CELHIN Assertive Community Treatment Teams (ACTT) Quality Improvement Initiative:

1. CELHIN Assertive Community Treatment Teams (ACTT) Quality Improvement Initiative: October 10th, 2013 ACT TOGETHER Prepared by

2. Project Overview – Mission and Success Increase capacity by 200 total spaces and flow within ACT Teams to potentially save 10,000 hospital days Project Mission • Find efficiencies and define standard practices within the topics of: • ACTT Intake & Referral • ACTT Treatment and Planning • Hospital and ACTT Relationships • Discharge From ACTT • Create MOUs to support the implementation of these efficiencies and standard practices for all ACT providers and primary stakeholders • Generate interest and support across the LHIN of these changes Project Success

3. Project Overview – The Work Regional Kaizen* Learning Day Topic specific Kaizens* Working Groups Reveal Day/ Final Report March 2012 June 2013 *Kaizen is Japanese for "improvement", or "change for the better" and refers to the LEAN philosophy or practices that focuses upon continuous improvement of processes.

4. Project Overview – Oversight Committee Each of the members of this group also participated in at least 1 working group to enable cross-pollination of ideas and to ensure working group suggestions were represented at the final decision-making table. • The mandate • Address larger system issues • Provide feedback and direction to the working groups as they developed their processes • Review and make final decisions on all materials included in this document. • Output • Creation of two visionary documents for this project; the Memorandum of Understanding and the Guiding Principles for Hospital and ACTT relations.

5. Project Overview - Current State Findings The majority of the basic processes within ACTT are consistent. There are however, variation in how these steps are ordered, dispersed throughout team members, and conducted. Standardizations • Items that created overall efficiencies and a more unified “brand” to external stakeholder groups were standardized. The following items are examples of this: • Letters • Forms • Timeframes • Waitlist protocols • Primary assessment tools (OCAN, ATR) Recommended Best Practices • Items where efficiencies were best determined at the individual team level were supported by recommended best practices. The following items are examples of this: • Meetings • Team functioning and task allocations (including the psychiatrist)

6. Working Group Outcomes – The Introduction Individual working groups submitted their recommendations for Oversight Committee review and approval for each of the following four areas: • ACTT Intake & Referral • Standardizing the approach and policies for referral to and intake by ACTT • ACTT Treatment and Planning • Ensuring consistent and best practice approach to treatment planning • Hospital and ACTT Relationship • Strengthening hospital and ACTT relationships and coordination • Discharge From ACTT • Standardizing the approach and policies for discharge from ACTT

7. Working Group Outcomes – Referral & Intake • Recommended best practices • ACT Team intake personnel • Client Welcome Package Checklist • Measures of success • Reduced inappropriate referrals • Reduced referrals without complete information • 30 day wait for notification Working group purpose • Identify ACTT appropriate clients sooner • Reduce notification timelines of acceptance to/declined ACTT service • Increase communication with referral sources and circle of care Standardized items • Referral source ACTT screening tool • Referral source ACTT referral form • Letters • Intake prioritization processes • Wait times of notification of acceptance/declined ACTT service to 30 days

8. Working Group Outcomes- Referral & Intake Screening Tool

9. Working Group Outcomes- Referral & Intake Common Referral Form

10. Working Group Outcomes- Referral & Intake Example of the many standardized letters

11. Working Group Outcomes – Treatment • Recommended best practices • Waiver for Group Programs • Collaborative Crisis Plan (within ACT Teams) • Measures of success • Fidelity to new process • Comparative OCAN data • Participate in ATR data collection • Reduced staff time spent on redundant paperwork • Current ACTT clientele identified as ready for reduced service levels or discharge Working group purpose • Ensure consistent and best practice approach to treatment by: • Streamlining processes and documentation • Enhancing communications with clients, families and community services • Reducing paperwork while increasing level of relevant information collected Standardized items • Expectations Agreement • OCAN used as the Treatment Plan • ATR used as a tool to identify potential for stepped care or discharge (with clinical judgement)

12. Working Group Outcomes – Treatment

13. Working Group Outcomes – Hospital Relationship • Recommended best practices • ACTT provides local schedule 1hospitals with updated client lists provided given client consent on a monthly basis • Measures of success • Psychiatrist communication increases • Continuity of care for client is enhanced Working group purpose • Define guiding principles for ACTT and Hospital relations Standardized items • Psychiatrist communications • Documentation between ACTT and Hospitals • Inclusion of ACTT in rounds, case conferences and discharge meetings • Timings

14. Working Group Outcomes – Hospital Relationship

15. Working Group Outcomes – Discharge • Recommended best practices • Defined stepped caremodel of service • Team staffing allocations through the discharge process • Client Disengagement Practices • Measures of success • Implementation of a stepped care model of service • Increased number of identified clients requiring and referred to reduced services Working group purpose • Standardize the approach and policies for discharge from ACTT Standardized items • ACTT readiness for stepped care overview • Service overlap between ACTT and new provider for up to 30 days

16. Working Group Outcomes – Stepped Care Model Proposed Model • Addition of 1 FTE RN to each ACT team within the CELHIN • Additional Funding for psychiatry to care for the additional ACT clients • Funding for Project Management to lead the implementation of the QII Functions • RN will be able to continue specific medication protocols that were established on the ACT team • ACTT Stepped Care Services or traditional ACT services will be interchangeable based on client need. • Stepped Care Model will be able to have a caseload of 25 clients (max) Outcomes • Increases the ACT capacity within the CELHIN by over 200 clients (the equivalent of two full ACT teams) • Subsequently decreasing inpatient days for clients that previously were waiting for ACT intervention

17. Next Steps What we will do…

18. Questions and Answers Access to ACTT /hospital WIFM approach to Main recommendation - Step down (newer philosophy – not abandonment – ACTT light) Reference Oversight at end of purpose