The H O P E Model ReImagining Home

The H. O. P. E. Model® Re-Imagining Home Care with the H. O. P. E Model of Neighbourhood Care Alaya. Care Better Outcomes 2019 Returning “visiting nursing” to its roots: community care 10 February 2020 #HOPEModel @SEHealth_SEHC September 19 th, 2019 @AMSHealthcare

WHY we exist To spread hope and happiness WHAT we do Home Seniors’ Living Health Care Hospital @ Home & Transitions VALUES 2 Education Elizz Caregiver Solutions We are collaborators We see possibility everywhere We believe in the power of people, families and communities

“The home setting and health services will become so synonymous that they may not be called home care; rather, they will just be modern health care” 3 Home Care Could be Heart of the U. S. Health System by 2024, Leaders Say (2015)

Homespital Diagnostics @ Home • Sample testing • Home imaging • Phlebotomy • Sleep, vision testing • Vital signs Pre-Post Acute Early discharge Palliative care Reactivation Surgery at home • ER Diversion • • Infusion Services • Home Chemotherap y • Home Hemodialysis • Other IV Mental Health Other • Cognitive • Ambulance drone testing • Vaccinations @ • MH Online home • VR – digital • Virtual Trials therapeutic @Zayna. Khayat

Pre- and post-acute business models “Healthcare with no address” “Care anywhere” “Focus Home” “Hospital without beds” Hospital to keep you out of hospital” “Canada’s 1 st virtual hospital” “Hospital with no patients” @Zayna. Khayat

“ 70% of what is currently done at the hospital, will not be done at the hospital” “mobile first; physical next” @Zayna. Khayat

“From the waiting room to the living room” @Zayna. Khayat

2017: Split Up Dutch Ministry of Health 1. Cure (hospitals, drugs) 2. Care (home, community, primary; seniors) 3. Public Health New Health Minister, Hugo de Jonge (2018) • € 2 billion removed from “cure”, added to “care” for seniors in the community 2030 Target: 50% of care moves out of institutions and into lived environment @Zayna. Khayat

Clients & Families Visiting Professionals Status Quo Home Care Provider Organizations Health System #HOPEModel @SEHealth_S

On a journey to reimagine home care Saint Elizabeth Nursing Care Manager Philosophy #HOPEModel @SEHealth_S

Inspiration

The Catalyst: A White Paper [2017] rks o w t e n r hei t , e l p o ld e u p o f h s o s e f i h yl ngt a e d r t y r s e e v h “T of e s ith n r w e t k t r a o p w ut b s and the ge for how we e m ho n a w t o s r i e the n i set th y l n o ot. n s , g s n t i t n t e e i es pat r a c l l a oss r c a o a s l e a v a h p i ersh d a e l g sin r u this n g d n n i l a b g a en n i Nursin y a l p to e l o r l a t ur. ” c c o pivo o t ion t a m r o f trans #HOPEModel @SEHealth_SEHC

H. O. P. E. Model® Home Opportunity People Empowerment People’s needs & aspirations Nurse-led, Accountable 24/7, Self-Directed Informal & Formal Networks Simplifying Processes & Tech | Knowledge Net | Partners #HOPEModel @SEHealth_S

Proof-of-concept pilot [2017] 50 medical+social complex citizens 4 nurses 1 coach 1 area (Hamilton) “You actually feel like you’re making a difference. . . It’s the most important job I’ve ever done. ” “I don't want to see 20 patients in a day to pay my bills. I don't think it's fair to the patients and it's not fair to us, right? It's nobody's fault, it's the way the system works. I get it, but it definitely makes you do your job better when you're not worrying about that…” #HOPEModel @SEHealth_S

#HOPEModel @SEHealth_S

Intent How might we test and position for spread & scale a holistic model of neighbourhood care? #HOPEModel @SEHealth_S

1 Hope Initiative 2 3 Sandbox & methodology to experiment (including digital enablement) Validate & build system capacity for adoption of H. O. P. E Model®, at scale Explore how technologies can be seamlessly included in compassionate neighbourhood care Ultimate goal: Self-empowered nurse-led teams are standard for how home care is organized, delivered & financed in Canada, as is happening in the rest of the world #HOPEModel @SEHealth_S

What is so different? Comprehensive “life care” plans including plans People’s needs & aspirations for caregivers Nurse-led 1 - maximize scope of practice 2 - autonomy - single ”go to” - do assessment & care Self-directed, Nurse-led teams, Informal & Formal plan accountable 24/7 Networks - 24/7 - pulls in others as Simplifying Processes & Tech | Knowledge Net | Partners needed - salaried 4 Tech enabled 3 Self-managed team - digital first (documents, - no manager (coach!); do own firing/hiring communication) - self schedule, no central scheduling - All on team + client have - fixed geographic neighbourhood (postal codes) access to chart - accountable to client & family, to each other, and the - 24/7 access – virtual#HOPEModel nurse @SEHealth_S

5 A transformation at multiple levels [concurrently …] System Inter-org. + CSS + CHC + LHIN + primary care + hospitals + EMS Organizational Community nursing model - Including use of technology People-family experience & empowerment - Including use of technolog

4 Parallel Work streams Living Lab (H. O. P. E Model®) Validate, test, refine the model setting it up for spread and scale. Layer in emerging technologies over 12 months • Target: 1000 patients over 3 years Developmental Evaluation Multi-pronged independent evaluation of H. O. P. E Model implementation where learnings are fed back to the team in real time in order to iterate Ecosystem Engagement Raise awareness, educate, support system-wide readiness to embrace new models of care Via: targeted stakeholder engagement, community of interest/practice, website, social media, events, roadshows, publications Program Management Overall program management and governance • Day to day operations of the core team, budget • Working teams • Workplan and milestone management • Governance, advisory council • Partner relationships

Living Lab #HOPEModel @SEHealth_S

Neighbourhood tests underway [12 month cohorts X 5 -6 neighbourhoods across Ontario] London-Middlesex • 4 nurse team • ~100 client load, 180 • • people in total Rural Geography Aug ‘ 19, 12 mths Englemount Lawrence • • 3 nurse team ~75 client load, ~200 total Urban, underserved Nov ’ 19, 12 mths Next neighbourhoods • 1 -2 more in 2020 • 2 -3 more in 2021

Coach Carter First 2 H. O. P. E. Teams Claudia (London) Vicki (Toronto) Irene (London) Cassie (Toronto) Tammy (London) Jan (Toronto) #HOPEModel @SEHealth_SEHC

Care coordinator (LHIN) Home care agency (SE or other) Nurse Personal support worker PT, OT, Social work, nutrition … Community supports Client & nurse experience Refer Intake Assessment Usual Care Service Plan Referral Service Delivery (Agency) (In the field) Change/Discharge (paper chart) (digital billing) Refer Onboard Lead H. O. P. E. nurse Getting to Know You (Inter. RAI) Your Life Care Plan Sense & Respond (deliver the plan) Maintenance (up to 12 mths) (if needed) + directly engage family, community assets, doctors, pharmacist, etc. Alayacare - Digital first documentation, planning Log time 3 ways: Direct in person, Direct virtual, Indirect #HOPEModel @SEHealth_S

Insights so far: the model Clients & Family caregivers Nurses Coach #HOPEModel @SEHealth_S

"As clients receiving H. O. P. E. care from us, they always feel very relieved when we tell them that we work on a 4 person team and that it will be one of us always delivering their care. You will hear them say, 'well isn't that nice'. You can definitively see the relief” [H. O. P. E. nurse] “an amazing, amazing nurse! so kind and genuine. goes over and above the call of duty” [H. O. P. E. client H] who left an unprompted voice mail to SE Health

“a new way of helping people without burning out. allows me to see my family and my clients without having to trade one for the other. With more control over my schedule I am able to have a more active role in my client's care. I am able to be with them in the doctor's office and as such can build relationships with the doctors and their staff. All around it means better care or our clients and less wasted time playing telephone tag and less frustration. ” [H. O. P. E. nurse] “I used the laptop in the home last week for the first time. I clocked in and out with it as well as did all of my charting. I am able to do my vitals and come back and chart them. My charting time is cut in half!!! Everything works so much batter than the tablet ” [H. O. P. E. Nurse] – after we switched hardware from tablets to laptops (because the nurses asked for this) ”One of the great things about Alayacare is that [before] I would only be able to do chart audits in the field after someone was discharged; now I can go into the chart in real time and help make iterations and offer real time advice when care planning” [Coach]

Technology to layer in over time Within each 12 month cohort Phase 1: Base tech Phase 2: Client tools Phase 3: Emerging tech (~6 months) (~3 months) Single shared record • Assessment (Inter. RAI) • Life care plans • Documentation Access to gov systems & data • Supplies & equipment ordering • Data (labs, Rx, hospital) • Tablet + data plan • Communication Access all data, files Text/video/email • Remote monitoring (incl. PREMs, PROMs) • Educational content • Caregiver tools • 24/7 virtual doctor or NP access TBD • AI-enabled voice assistant TBD • Virtual Reality TBD #HOPEModel @SEHealth_S

Living Lab Developmental Evaluation Program Management #HOPEModel @SEHealth_S

Developmental evaluation • Real time feedback cycles • Embedded scientist Design Principles Stakeholder Engagemen t Client & Nurse Experience Financial Evaluation: Quality & Safety Health Outcomes • ROI at health system level • Independent Implementa -tion Costs Care Delivery Costs • Cost model • Vs. Usual care #HOPEModel @SEHealth_S

Early insights Design Principles Stakeholder engagement Opportunity for deeper critical reflection on operationalization of key model components Client & Nurse Experience Quality & Safety Outcomes Underestimated learning curve on support structures required for new behaviours • Self-managing teams • In person vs digital • Proactive community connections • Proactively engaging other members of formal circle of care Implementa tion Costs Care Delivery Costs Leverage learnings from other innovative pre- and post-acute programs at SE Health #HOPEModel @SEHealth_S

Andrea Carter, RN H. O. P. E. Coach Tori Edgar, MSc Program Manager Brianna Croft, MSc Technology Lead Test & learn team Embedded Scientist(s) Developmental Evaluation Zayna Khayat, Ph. D Co-Lead Tazim Virani, Ph. D, RN Co-Lead + extended internal team at SE Health: Clinical Practice, Ops, Digital, IT, Finance, HR, Communications

Partners Advisory Council Shirlee Sharkey, Kaiyan Fu – SE Health Leader and host overall Core team funding & other support (4 years) Gail Paech, Gail Donner – AMS Healthcare Delivery partners in local neighbourhoods (fund a cohort for 12 months) Judy Berger – patient advisor Financial biz case (Ivey); System ROI (Mc. Master) Samira Chandani – family caregiver In kind marcomm – brand, logo, website Daryl Nancekivell – Southwest LHIN Tess Romain – Toronto Central LHIN Barbara Steed – Markham Stoufville Hospital Ru Taggar – Sunnybrooke Health Sciences Center Cheryl Reid-Haughian – Nursing thought leader Funds to support technology integrations –EMR, remote monitoring, portal, etc. Core software partner – clients, nurses In kind: tablets (patients) Anya Kravets – Gene (marketing/comms partner) Scott Ovenden – Baycrest Health Sciences Center May 8 summit partners (2019) Paul Woods – London Health Sciences Center 35 #HOPEModel @SEHealth_S

Lessons - advice • Living Lab (H. O. P. E Develop joint work plan earlier – Model®) external AND internal partners • Agree on “MVP” for initial launch, focus there • Build in on-going education and support for team re: core model principles, use of technology Evaluation Have frequent points of contact for discussion and observation Feedback at frequent intervals in flexible modes (including facilitated conversations) Ecosystem Engagement Be targeted in who to engage, why (messages), how Continue engagement at every stage of project Encourage relationship building at grassroots Program Management • Build more flexibility into team/role design so adjustments can be made as you learn • Involve more patients & caregivers in co-design • Design Advisory Council more organically #HOPEModel @SEHealth_S

Design for spread & scale 2017 -2019 Proof of concept pilot 2019 -2022 Proof of value pilot – multi-site 3 one-year cohorts 2023+ Spread & Scale Multi-neighbourhood roll out Use system-level financial ROI + Implementation playbook to systematically roll out the model to neighbourhoods across Canada Health. Links cohort (50 clients) - 4 nurses - 1 coach + 4 other LHINS, 1 hospital (pipeline) HOPE Institute Position for spread and scale in parallel via: • Advisory Council (champions) • Multi-stakeholder engagement strategy (starts in year 1) Train other home care professionals and teams on how to deliver the model – Ontario, Canada, internationally

ü Coordinated continuum of care ü 24/7 access ü KPIs: Quadruple Aim outcomes ü Single accountability framework ü Integrated funding envelope ü Reinvest into front line care ü Digital first: providers AND patients

1. Status Quo home care is not optimal for people & families, carers, delivery orgs, the system, society 2. We are part of global movement testing & building capacity for empowered models of care; focused on people & their lives 3. A key focus: give front-line autonomy to do what they are trained to do & are passionate about 4. This is multi-layer, multi-year journey – a theory and methodology for system change and “lab” approach are key Summary

Learn More & Engage With Us Hope Initiative Website – public webinars Empowered Home Care Summit Report & Video (May 2019) Join Our Community of Interest-Practice www. hopeintiative. ca #HOPEModel @SEHealth_S

www. hopeintiative. ca Contact the H. O. P. E Team: SEFutures@sehc. com @SEHealth_SEHC @AMSHealthcare #HOPEModel

Appendix

Client flow, at-a-glance [Initial prototype – to be refined by the HOPE nurses in each neighbourhood] I. Refer New referrals OR existing longterm clientele due From gov agency for reassessment` From hospital From primary care From EMS ? From community II. Onboard Referral to central H. O. P. E. phone / email Referral received by “coordinator role” on H. O. P. E. team; team determines optimal lead nurse Registration with lead H. O. P. E. nurse wherever the client & caregiver are (telephone, in person, at clinic) SE Health H. O. P. E. Onboarding 2019 Self refer/ outreach? III. Getting to know you Holistic assessment Simple, pragmatic • inter. RAI CHA + supplement(s) if need • Client/ caregiver goals • Caregiver Assessment IV. Your Life Care Plan V. Sense & Respond VI. Off service Develop care plan with client, caregiver & appropriate formal/informal supports • Iterative, done in parts • Enter into collaborative record H. O. P. E. team delivers care plan; in connection with informal & formal supports Confirm resources available for plan Moved out of neighbourhoo Formal reassessment d -- frequency based on progress; or Asked to leave changes in status or program client/family goals Organically review/refine plan with client + caregiver (and other partners) Getting to Know You/ Life Care Plan / Sensing & Responding H. O. P. E. team may get started immediately on assessment, some care planning, and some interventions i. e. solving needs of client before completing all formal processes & documentation. Discharged to maintenance phase Entering LTC facility or Hospice Death Etc. 43

H. O. P. E. ™�Model Components (I of II) Nurse-led, Self-Directed, Accountable Teams • • Interdisciplinary teams with full scope or practice Self-managed, autonomous, empowered shared decision making Clear accountability – designated Primary Nurse Built in flexibility 24/7, Client/Family Centered Care • Client & family centered approach • Enable to live at home safely with dignity and independence • Collaborative care plans • Full range of supports – prevention to self-management; SDOH key focus • Communication & coordination across entire continuum of care • Patient/family teaching and supports for system navigation • Access to the data, care plans, etc. • 24/7 including virtual tools Informal & Formal Networks • Sharing of the caregiving • Access and link to informal and formal care (e. g. primary care, CSS) and supports • Community capacity development • Conduct neighborhood environmental scans: proactive connections to community assets (e. g. for peer supports, transpiration, psychosocial supports etc. ) Simplifying Processes and technology | Knowledge Net | Partners

H. O. P. E. ™�Model Components (II of II) Simplifying Processes and technology | Knowledge Net | Partners • • Common, shared, cloud based electronic system Web-based documentation of learnings, tools so all H. O. P. E. nurses can seamlessly access across teams One go to “lead nurse” for the client and family One number and voice box for patients to reach the team On-call system organized by team Limited barriers to maximize the team’s creativity Strong partnerships with formal and informal community partners, and broader health system partners