Written by Lisa Bournelis, Senior Consultant, STT, Stratetic Tranformation Team

Frequent users of our emergency departments "familiar faces" account for 12,000 visits in Fraser Health annually. Here's what we're doing now to help these patients receive the best care.

These patients deserve the right care at the right time and in the right location. The goal of the Familiar Faces initiative is to improve both patient outcomes and experiences by bringing together community health service area teams comprised of staff from: Emergency/Acute, Home Health, Mental Health, Primacy Care, BCEHS, Fire Chiefs and shelters. These teams create local solutions to create meaningful impacts for patients.

What is the change in approach?

  1. We are finding new ways to share information and communicate across care settings. We are working to build stronger connections between hospital and community teams, with community physicians, and other care partners.
  2. We are expanding our approach to care planning for Familiar Faces clients. Multidisciplinary teams are working together to develop a shared care plan so we provide consistent care and messaging at all points of care.
  3. We are also inviting hospitals and their health service area teams to develop locally based solutions to address the needs of their patient populations.
  4. Local teams of hospital and community providers are also working on plans to improve community-based supports. These system-wide changes can reduce emergency department visits for the community as a whole.

Why the change?

The emergency department is not always the best place for patients. Many Familiar Faces clients arrive in emergency due to chronic needs that could be managed in the community. For example, 67 per cent of our familiar faces under the age of 70 present with mental health or substance use issues while close to 70 per cent of our familiar faces over 70 years present with chronic disease concerns. As such, the plans and solutions for this issue are much broader than the emergency department.

Global studies also show that frequent emergency department users have longer stays in hospital and increased mortality. These patients are also experiencing poorer service quality as their needs are not being met in the right care location. We are working to enhance community and patient-centered health care to improve service delivery to vulnerable populations.

When will the change happen?

By April 2017, we aim to have:

  • Local strategies developed and implementation launched
  • Shared Care Management Plans and systems in place / communicated
  • New Familiar Faces data profile log to allow teams to understand where clients are accessing emergency services, for what reasons, if they have any attachments to other services, and how they arrived at the emergency department
  • Data dashboard to monitor familiar faces trends regionally and live at the site level
  • A more efficient system for clinicians to access and view the shared Care Management Plans in MEDITECH and PARIS

Progress so far

  • An integrated roadmap for services across acute, primary and community care for familiar faces clients has been developed.
  • Local Familiar Faces teams are in place for each of the hospitals/communities. Each has reviewed data profiles for their clients and is in the process of developing two local strategies above and beyond the shared care planning to support clients in their communities. 
  • The metrics for monitoring the trajectory of these clients at a site and regional level have been determined, and a dashboard is under development. 
  • Training for staff to input Care Management Plans in MEDITECH and PARIS is expected to be completed by the end of March.

How does this impact my job? What are the impacts of the change?

  • New and improved shared Care Management Plan process (with multidisciplinary teams in hospital and community setting)
  • Patients and their families will be included in the shared care planning and referral process
  • New ways of delivering primary care in community beyond family practice settings
  • New site expectations around how resources are directed in the community and how local solutions are empowered
  • Technology to include primary care and cross-health authority interface

More information

Please contact Mary Van Osch for more information.


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