MP19 - Accessing Regional Diabetes Services through CCAC

OACCAC Conference
Centralized Diabetes Intake
Cheryl Luke
Dave Merkley
June 2014
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Presentation Objectives
To highlight how Centralized Diabetes Intake at
the Central East CCAC enhances patient access to
Regional Diabetes Services through CCAC system
navigation and state of the art Geospacial
Information Systems.
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Ontarians with Diabetes account for:
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32%
43%
30%
51%
70%
of
of
of
of
of
heart attacks
heart failure
strokes
new dialysis
amputations
Prevalence of Diabetes in the Central
East LHIN
• For every 100 adults in the Central East LHIN,
about 11 are living with diabetes. This
prevalence (10.80 per 100) is higher than the
Ontario average (9.64 per 100)
• Diabetes prevalence is highest in Scarborough
(12.45 per 100)
• Durham region has a higher-than-average
prevalence (10.09 per 100)
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Centralized Intake Overview
• The implementation of a centralized
diabetes intake and referral process for all
DEPs and CCDC in the Central East is a
MOHLTC-mandated deliverable
• This process will enhance integrated access
to multiple services and resources
• Provide accessibility to both Health Care
providers and those living with diabetes
within the Central East region
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Diabetes Education Programs
 24 DEPs across the Central East region
 11 adult and two pediatric DEPs are now accountable
to the Central East LHIN
 Provide basic-intermediate level diabetes education
services to individuals with or at risk of diabetes
 The primary role of the DEP is to educate people with
diabetes to self-manage their disease
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Centre for Complex Diabetes Care –
CCDC
• 6 CCDCs across the province
• Additional program in the continuum of care
• Shared model of care that includes an interprofessional team
• Physicians and community-based services
are integrated as needed
• Transition/discharge planning with PCP and
DEP
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Centre for Complex Diabetes Care –
CCDC
In the Central East, there is one CCDC with 4
sites:
Referral and Initial Assessment
• Central East Community Care Access Centre
(CCAC)
Care Delivery Sites
• Lakeridge Health, Whitby
• Peterborough Regional Health Centre
• The Scarborough Hospital, General Campus
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Barriers to Accessing Diabetes
Services
Consumer consultations indicated that some
barriers to services included:
• Provider focused vs. patient focused
• Limited access in the evenings or week-ends
• Limited services available in the language of the
patient
• Cost of parking
• Lack of understanding of value of DEP
programming
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Opportunity for Centralized Diabetes
Intake and Referral Process
• Hospital based DEPs tend to provide care for the
more complex cases
• Community based DEPs tend to provide care for
the less complex cases
• Physician referral patterns tends to refer all of
their patients to one DEP
• Supply does not match demand
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Centralized Intake- Desired Outcome
• A more streamlined and integrated service
• Supports the Ontario Diabetes Strategy
• Decreased emergency department visits and
hospital admissions
• People living with diabetes may self-refer
• Improved match with demand with supply
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The Model
• A common referral form based on best practices
• A single telephone call or faxed referral from a
physician/provider, or a patient will initiate the
intake process
• E-Referral via Health Partner Gateway allows all
client referral information to be sent electronically
from the Central East CCAC to the DEPs and CCDC
in a secure and timely manner
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The Central East CCAC
• Will support intake and patient referrals to DEPs
and CCDC
• Offer patients assistance with system navigation
• The services to be accessed include:
o Diabetes Education Programming
o Centre for Complex Diabetes Care
o Community Care Access Centre services
o Community Support Services
o Health Care Connect
o The Central East Self-Management Program
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Role of the Centralized Diabetes
Intake Care Coordinator
• Receive referrals, assess and determine
eligibility for CCDC or DEP and provide
linkages to community support services
• Provide diabetes education to patients
• Collect and send appropriate documents to
CCDC or DEP
• Liaise with physicians, HSP, CCDC hospital
site teams or DEPs as needed
• Monitor 1-888 number and voicemail and
provide information to the public regarding
Diabetes services
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The Intake Process
• Patients are contacted by a the CDI Care
Coordinator who will complete a RAI
assessment
• Geospacial Information Systems used by the
Care Coordinator which shows the available
resources to the patient
• Referral is made to the most appropriate
DEP/CCDC
• Linked with CCAC and Community Support
Services as needed
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The Challenge
Create a tool that would:
• Juggle large volumes of data but still make the
call natural and patient driven
• Explore patient requirements in the context of
geography
• Explore access for home and work addresses
• Make the best choices intuitive to find and easy
to explore
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The Solution
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Map based geospatial tools
Geocode an address on the fly
Select from a list of requirements
Darkest dot is most appropriate
Review more information by clicking dots
Demo
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How to Refer
• Admission is completed through the Central East
Community Care Access Centre (CCAC)
• The Centralized Diabetes Intake Referral Form
can be found by doing a search at:
http://healthcareathome.ca/centraleast/en and
faxed to 905-444-2544
OR
• Call the Centralized Diabetes Intake Service at:
1-888-997-9996 to be connected with a CDI
Care Coordinator to facilitate the referral
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Summary
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Stats on Diabetes
Centralized Intake Overview
Barriers to Accessing Diabetes Services
Opportunities and Desired Outcome
Role of Central East CCAC
Geospatial Information System
How to Refer
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Questions?
Cheryl Luke
Senior Manager, Diabetes Services
Central East Community Care Access Centre
905-430-3308 ext. 5842
[email protected]
David Merkley
Senior Manager, Decision Support
Central East Community Care Access Centre
905-430-3308 ext. 5433
[email protected]
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