single patient at every interview – by listening deeply, attempting to understand their situations, concerns and needs and have them co-design their own plan of care.

It is very meaningful work.

Do you foresee the ability to scale up your work to a greater population base or to other populations?

We are working on a scale up right now. With BHLC, we started with just five patients, scaling up to 25 by the end of March and we’re aiming for 125 by June 30. By incorporating the 200 patients in the 2013 HealthLink project, we in fact aim to get to 225 by end-March and 325 by end-June. Ultimately, we need to get to all 6,400 high-cost, high-needs patients, so we know this will be a challenge. It requires a solid plan for resources – in terms of both time and HR.

A core working team of about 12 is now solidified and confident. Our sponsorship and lead partners are very supportive. We’ve tested and implemented new tools and processes, and have started to track the data. Our momentum is growing.

How did Quinte HealthLink’s involvement with the Triple Aim and with CFHI lead to other improvement interests?

When we started looking more closely at the CFHI website, we learned about the COPD “Inspired” program initiative. We were impressed with the improvement results. This was timely, as we had recently identified a need in our community for better COPD patient care and wanted to explore the potential for a cross-sectoral integrated model of care, targeting this high-needs sub-population. We have just pulled together a working group to address this.

What value does CFHI bring to IHI’s collaboratives?

We never would have been able to participate in the IHI collaborative without the financial support of CFHI. Thank you for enabling this. We know our HealthLinks improvement outcomes will be much more successful because of all that we have learned in the BHLC collaborative. We now have new methods and measures which are really key for our ongoing work.