HNHB LHIN Restorative Care Bed Review: Final Report and Recommendations. April 2013

Transcription

1 HNHB LHIN Restorative Care Bed Review: Final Report and Recommendations April

2 Table of Contents INTRODUCTION...3 BACKGROUND...3 Project Scope and Objectives...4 Process...5 Rehabilitative Conceptual Framework...10 Applying the Methodology Phase 1 Sizing of Restorative Beds...12 RECOMMENDATIONS...17 APPENDICES A. HNHB LHIN Alternate Level of Care (ALC) Steering Committee Restorative Stream Working Group Terms of Reference B. HNHB LHIN Restorative Stream Working Group Membership C. Restorative Bed Worksheet D. Restorative Data Review E. Complex Care Bed Numbers Post Implementation February

3 INTRODUCTION In November 2009, the Hamilton Niagara Haldimand Brant (HNHB) Local Health Integration Network (LHIN) completed an extensive population based planning study to develop a Clinical Service Plan (CSP) that would provide the foundation for strategies and activities to achieve improved outcomes and foster health system sustainability 1. The CSP identified 18 clinical program areas where potential existed to develop LHIN-wide integrated programs 2. Two areas for clinical program integration targeted in the first year of a three year plan were complex continuing care and rehabilitation. To complete this work two Task Groups were established; the Complex Care (CC) and the Rehabilitation Task Groups. The HNHB LHIN Complex Care Task Group s (Task Group) June 2009, final report proposed an integrated CC service model that included common definitions for CC and its sub streams and proposed a relatively new way of thinking about CC. In this model the CC bed was no longer intended as a final destination for the patient rather a plan of discharge was required on admission. Lengths of stay were targeted within a range of days, with clear goals set, in order to enable appropriate care to be provided at home or at a different level (e.g., long-term care (LTC) or supportive housing). Key recommendations in the final report included an overall reduction of the HNHB LHIN s CC bed capacity and recommended CC bed sizing by sub streams. To operationalize and implement the HNHB LHIN s Integrated CC Program a Complex Care Implementation Steering Committee (SC) was established under the auspices of the HNHB LHIN Alternate Level of Care SC. It was expected that the CC program would be fully implemented by April During the development and implementation of the Integrated Program for Complex Care in the HNHB LHIN a number of reports (Walker, Senior Friendly Hospitals) have been published on the readiness of the health care system to meet the needs of Ontario s aging population. Current models of care were described as relying too heavily on the acute care hospital system that is designed for rapid diagnosis and management of serious illness. This system, for frail older seniors, can result in less than optimal outcomes and functional decline and a culture that emphasizes long term care placement rather than considering an older patients ability to recover sufficiently to return home 3, 4. Both reports recommend acute hospital care introduce strategies/care models that aim at preventing functional decline in older adults and supporting restorative programs that optimize their recovery. BACKGROUND During the implementation of the Integrated Program for Complex Care, the HNHB LHIN was also implementing a three year Action Plan to improve patient flow. The HNHB LHIN s Action Plan (Action Plan) was based on the findings and recommendations of two patient flow reviews completed by PriceWaterHouseCoopers LLP and Dr. Walker s ALC Action Team. A strong message resonated from both reports that a systematic change was needed in the planning and delivery of health care services to address the needs of an increasing aging population. The HNHB LHIN s Patient Flow Action Plan was developed to incorporate a culture that integrated a Home First philosophy and included initiatives that emphasized and promoted a culture where patients were always considered 1 HNHB LHIN Clinical Services Plan, November HNHB LHIN An Integrated Program for Complex Care, June Walker, Dr. David. Caring for Our Aging Population and Addressing Alternate Level of Care. June 30, Ontario LHINs. Senior Friendly Hospital Care Across Ontario Summary Report and Recommendations. September

4 and assessed for programs that optimized their recovery allowing them to return home. The impact of the HNHB LHIN s Action Plan was demonstrated in the reduction in number of individuals waiting in hospital for long term care (360 in 2010 to 135 in 2012), increased referrals to restorative programs (80% of 830 individuals were successfully discharged), discharged 1,350 individuals from hospital through Home First (341 received more than two hours of personal care per day), transitioned 129 individuals that accumulated 24,622 ALC days to the right level of care (LTC), and the Acute ALC rate reaching 12.94% - the lowest reported rate since The HNHB LHIN was challenged with increased demand for restorative beds occurring in parallel to the implementation of the integrated complex care plan that recommended reduction of complex care beds. The change in how providers assess and determine care trajectories for our senior population following or prior to an acute care event in hospitals, has led to a fundamental change in our system. This recalibration has prompted the review of the Complex Care plan bed map of which was developed prior to the culture shift. A demand for restorative type programs, where seniors over a longer period of time than traditional rehabilitation programs, are given the opportunity to regain functional capacity to enable them to return home has risen. Project Scope and Objectives In January 2012, the HNHB LHIN established the Restorative Stream Working Group to review the HNHB LHIN s bedded restorative resources. The working group was comprised of individuals with expertise in restorative care, administration, planning, epidemiology and community care. The working group took into consideration the findings and recommendations from the Walker and Senior Friendly hospital reports; to reaffirm the number of inpatient restorative beds needed to meet the needs of individuals requiring restorative services prior to discharge from hospital now and in the next five years, and to provide clarity as to how the populations in the current restorative care beds differ. The HNHB LHIN Rehabilitation Task Group, in consideration of this review, put their work on hold pending the final report and key recommendations. The Restorative Stream Working Group was charged with the following goals, actions and deliverables: Goals To ensure individuals that require restorative care have timely access to these services, To ensure bedded restorative resources are optimized by the appropriately streamed individuals, and To have a clear understanding and ability to delineate between bedded restorative streams. Actions Review population health data, Walker report, Senior Friendly Hospitals report and any other relevant reports, Determine the bedded restorative steams and needs for the HNHB LHIN population now and in the next five years (including sizing and siting) based on the population needs, best practices, and clinical outcomes. Deliverables Inventory of current and planned restorative beds in the HNHB LHIN. Define and delineate bedded restorative streams. Prepare a final report with recommendations for submission to the HNHB LHIN ALC Steering Committee. 4

5 For the Restorative Stream Working Group s task, restorative beds were defined according to the following streams: Restorative stream in Complex Care, Debility, medically complex and geriatric stream(s) in Rehabilitation, Convalescent care, Assess and Restore, and Slow Stream Rehab. Terms of Reference and Membership are attached as Appendices A and B. Process Step 1 Literature Review The working group, as a starting point, reviewed relevant literature, which included Caring for Our Aging Population 5, A Summary of Senior Friendly Hospital Care in the HNHB LHIN 6, An Integrated Program for Complex Care in the HNHB LHIN 7, and population health data. It was noted, in Caring for Our Aging Population report that an Assess and Restore philosophy and function must be central to health care delivery. Many frail seniors arrive at the ED could and should be directly transferred to the Assess and Restore programs delivered in either Complex Care or Rehab hospitals or in short-term/transitional programs in LTC. Similarly, patients designated ALC in acute care hospitals should have an opportunity to receive immediate Assess & Restore services in CC/Rehab or LTC settings, rather than waiting in hospital at risk of deterioration 5. Step 2 Development of Methodology The working group applied the methodological approach used in the Complex Care report to determine the LHIN s restorative bed requirements. Adjustment factors incorporated into the methodology included existing information regarding best practices, advances in health care, care paths and clinical expertise. Refer to table 1 below. 5 Walker, D., (2011) Caring for Our Aging Population and addressing Alternate Level of Care, MOHLTC 6 Pizzacalla, A., Marr, S., (2011), A Summary of Senior Friendly Care in the HNHB LHIN. Regional Geriatric Program central 7 Pisko, L., et. all (2010) An Integrated Program for Complex Care in the HNHB LHIN 5

6 Table 1: Planning Methodology for Restorative Care Beds Steps Step 1 Adjustment Factors for Consideration Determine current utilization Description Outline current utilization of restorative beds. Step 2 Adjust for changes in prevalence of health conditions The purpose of including an adjustment changes in prevalence rates is to take into consideration significant changes that will impact demand for restorative services in the future. Step 3 Address unmet need The purpose of including an unmet need adjustment is to take into consideration patients who are not currently receiving restorative services but meet the definitions and criteria. Step 4 Address advances in health care The purpose of including an adjustment for advances in health care is to take into consideration significant changes that will impact demand for restorative services. Step 5 Step 6 Step 7 Address changes in scope of practice/delivery of health services Adjust for population changes (growth and aging) Apply target length of stay The purpose of including an adjustment for changes in the delivery of health services is to take into consideration significant changes that will impact demand for restorative services (e.g., shifts from inpatient to outpatient service). Adjust for population changes in the next 5 years by area of patient residence. Apply target average length of stay. Step 8 Apply target ALC Apply target ALC rate. (Alternate Level of Care) rate Step 9 Calculate bed equivalents Calculate bed equivalents by applying an occupancy rate. This calculation will provide bed numbers for restorative services in the HNHB LHIN based on population need by geographic area. Step 3 Snapshot and Data Analysis To obtain a snapshot of the current state the Restorative Stream Working Group gathered information on restorative stream beds throughout the HNHB LHIN from a variety of settings to review the different programs according to bed type, staffing models, length of stay (LOS), admission/discharge criteria, discharge destination, percent of patients discharged home, and mean age of patients admitted into the program (Appendix C). A further review included an analysis of data from the National Rehabilitation Reporting System (NRS) for the debility / medically complex stream (Appendix D) and RAI (Resident Assessment Instrument) characteristics of the transitional care population which included: Assess and Restore, Assess, Restore and Reactivation, Slow Stream Rehab, Complex Care Restorative Stream, Convalescent Care, and Goldies2Home an outpatient slow stream rehab program refer to Table 2. The Working Group s reviewed the data on the characteristics of the populations that accessed the restorative programs and concluded that for the most part they were similar. 6

7 Table 2: RAI Characteristics of Clients Assess and Determined Eligible for a Transitional Care Bed RAI Characteristics of Clients Assessed and Determined Eligible for a Transitional Care Bed Assess Restore: All sites Assess Restore React: Wellington Park LTC Slow Stream Rehab: HDS NGH Complex Care Restore: BCHS HWMH Convales Care: Dundurn Shalom Goldies 2 Home: Shalom # of Clients Average Age Female 67.3% 33.3% 81.8% 58.8% 67.8% 66.7% 66.3% CVA 17.9% 33.3% 9.1% 21.6% 12.6% 16.7% 16.4% CHF 17.3% 11.1% 9.1% 17.6% 14.9% 11.8% 15.0% COPD 23.0% 22.2% 0.0% 23.5% 18.4% 19.4% 20.3% Dementia 13.8% 44.4% 0.0% 21.6% 5.7% 6.9% 10.6% Hip Fracture 11.2% 22.2% 27.3% 17.6% 17.2% 18.1% 15.7% Any Fracture 31.1% 33.3% 27.3% 23.5% 55.2% 47.2% 41.5% Any Behaviours 4.6% 0.0% 0.0% 13.7% 1.1% 5.6% 4.4% Bladder Incontinence 44.4% 55.6% 18.2% 45.1% 32.2% 29.2% 36.8% Bowel Incontinence 14.8% 44.4% 0.0% 49.0% 12.1% 8.3% 15.6% 2+ Falls in Last 90 Days 27.0% 22.2% 0.0% 35.3% 24.7% 33.3% 28.0% 3+ Falls in Last 90 Days 9.7% 11.1% 0.0% 15.7% 11.5% 15.3% 12.0% Avg ADL Long Avg IADL Difficulty Avg CHESS Scale Avg MAPLe score Avg Cognitive Performance Scale CPS % 66.7% 27.3% 64.7% 24.7% 28.5% 34.2% Avg Depression Rating Scale Avg # Hospital Admits in Last 90 Days Avg # ED Visits in Last 90 Days Source: HNHB CCAC September 1, 2011 to March 31, 2012 Step 4 Define and Delineate Restorative Streams An inventory of the five HNHB LHIN restorative bed streams by service description and target LOS was gathered and reviewed along with the snapshot and data analysis refer to Table 3. The five restorative bed streams included the debility/medically complex rehab stream, restorative stream in complex care, slow stream rehab, assess and restore/reactivation and convalescent care. The working group concluded that the patient populations accessing these programs were similar and consensus was reached that all beds can be grouped under Restorative Stream. Total 7

8 Table 3: Current HNHB LHIN Restorative Bedded Service Definitions Program Inpatient Rehabilitation Classifications; Debility / Medically Complex Complex Care: Restorative Stream Inpatient program Slow Stream Rehabilitation Program Service Description A progressive, dynamic, goal-oriented and time-limited process, which enables an individual with impairment to identify and reach his/her optimal mental, physical, cognitive and/or social functional level. Rehabilitation provides opportunities for the individual, the family and the community to accommodate a limitation or loss of function and aims to facilitate social integration and independence. The patient is in need of an interdisciplinary rehabilitation program. (Source: WHO & HNHB LHIN Rehab Task Group March ) People with a multiple medical and/or functionally complex condition(s) who are expected to benefit from low intensity, long duration interventions provided by an inter-professional team, with clearly articulated functional improvement goals that can be attained within the average length of stay. a) Mini-mental exam (MMSE) score >16, b) Presence of significant physical/functional impairments, c) Physical tolerance that permits participation in programming, d) Goal to go home or a retirement home (Source: An Integrated Program for Complex Care in the HNHB LHIN Final Report June ) Patients, who are presently waiting in acute beds would be admitted and participate in a comprehensive slow stream rehabilitation program in order to enhance their functional and cognitive ability such that they may be eligible to be discharged home or to a retirement home with enhanced services provided through the CCAC Community Slow Paced Rehabilitation Program. (Source: Slow Stream Rehab Demonstration Projects May 2008) Target LOS Days Assess Restore Inpatient Program Assess Restore & Reactivation Inpatient Program Convalescent Care Program The Assess Restore program will: Provide an area where patients that have completed the acute phase of their hospital care can be assessed for longer term care needs in the community or a residential setting. Provide an area where patients discharged from acute care receive the appropriate level of care to prepare them (recover strength, endurance and functioning) for discharge to the community or another appropriate residential setting. (Source: HNHB LHIN Assess Restore Program Model April ) The Assess Restore Reactivation program will: Provide an area where patients that have completed the acute phase of their hospital care can be assessed for longer term care needs in the community or a residential setting. Provide an area where patients discharged from acute care receive the appropriate level of care to prepare them (recover strength, endurance and functioning) for discharge to the community or another appropriate residential setting. (Source: HNHB LHIN Assess Restore Reactivation Program Model June ) The Convalescent Care Program (CCP) is a short-stay program for persons who need time to recover strength, endurance or functioning and who are anticipated to return to their residences after admission to the CCP. The maximum CCP stay that can be authorized by the CCAC for an eligible person is up to 90 continuous days at one time, with a total maximum of 90 days in a calendar year. (Source: MOH-LTC Policy for the Operation of Short-Stay Beds July 1, 2010) Day Max LOS 45 8

9 Step 5 Inventory of Current Utilization of (February 2013) Restorative Programs by Geographical location and Bed numbers in comparison to the Identified Need of Restorative Stream beds in the 2010 Integrated Complex Care Program Report A summary of the existing Assess Restore, Assess Restore Reactivation, Slow Stream Rehab, Convalescent Care and Complex Care Restorative beds as of February 2013 in comparison to the identified need of restorative stream beds in the 2010 HNHB LHIN Integrated Complex Care Program Report. See Table 4. Table 4: Current Utilization of Restorative Beds as of February 2013 and the Identified Need for Restorative Beds in the Complex Care Program Current Utilization of Restorative Beds in the HNHB LHIN February 2013 Hamilton Burlington Brant Norfolk Haldimand Niagara Total Assess Restore Assess Restore 6 6 Reactivation Slow Stream Rehab Convalescent Care Complex Care Restorative * Total Identified Need for Restorative Beds HNHB LHIN Complex Care Report 2010 Hamilton Burlington Brant Norfolk Haldimand Niagara Total Total Variance Between Current Utilization and Identified Need Hamilton Burlington Brant Norfolk Haldimand Niagara Total Total *Patients not admitted according to streams at the reporting time **Includes 13 restorative beds at the NHS- Niagara-on-the-Lake site for which implementation is on hold 9

10 Step 6 Service Definition, Eligibility Criteria and Expectations of the Program To bring clarity to the multiple programs that are currently classified as restorative yet provide like services to similar populations the Restorative Stream Working Group developed a draft Service Definition, Eligibility Criteria and Expectations of the Program and chose to adopt the Rehabilitative Conceptual Model presented by the Rehabilitation and CCC Expert Panel to frame detailed below. The application of the Framework to the LHIN s restorative programs is shown in Table 5. Rehabilitative Conceptual Framework 8 : Foundational Principles Early access to rehabilitative care should be equitable. All patients should receive rehabilitation care to their level of tolerance with the goal of achieving maximum functionality. Every one of these services can be described or measured by data elements. Every care service can be mapped to a CIHI NRS or CCRS category and to an OHRS category. The care delivered to every category, cluster and in every location would be guided by best practices where they exist. All services would be delivered in an age appropriate manner (e.g. seniors focused, paediatric friendly). Within each program or service there is flexibility to care for patients as their tolerance for treatment changes to minimize transitions. There is recognition that clustering patients with similar care needs leads to better outcomes. Rehabilitative care is defined into four functional groupings. These categories are distinguished by the level of functioning of a patient combined with their capacity for restoring or maintaining function and their relative complexity. The determination of category is done at the time of transition from one destination to another using agreed-upon assessment tools. The four groupings are: Group 1: slow progress/low capacity for functional improvement Group 2: slow to moderate progress/low to moderate capacity for functional improvement Group 3: moderate to rapid progress/moderate to high capacity for functional improvement Group 4: rapid progress/high capacity for functional improvement 8 Rehabilitation and Complex Care Expert Panel Update, December 9,

11 Table 4: Application of the Rehabilitative Conceptual Framework to Current HNHB LHIN Restorative Programs Potential for Functional Improvement and/or attainable goals Group 1 Group 2 Group 3 Group 4 slow progress / low capacity for functional improvement slow to moderate progress / low to moderate capacity for functional improvement moderate to rapid progress / moderate to high capacity for functional improvement rapid progress / high capacity for functional improvement LOW LOW / MOD MOD / HIGH HIGH Risk of Deterioration HIGH HIGH HIGH LOW Complexity related to comorbidities HIGH LOW HIGH LOW Complexity related to psychosocial factors LOW HIGH HIGH LOW HNHB LHIN Programs Assess Restore Assess Restore Reactivation Assess Restore Slow Stream Rehab Convalescent Care Complex Care Restorative Stream Inpatient Rehabilitation Deb/Med Complex Hospital Based Rehabilitation Maximum LOS 90 days (Assess Restore, SSR) 90 days (Convalescent Care) Target LOS 45 days 45 days 21 days Intensity of Therapy Level of Participation in Rehabilitation Therapies Frequency of Physician Assessment Minimum 1 3 hours per day Low 30 minutes to 1 hour per day On admission and weekly follow up or as clinically necessary Minimum 1 3 hours per day Low to Moderate Typically 30 minutes to 2 hours per day On admission and weekly follow up or as clinically necessary Minimum 3 hours / day High Typically 3 hours per day Daily Set by patients diagnosis and goal Greater than 3 hours / day High 3 hours per day Daily 11

12 Recommendation #1 - The Restorative Stream Working Group recommends the following Definition, Eligibility and Expectations of the Program for groups 1 and 2 noted above. Definition Patients with multiple medical and/or functionally complex condition(s) who are expected to benefit from interventions provided by an inter-professional team, with clearly articulated functional improvement goals and/or, goals that address remediation of barriers to be discharged home Overall Eligibility Criteria 18 years of age or older Needs daily skilled assessment by an inter-professional team Requires 24/7 nursing care Medically stable: o The patient has completed the acute phase of illness o The major portion of diagnostic tests for the patient has been completed or the results of the diagnostic tests will not affect participation in restorative program o Does not require daily physician visit Patients being considered for admission from an acute care hospital program have had their reason for their acute care visit defined, addressed and communicated to the patient. Presence of functional consequences of physical and/or cognitive impairment Physical tolerance and cognitive ability that permits participation in programming Clearly defined goals have been established (including a date of discharge). Anticipated discharge to home or community setting (not including LTC) Expectations of the Program Reasonable access to necessary consultations and appointments as required Seen by most responsible health professional physician, registered nurse extended class or physician assistant - within accordance to the Public Hospitals Act and the Long Term Care Home Act. Initial plan of care identified at time of admission Access to full range of inter-professional team services (includes a core team and consulting services) Applying the Methodology Phase 1 Sizing of Restorative Beds Step 1 Determine Current Utilization of Restorative Care Beds Incorporating the patient populations that utilize the Assess and Restore, Assess Restore Rehabilitation, Slow Stream Rehab, Convalescent Care, and Complex Care Restorative stream under one Restorative umbrella with a common new definition and eligibility criteria would facilitate the identification of individuals requiring restorative services and matching them with the appropriate resources in a timely manner. At this point the Restorative Stream Working Group noted that the population that accessed the debility/medically complex beds, while similar, experienced a shorted LOS. As such the Restorative Stream Working Group agreed to defer the sizing of these beds to the Rehab Task Group. 12

13 It is important to note that implementation of the Complex Care plan was not fully implemented at all sites which impacted the ability of some sites not being able to submit data. Based on the current bed map and utilization up to January 2013, an increased demand for Restorative streams has been noted, along with a decrease in demand for the Medically Complex Stream (Appendix E). Step 2 Adjust for Changes in Prevalence of Health Conditions This methodology made the assumption that there would be no quantifiable change in the health status of the population over the next five years. Step 3 Address Unmet Need The methodology includes an assumption that the unmet need is demonstrated by: the continued demand and utilization of the assess restore, slow stream rehabilitation and convalescent care capacity that were excluded from the complex care report; and the average number of individuals ALC to restorative, convalescent care, LTLD (CC and Rehabilitation), AR and SSR over a 24 month trend 9. A review of data revealed approximately 48 patients per month across the HNHB LHIN were designated ALC to a restorative type program. A review of wait times for closed cases showed a median wait time for restorative type programs of approximately five days (January 16, 2013 data pull volume of closed cases 2054) Source WTIS ALC. This methodology did adjust for a wait time for the population waiting greater than the median wait time of five days. It is noted that ongoing monitoring will continue to be required due to the multiple changes occurring in the system. Step 4 Address Advances in Health Care This methodology recognized a number of initiatives that are underway or being planned that are intended to have an impact on individuals preventing or reducing the degree of functional decline seniors experience during an admission to hospital. These include but are not limited to: falls prevention programs, senior friendly hospital initiatives, optimize use of ambulatory based or in home care over hospitalization e.g. hospital at home program, interrai early intervention screener, and health promotion and wellness programs. Step 5 Address Changes in Scope of Practice/Delivery of Health Services This methodology made the assumption that there will be a shift to move inpatient restorative programs to outpatient community based restorative programs and convalescent care resources in the community over the next five years. This shift together with the impact of initiatives to prevent or reduce the degree of functional decline the number of restorative inpatient beds will reduce the demand allowing for a reduction in restorative inpatient beds. Step 6 Adjust for Population Changes (Growth and Aging) A review of population projections from show that the overall HNHB LHIN population will increase by 59,189 - of which 11,324 will be 75 years or older (6,623 will be 85 years and older) refer to Table 6. 9 HNHB LHIN ALCIS for Calendar years 2011 &

14 Table 6: Projected Population Counts for HNHB LHIN by Country and Age from Projected Population Counts for HNHB LHIN and by County and Age Group from 2012 to 2017 Age group Hamilton Niagara Haldimand & Brant Halton HNHB LHIN Norfolk <15 84,756 84,913 66,534 67,333 17,311 16,922 25,073 26,081 99, , , , , , , ,405 39,645 38,141 55,656 57, , , , , , , , ,917 34,348 33,291 39,543 40, , , , , ,791 53,289 43,656 51,988 10,895 13,175 11,368 14,790 38,348 47, , , ,109 29,142 27,716 29,283 6,302 6,895 6,835 7,242 22,652 26,442 78,833 83, ,176 15,349 12,632 14,738 2,535 3,042 3,232 3,643 9,732 12,920 35,856 42,479 Total 540, , , , , , , , , ,478 1,425,871 1,485,060 Change in Projected Population for HNHB LHIN and by County and Age Group from 2012 to 2017 Age group Hamilton Niagara Haldimand & Brant Halton HNHB LHIN Norfolk Number % Number % Number % Number % Number % Number % < % % % 1, % 12, % 5, % % % -1, % 1, % 24, % 6, % , % 1, % -1, % % 20, % 9, % , % 8, % 2, % 3, % 9, % 26, % , % 1, % % % 3, % 4, % 85+ 2, % 2, % % % 3, % 6, % Total 16, % 13, % % 7, % 74, % 59, % Sources: Pop Proj Summary LHIN, Ontario Ministry of Health and Long-Term Care, IntelliHEALTH ONTARIO. Pop Proj Summary County, Ontario Ministry of Health and Long-Term Care, IntelliHEALTH ONTARIO. Note: Based on population projections from the Ontario Ministry of Finance, the lowest level of data available by geography is by county. County level data does not sum to the HNHB LHIN total as counties do not directly map to the HNHB LHIN boundaries. For example, data for Burlington is included in the population projections for Halton and all of Norfolk County is included in the projections for Haldimand and Norfolk. A review of HNHB LHIN hospital acute care discharges in 2012 showed that there were approximately 21,000 individuals 75 years and older and accounted for 30,172 discharges. Based on the population projections for 2017 (126,563) the number of individuals 75 years and older discharged is projected to be 23,142 accounting for 33,375 discharged if all other factors stay the same, an overall increase of 3,193 discharges. The methodology, while recognizing the projected increase in hospitalization by individuals 75 years and older for 2017, made the assumption that a culture shift in how care is provided to seniors in hospital will occur over the next five years. This combined with the early recognition of high risk seniors and the shift to community and outpatient care will bend the curve in demand for hospital based restorative care and will offset the proportion of projected population 75 years or older that would require the same level of hospital based restorative care. The impact may potentially decrease the number of beds required. Step 7 Apply Target LOS 45 days 14

15 Step 8 Apply Target ALC (Alternate Level of Care): This methodology did not adjust of the ALC rate for acute and complex care. Acute 11% Complex Care ALC 17% It is important to note that the target ALC rates are overall HNHB LHIN rates and some sites have achieved an ALC rate below these, while others continue to be above the target rate. Recommendation #2: That LHIN hospitals continue to identify and implement strategies that will result in a sustainable ALC rate in Complex Care of 11% or lower. Step 9 Calculate Bed Equivalents Target 95% occupancy Assumption the unmet need is demonstrated by: Current restorative capacity located in Assess Restore and Slow Stream rehab programs located within permanent locations across the LHIN, Average number of individuals ALC to restorative programs that experience waits longer than five days, and Assess Restore beds at St. Joseph s Villa are located at a site that could not be considered permanent. 15

16 Steps Step 1 Step 2 HNHB LHIN Restorative Bed Sizing Adjustment Factors for Consideration Determine current utilization Adjust for changes in prevalence of health conditions Description A review of existing restorative bed capacity and utilization identified: 220 restorative beds in existing complex care beds at 90% occupancy 134 AR/SSR beds at 91% occupancy 35 Convalescent Care beds assuming a 92% occupancy Total = 389 This methodology made the assumption that there would be no quantifiable change in the health status of the population over the next five years Step 3 Address unmet need 134 AR/SSR operational in individuals waiting > five days for access to restorative beds for an average LOS of 45 days 10 equates to a 3.3 bed gap. Step 4 Step 5 Step 6 Address advances in health care Address changes in scope of practice/delivery of health services Adjust for population changes (growth and aging) Step 7 Apply target length of stay Target average LOS is 45 days. This methodology made the assumption that the impact of advances in health care would have a five year trajectory. This methodology did not adjust for the anticipated shift to community rehab. This methodology made the assumption that a culture shift in how care is provided to seniors in hospital will occur over the next five years. This combined with the early recognition of high risk seniors and the shift to community and outpatient care will bend the curve in demand for hospital based restorative care and will offset the proportion of projected population 75 years and older that would require the same level of bedded restorative care. Step 8 Step 9. Apply target ALC Apply target ALC rate - This methodology has not adjusted for the ALC target. (Alternate Level of Care) rate Calculate bed equivalents 389 existing restorative capacity as noted in step 1 + four beds to address wait list Total required restorative capacity = 393 (which is a gap of 14 beds) 10 Source: HNHB LHIN ALCIS & CCO WTIS Calendar Years 2011 & 2012 The 14 bed gap will be reduced by the following: + 28 convalescent care beds approved in five beds through adoption of a targeted occupancy rate of 92% + nine based on the assumption that NGH s restorative needs are being currently in their SSR program Total required restorative capacity after adjustments = 351 As a result of the above adjustments, the system has excess capacity of 28 beds. Reducing the ALC rate in complex care to 11% will result in an additional 11 beds becoming available to the system for restorative care which will result in excess capacity of 39 beds. 16

17 Assumptions: Occupancy of convalescent care beds is > 97%. Occupancy rate reported by hospitals for their restorative beds reported on the CC implementation reports. Restorative beds in CC are the beds hospitals have identified as restorative and are admitting by streams. The HNHB LHINs Complex Care Report An Integrated Program for Complex Care released in June 2010, recommended the sizing of 221 restorative care beds and 141 medical complex beds. Current utilization and demand for restorative care bedded programs demonstrate a need greater than that projected in the complex care report. Current restorative beds operating in complex care (393 vs. 220) demonstrate a gap of 173 beds. Assuming the continued operation of AR/SSR bed capacity of 124 beds and the 35 convalescent care beds, the gap is reduced to 14 beds. The 14 bed gap will be further reduced by the following: + 28 convalescent care bed s coming into the system in beds through adoption of a targeted occupancy rate of 92% + 9 based on the assumption that NGH s restorative needs are being currently in their SSR program As a result of the above adjustments the system has excess capacity of 28 beds. Note: these numbers have not been adjusted for the 13 beds at NHS that are currently on hold. Reducing the ALC rate in complex care to 11% will result in an additional 11 beds available to the system for restorative care and will result in excess capacity of 39 beds. RECOMMENDATIONS Recommendation #1 - The Restorative Stream Working Group recommends the following Definition, Eligibility and Expectations of the Program for Groups 1 and 2. Patients with multiple medical and/or functionally complex condition(s) who are expected to benefit from interventions provided by an inter-professional team, with clearly articulated functional improvement goals and/or, goals that address remediation of barriers to be discharged home Overall Eligibility Criteria: 18 years of age or older Needs daily skilled assessment by an inter-professional team Requires 24/7 nursing care Medically stable: o The patient has completed the acute phase of illness o The major portion of diagnostic tests for the patient has been completed or the results of the diagnostic tests will not affect participation in restorative program o Does not require daily physician visit Patients being considered for admission from an acute care hospital program have had their reason for their acute care visit defined, addressed and communicated to the patient. Presence of functional consequences of physical and/or cognitive impairment Physical tolerance and cognitive ability that permits participation in programming Clearly defined goals have been established (including a date of discharge). Anticipated discharge to home or community setting (not including LTC) 17

18 Expectations of the Program: Reasonable access to necessary consultants and appointments as required Seen by most responsible health professional physician, advances practice nurse - within 24 hours of admission to the program and in accordance to the Public Hospitals Act and the Long Term Care Home Act. Initial plan of care identified at time of admission Access to full range of inter-professional team services (includes a core team and consulting services) Recommendation #2: That LHIN hospitals continue to identify and implement strategies that will result in a sustainable ALC rate in Complex Care of 11% or lower. Recommendation #3: That each individual LHIN restorative program aims for an occupancy target of 95%. Recommendation #4 That LHIN s current restorative capacity be monitored for demand and utilization on a quarterly basis. Increases in demand must be evaluated against hospital s performance on implementing strategies to reduce cognitive and functional decline. 18

19 Appendix A Hamilton Niagara Haldimand Brant (HNHB) Local Health Integration Network (LHIN) Alternate Level of Care (ALC) Steering Committee - Restorative Stream Working Group Terms of Reference - January Purpose: To review the LHIN s bedded restorative resources, taking into consideration the findings and recommendations from the Walker and Senior Friendly hospital reports; to reaffirm the number of inpatient restorative beds needed to meet the needs of individuals requiring restorative care services prior to discharge from hospital now, in the next 5 years and to provide clarity as to how the populations in the current restorative care services differ. For this working group restorative beds are defined in these streams: restorative stream in complex care, debility, medically complex and geriatric stream(s) in rehab, convalescent care, assess restore, and slow stream rehab. Goals: To ensure individuals that require restorative care have timely access to these services. To ensure bedded restorative resources are optimized by the appropriately streamed individuals. To have a clear understanding and ability to delineate between bedded restorative streams. Actions: Review population health data, Walker report, Senior Friendly Hospitals report and any other relevant reports. Determine the bedded restorative streams and needs for the HNHB LHIN population now and in the next 5 years (including sizing and siting) based on population needs, best practices, and clinical outcomes. Deliverables: Inventory of current and planned restorative beds. Define and delineate bedded restorative streams. Prepare a final report with recommendations for submission to the HNHB ALC Steering Committee. Membership: Working group membership is comprised of decision makers from a variety of post-acute restorative care settings, including: Assess & Restore, Slow Stream Rehab, Convalescent Care, Complex Care, Rehab and the HNHB LHIN. Members: 2 members from HNHB LHIN Assess/Restore SSR Committee 2 members from HNHB LHIN Complex Care task force 4 members from HNHB LHIN Rehab Task Group 1 member from Convalescent Care Program 1 member from CCAC if not already identified Complex Care Coordinator Geriatrician Ex officio: Patricia Ciccarelli, Director, Finance, HNHB LHIN Rosalind Tarrant, Director, Access to Care, HNHB LHIN

20 Kelly Cimek, Epidemiologist and Information Controller, HNHB LHIN Shirley Stewart, Advisor, Health System Transformation, HNHB LHIN Cheryl Cullimore, Advisor, Access to Care, HNHB LHIN Reporting Relationship and Membership Accountabilities: Working group will be accountable to the ALC Steering Committee Working group members represent their committee and their expertice with respect to decisions made by the group. Members are responsible for attending meetings, advising on items presented for discussion, reviewing and providing feedback on materials as distributed. The working group will be required to report back monthly to the ALC Steering Committee regarding their progress. Decision Making: The working-group decision will be based on consensus. If consensus is not possible, the chairperson may call a vote. Decisions arrived at by voting will be recorded with the percentage in favor of the decision and the content of any opposing positions. Decisions by consensus or vote require a quorum, set at 50% of working group members. Meetings: Working-group meetings will be scheduled bi-weekly. Frequency may be changed by the chairperson to meet objectives set out in these terms of reference. The meetings will continue for a period of two to three months, from January 2012 to February 2012, at which time the objectives set out are to be met.

21 Appendix B Hamiltion Niagara Halimand Brant (HNHB) Local Health Integration Network (LHIN) Restorative Stream Bed Working Group Membership list Jennifer Kodis Rehab Task Group HHS Lina Rinaldi Rehab Task Group BCHS Jane Loncke - CHAIR CC Task Force SJHH Jane Rufrano CC Task Force HDS Kathryn Leatherland Assess Restore CCAC Heather Patterson Assess Restore NHS Michelle Draper Convalescent Care & LTC Shalom Village Nesathurai Dr. Shanker Rehab Task Group HHS Physiatrist Ciccarelli, Patricia Finance HNHB LHIN Cheryl Cullimore Access to Care HNHB LHIN Shirley Stewart Health System Transformation HNHB LHIN Kelly Cimek Epidemiologist/Information Controller HNHB LHIN TBA Geriatrician February 2012

22 Bedded Restorative Programs - Current State Hotel Dieu Shaver Health and Norfolk General Hospital Rehabilitation Centre Hotel Dieu Shaver Health and Rehabilitation Centre Niagara Health System (5 hospital sites) Niagara Heatlh System (5 hospital sites) Wellington Park Wellington Park Brant Community Healthcare System Brant Community Healthcare System Brant Community Healthcare System Hamilton Health Sciences Hamilton Health Sciences Dundurn Convalescent St. Joseph's Healthcare Hamilton Shalom Village St. Joseph's Villa Actual Core Team Members Slow Stream Rehabilitation Beds PT,OT,PTOTASS'T,SLP, REC TH,NUR Restorative Inpatient Beds in Complex care Nursing, Physiotherapist, Occupational therapist, Speech pathologist, rec therapy, social work, pastoral care, dietician Slow Stream Rehabilitation Beds Nursing, Physiotherapist, Occupational therapist, Speech pathologist, rec therapy, social work, pastoral care, dietician Restorative Inpatient Beds in Complex care PT,OT, PTA/OTA Rec Therapy, Social Work discharge Planning, Speech, Dietician, Nursing, NP Assess Restore Beds PT,OT,PTA/OTA, Rec Therapy, Nursing,Social Work, Slow Stream Rehabilitation Beds/Reactivation Beds Assess Restore Beds *Inpatient Rehabilitation Bed Classifications; Debility/Medically Complex 6 6 PT,OT,OTA/PTA,RN,RPN, Unit Clerk, Physician, Speech Language Pathologist, Dietician, Social Worker, *******Physiatrist Restorative Inpatient Beds in Complex care PT, OT, RT, OTA/PTA, RN, RPN, Unit Clerk, Physician, Speech Language Pathologist, Dietician, Social Worker Assess Restore Beds PT, OT, RT, OTA/PTA, Social Worker, (Nursing/Clerical Resources provided by CC Unit), Physician, Speech Language Pathologist, Dietician, Social Worker Inpatient Rehabilitation Bed Classifications; Debility/Medically Complex Nursing, OT, PT, SLP, RD, SW, Rec Therapy, Pharmacy, Geriatricians, Family Physician Restorative Inpatient Beds in Complex care Nursing, OT, PT, SLP, RD, Rec Therapy, SW, Pharmacy, Family Physician Convalescent Care Beds Program Manager; Charge Nurse; Medication nurse; PSW's; Social Worker; Dietician; Occupational Therapist; Physiotherapist; Physiotherapist Assistant; 2 Physicians; 2 Restorative Aids; Recreational Worker; CCAC CM Inpatient Rehabilitation Bed Classifications; Debility/Medically Complex Convalescent Care Beds Assess Restore Beds Phyiotherapists, Occupational Therapists, Recreation Therapist, SLP, SW, Physiatrist, Hospitalist,RN, RPN, Rehabilitation Assistants Program Manager, Nursing, PSW, PT, PTA, Recreation, Dietitian, CCAC CM, Physician, Social Work, SLP by consultation see attached Actual Minimum Physician visits per week 3 2 per week 2 per week Patients with Hospitalist as MRP seen Daily, patients with Family Doctor varies depending on Physician 2 unless physician called for change in care needs 2 unless physician called for change in care needs Hospitalist: 1/week: Physiatrist: 1/week as required Therapy hours per day hrs per day 2 hrs per day hour 1 hour 1.39 hrs/day.99 hrs/day 1.85 hrs/day hrs - 7 days per week 3h incl OT,PT, Rec Therapy Nursing ratios on days 5:01 1 to 5 1 to 5 9 to 1 1:06 1:13 1:5 1:5(4) 1:5 1:04 1: Reg.Staff per PSW per 20 Bi Weekly, and other visiting physicians available x3 per week as needed 4 physicians each visit unit at least weekly 5 hrs x 5 days per week 22.5 (average) 5-6:1 2.0 Registered Staff per 15 3:51(registered staff only) Nursing ratios on nights 10:01 1 to 13 1 to to 1 1:06 1:13 1:8 1:9 1:7 1:08 1:15 1 Reg.Nurse; 1 PSW 8-9:1 1 RN, 1.5 PSW 1:51(registered staff only) Nursing Model RPN, PSW) (RN, RN/RPN RN, RPN RN, RPN RN/RPN/PSW RN/RPN/PSW 1 RN, 1 RPN, 2 x PSW 1 RN, 1 RPN, 2 x PSW RN,RPN RN,RPN RN,RPN RN, RPN RN, RPN 3 RN's, 2 RPN's, 5 PSW per 24 hrs Rn/Rpn 3 RN/RPN and 5.5 PSW per 24 hours Length of Stay target (days) < days days days see attached Admission / Discharge Criteria (attach as appendix) attached see attached see attached Admissions Criteria.doc DC Criteria.doc attached attached Michelle Draper will be attaching this piece Fuctional goals; Medically stable; able and willing to participate in 2h or more programming/day; meet goals/ return home in 4 weeks or less Sent Jan 26, 2012 Discharge Destination defined (based on accepted admission) home home home home home home home home home home home home home home home home Percent of patients discharged to home (home includes retirement home) or to defined admission destination in 2010/ % % 75.30% 42.69% Home with or without Home Care; 53.2% if you include Retirement Homes 86.81% 47% % %*** 52%** 83% 92% 70% (discharges to acute care also count as a dc to another level of care) 68.10% 76% home % hospitals- 11.7% LTC- 8.5% rehab- 4.3% 74.07% Budgeted/Funded Beds in 2010/ , , (ALL RCGS) 15 41/month Patient Days in 2010/11 3,660 10,184 4,363 63,970 6, days days , 2854 days ,130 12, days actual patient days days ( # of census days; 5475 days - # of lost bed days; 431. This number will include the residents who were admitted before April 1/ 2010 and were present in the facility after April 1/2010) 14,698

23 Hotel Dieu Shaver Health and Norfolk General Hospital Rehabilitation Centre Hotel Dieu Shaver Health and Rehabilitation Centre Niagara Health System (5 hospital sites) Niagara Heatlh System (5 hospital sites) Wellington Park Wellington Park Brant Community Healthcare System Brant Community Healthcare System Brant Community Healthcare System Hamilton Health Sciences Hamilton Health Sciences Dundurn Convalescent St. Joseph's Healthcare Hamilton Shalom Village St. Joseph's Villa *Inpatient Rehabilitation Bed Classifications; Debility/Medically Complex Inpatient Rehabilitation Bed Classifications; Debility/Medically Complex Slow Stream Rehabilitation Beds Restorative Inpatient Beds in Complex care Slow Stream Rehabilitation Beds Restorative Inpatient Beds in Complex care Assess Restore Beds Slow Stream Rehabilitation Beds/Reactivation Beds Assess Restore Beds Restorative Inpatient Beds in Complex care Assess Restore Beds ALC Days in 2010/11 0 not available not available 36, %***** ,004 Mean Occupancy Rate in 2010/11 Bed Equivalents based on 95% Occupancy 73% 90% 79.6 in 2010/ /12 9 months Restorative Inpatient Beds in Complex care Convalescent Care Beds We had a total of 1289 ALC days in our internal rehab program for 2010/11. However, this 75.8 days; 6 Clients: 1- is for all rehab patients. 78 days; 2-54days; 3-84 This is not available by days; 4-85 days; 5-84 RCG grouping days; 6-70 days 96.80% 83.60% 90% 90% 92%********* 90% 67% 98.8% 98.6% 90% 73.85% (By Service all RCG groups Data Source: Finance Occupancy File) ********** beds 19 out of Mean LOS in 2010/11 31days (median = 20) 23.4 (median = 19.9) 59 days days , 51 days Total Number of Admissions in 2010/11 97 not available 104 1, in in 2010, 55 in 2011 Age Range of Admissions not available yrs yrs in in 2010, in 2011 Mean Age of Admitted patients Percent of Patients > 65 years of age Percent of patients outside local catchment area (eg City/Town) Budgeted/Funded Beds in 2011/12 in Operation not available yrs yrs 80 in in 2010, 81 in 2011 not available 89.42% 80% 86.18% % in % in 2010, 96% in not available not available 41.12% (based on outiside the local catchment of each NHS site) 0.92% (If you consider the catchment area to be Niagara Region) 27*** days days 59.2 days; this has increased since we have been getting more acutely ill referrals Inpatient Rehabilitation Bed Classifications; Debility/Medically Complex Convalescent Care Beds Assess Restore Beds 90 days - These days accounted for by 5 residents as follows: 20 days 3 days 17 days 26 days 24 days days ( The mean LOS covers residents admitted during the period Apri 1/2010- March 31/2011. N/A 92.13% 98.22% ( 193 discharges) *** 35-98** yrs - 99 years *** 77** N/A 75%*** 83%** 88% 3% 26% 76% 83% (Data Source: 3M) 76.60% N/A 3.5% ****** not available not available 12.5% 12% 4.40% Approx 10% (Data Source: 3M) Berniece called CCAC to provide this informationwaiting for their call back (ALL RCGS) 15 April-Aug-41 Sept-Mar years N/A Note: Catchment area can only be determined on direct admits and not on transfers in from GNG CC to GNG Assess Restore 40.28% (if you consider the catchment area to be Niagara Falls/Chippawa) Notes:*All data provided is for all Rehab Inpatients, not only for Medically Complex or Debility. **2010/11 Data Unavailable. Data is for the period of April 1, 2011 to December 31, ***Based on 2010/11 NRS Data. ****Therapy Hours/Pt Days *****ALC Days for Restorative Care alone are not available. Number represents the percentage of Patient Days that are ALC for all CC Beds in 2010/11. ******Percentage of Patients outside of HNHB LHIN *******Physiatrist is the Chief of the Inpatient Rehab Program ********Therapy Staff, RN,RPN and Unit Clerk are Staffing Resources directly assigned *********Rate is not 100% due to beds blocked to accommodate patients in need of **********Bed Equivalents calculated based on 2010/11 Data. 2011/12 Occupancy currently 93% as of Q3