Transforming Pathways to Service at CNIB

1. Transforming Pathways to Service at CNIB Service Pathways Project Team June, 2014 (Revised)

2. Passionately providing community-based support, knowledge and a national voice to ensure Canadians who are blind or partially sighted have the confidence, skills and opportunities to fully participate in life. Community-Based Support Helping people who are blind or partially sighted develop the confidence, skills and opportunities they need to fully participate in life. National Voice Creating an inclusive and barrier-free society with access to rehabilitation services and technology. Knowledge Improving the eye health of Canadians and eliminating avoidable sight loss.

3. CNIB – Who We Are • Registered Charity • Funding – about 30% from Government • 53 offices across the country, divided into 6 regional management centres, each with an ED, plus a national support services office in Toronto • Employees – 850 • 200,000 volunteer hours/year

4. CNIB Vision Rehabilitation Services • Independent Living Skills • Low Vision Services • Independent Travel: Orientation and Mobility • Child &Family Services: Early Intervention • Library Services • Deafblind Services • Peer Support Programs • Consumer Products & Assistive Technology

5. Why Create Pathways to Service? • Rehabilitation Services integrated and funded within the continuum of care • “Rights” (rehabilitation services) vs. “Enhancements” (other than rehab services) • Professionally delivered and customer-focused services for all

6. All new clients by FVC 2013 • 35% better than 20/70 (considered mild vision loss or near normal, but we are not sure if they were “best corrected.”) • 55% better than 20/200 • 31 % legally blind (20/200 or worse or documented field loss of less than 20 degrees.) • 2% 20/1200- NLP • In 2012, 40% at time of registration have no eye report

7. The Need for Transformation • The foundations for modern day Vision Rehabilitation were established at the end of WWI, when many returning from the war were totally blind. • We have assimilated low vision rehabilitation within the model of service delivery designed for those who are blind • We have a history of encouraging “all who need us” to come for our help

8. The Need for Transformation • Today’s Accepted Standard- Low vision rehabilitation begins with a careful evaluation by an optometrist or ophthalmologist • We allowed new referrals to bypass this fundamental requirement prior to the start of rehab services, and this number appears to be increasing: • In 2012, we had 6% of all new clients with no eye report; in 2013, it has been 13%, more than double. • In 2014, we introduced the requirement of an eye report prior to service

9. The Need for Transformation • 1600 of the new clients we served in 2012 have an “Unknown” cause of vision loss but still received nearly 10,000 hours of service • 3,000 new clients with vision better than 20/70 participated in rehab service delivery

10. Self-referral (including family member) Practitioner referral Leading to… Current Pathways-Adults

11. The Buffet--

12. Self-referral (including family member) Interest, based on choices offered Practitioner referral Range of services offered through Intake Interview If interested, those services are “assigned” Perhaps many or most have a FVA done first, but NOT ALL Current Pathways-Adults

13. The Need for Transformation • By endeavoring to assist everyone in the same manner, we risk offering similar service to all who come to us (a “smorgasbord”) • Proper assessment and case management guidelines are needed • We will be challenged in our efforts to be integrated within the continuum of care if we continue to operate outside of it • We must transition access to and the delivery of vision rehabilitation in order to effectively meet the needs of those we seek to serve

14. Resulting in… We have evidence, through our research, and EVRR, of: • Client confusion-who does what? What does each discipline do? Why is there so much to choose from? • Some clients getting service they do not need; some clients not getting service they do need, or waiting too long for it, and an inability of the system to adjust the intensity as needed • Inability for us to justify the rehabilitative nature of our work to health funding sources • Ordering of devices that do not meet the need • Lack of follow-up with clients • Many clients getting only 1-2 hours of service, and then no more (but do some need more?)

15. Collaborators • Models we visited (or had information sharing with) as part of the data gathering process: • MAB-Mackay, Montreal • Lighthouse International, New York • University of Waterloo Centre for Sight Enhancement • Vision Australia • RNZFB

16. Improving Client Experience This model of care has been designed to improve outcomes for clients by: • placing clients on the Service Pathway that is appropriate to their level of functioning, level and type of vision loss, and urgency of the individual situation • delivering client-centered care according to individualized needs; and • for the first time, coordinating service for clients through one point of contact (Service Coordination Specialists), aims to decrease reports of client confusion and/or overwhelm when coming to CNIB.

17. SP Phased-In Approach • Phase 1-Implementation of the Eye Doctor Referral Form-launched July 22, 2014 • Phase 2-Implementation of the new Triage Tool, the Comprehensive Assessment of Needs (CAN), and the pathways referral processes-will launch late fall, 2014 • Phase 3-Exit Survey, Follow-up Centre, and Discipline Based Assessments revised

18. Proposed New Pathways • “Adjustment to Vision Loss” • “Sight Enhancement” • “Sight Substitution/Urgent Care”

19. “Adjustment to Vision Loss” Pathway

20. “Sight Enhancement” Pathway

21. “Sight Enhancement” Pathway

22. “Sight Enhancement” Pathway

23. “Sight Substitution/Urgent” Pathway

24. “Sight Substitution/Urgent” Pathway

25. Doctor Referral Form-Development • Original form reviewed by 5 eye doctors (one ophthalmologist, 3 optometrists in private practice, and 1 academic/clinical optometrist); Feedback was also collected from a small LV leadership group • Final form includes items desired by both groups: e.g. primary reason for referral.

26. Notes-Doctor Referral Process • Drs have been asking for a “click and submit” option • The Eye Doctor Referral (EDR) may be completed online (click and submit) and will be directed to data entry people • If the EDR is received before the client has called us, the client will be registered in database, then phoned to conduct the Triage Tool

27. Triage Tool Development • The Triage Tool contains the list of items about functioning for determining the person’s needs quickly, will help determine pathway and urgency • Triage Tool - four areas: • Safety • Employment and academic success • Emotional and social well-being • Functioning with vision loss

28. Triage Tool Development • Development included review of: • Our Current Intake • Vision Australia Common Intake Tool (CIT) • Functional Vision Screening Questionnaire items (Wisconsin Department of Health Services) • VF25-QOL • VFQ 14 • MacKay Global Assessment Form • University of Waterloo Centre for Sight Enhancement Patient Information Form

29. Notes-Triage process • The Triage tool will now be separate from the Eye Report (which will be called the Eye Doctor’s Referral Form) • Triage will be handled almost exclusively by the Registrars and similar positions (as designated by Service Managers); there will be occasional exceptions (Eg. Deafblind services; children’s services)

30. Notes-Triage Process • All those conducting triage will be fully trained: new Eye Docs’ referral, triage tool, pathways processes • National Helpline will provide back-up to the registrars and the rest of the service team, for the triage process

31. Notes-Triage Process • Triage form will be completed over the telephone in EVRR in real time, with the registrars and similar position titles. Registrars will create the EVRR record as they do presently. • The Eye Doctor Referral form will continue to be scanned in; and the eye information entered into the database by hand.

32. Comprehensive Assessment of Needs (CAN) • Purpose: Stream rehabilitation clients to appropriate services • Development included review of: • Our Current Intake • Our Current EVRR discipline based assessments • Vision Australia Comprehensive Assessment Tool (CAT) • VF 25 • VF 14 • Veterans Affairs LV VFQ 48 • Veterans Affairs LV VFQ 20 • MacKay Global Assessment Form

33. Notes-The CAN process • Affects slightly the role of LV Specialists • Affects the role of the current Intake Coordinators • Intake coordinators will take on role of Specialist, Service Coordination-all have been briefed as of late October

34. Notes-The CAN Process • True service coordination will be the hallmark of this position • Following clients through the process of rehabilitation, and carefully managing these cases • A flag will be put into EVRR to deal with when a client needs the next service on their list

35. Notes- Training • Those slated for training are: • Service Coordination Specialists • Registrars/Back-ups • LV Specialists • Those slated for e-learning module on Pathways-all staff

36. Notes-Training Slated for summer, and fall 2014 Training sessions: • Pathways overview • Interviewing skills; conflict resolution • Processes • Forms review and having the conversation • Client records management • Outlook scheduling

37. Additional Considerations • Building in outcomes measures • Fulfilling reporting requirements • Creating an Evaluation plan for the new project • Turning “on” certain functions-automation (e.g. priority switches)

38. Quality is never an accident; it is always the result of high intention, sincere effort, intelligent direction and skillful execution; it represents the wise choice of many alternatives. Evaluation of the project“Age Related Vision Loss” Biljana Zuvela, CNIB Research William A. Foster

39. Your Questions!