Item Enhancing Care in the Community

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1 BRIEFING NOTE MEETING DATE: October 30, 2014 ACTION: TOPIC: Decision Item Enhancing Care in the Community PURPOSE: To provide information regarding enhancements to care in the community and recommend investments in advanced care planning, convalescent care, nurse-led outreach in long-term care, and community-based geriatric specialist nursing. ABP Initiatives: Creating a More Seamless and Coordinated Healthcare Experience Strengthen and maximize the current quality and capacity of community services. Remove barriers for people waiting for an Alternate Level of Care (target 9.5% ALC in hospitals) Improve care for seniors through implementing key recommendations of the provincial seniors strategy Improve the quality of care in long-term care homes Leading a Quality healthcare System using Evidence-Based Practice Expand and enhance integrated programs that ensure quality and deliver best practice care across the continuum of care in Hospice Palliative Care BACKGROUND INFORMATION: There are numerous efforts underway to continue to improve health outcomes, patient experience and value-for-money in community health care services. Recently, WWLHIN has made onetime investments to accelerate these improvements and ensure residents receive high-quality, integrated care. These investments include: Developing capacity and a collaborative approach to support seniors in need of addictions and mental health services through investing $45,000 with Canadian Mental Health Association, Waterloo Wellington Dufferin. This investment will foster cross-agency and cross-sectoral partnerships with stakeholders in mental health services, addictions, CCAC, acute care, long term care, emergency management, primary care, community support services, and specialized geriatric services; and

2 Enhancing access to care close to home using telemedicine through investing $8,000 with St Joseph s Health Care Guelph. In addition to these one-time investments, a number of other opportunities exist to accelerate improvements to care for residents aligned with advancing our local strategy and the provincial plan for the health care system. These investments are described in Appendix A. NEXT STEPS: Following the funding decision, efforts to implement these services will immediately commence to ensure residents receive the benefits of these investments as soon as possible. RECOMMENDATION: That the WWLHIN Board of Directors approve funding of: Up to $400,000 per year in each of 2015/16, 2016/17 and 2017/18 plus $180,000 in 2014/15 to Hospice Waterloo to develop and implement the Advanced Care Planning project across WWLHIN; Up to $325,000 annualized based funding starting in 2014/15 to provide 10 beds of convalescent care through existing long-term care stock in the Guelph area developed through a Request for Service process; Up to $21,500 annualized base funding starting in 2014/15 to St Joseph s Health Centre, Guelph to enhance the nurse-led outreach program; and Up to $240,000 annualized base funding starting on 2014/15 to Canadian Mental Health Association Waterloo Wellington Dufferin (CMHA WWD) to expand access to community-based geriatric specialist nursing. 2

3 Appendix A Description of Recommended Investments Advanced Care Planning (Hospice Waterloo) Up to $400,000 per year in each of 2015/16, 2016/17 and 2017/18 plus $180,000 in 2014/15 to Hospice Waterloo to develop and implement the Advanced Care Planning project across WWLHIN An Advanced Care Plan (ACP) is a plan that provides the resident, their family and caregivers an opportunity to consider what medical and social care a person would prefer, or refuse, during a time of crisis or end of life. This plan is more than a single document; it is an holistic view of the needs and wishes of a person during end of life care and should help to define the persons personal desires regarding their end of life. An ACP helps to facilitate conversation, provide direction and reflects a person s wishes. The Waterloo Wellington Advance Care Planning Education Program (ACPEP) is designed to build system capacity and enhance the quality of palliative care and patient/family experience for residents of Waterloo Wellington. It is a program that reaches community and health care settings as critical sites for engagement and education. Connecting community partners and health care providers is foundational for achieving substantive and meaningful change. As a full system approach, the Waterloo Wellington ACPEP can increase understanding and build skills to ensure correct advance care planning (ACP) practices are delivered across the continuum of care. ACP benefits residents and health care practitioners and once widespread, can contribute to more effective and efficient use of health care resources. As part of the workplan, the Steering Committee that would be established for ACP would help to define all the specific measurements and indicators, however planned outcomes include: Reduction of ALC days attributed to palliative care 85% clients receiving HPC services die in place of choice as documented on the collaborative/coordinated care plan 95% of residents with ACP on file in LTC Homes Health Care Provider experience, improved comfort and competencies in having ACP discussions 85% clients receiving HPC services die in place of choice as documented on the collaborative/coordinated care plan Improved end of life experience for residents, families and caregivers 3

4 This Advanced Care Plan strategy aligns with research completed by the Canadian Hospice and Palliative Care Association Model Guide to Hospice Palliative Care, helping to relieve patient suffering and improving end of life care for residents and their caregivers and family. A system wide Advanced Care Plan strategy also aligns with the provincial government s Advancing High Quality, High Value Palliative Care in Ontario, A Declaration of Partnership and Commitment to Action (the Declaration, Dec 2011). Convalescent Care Guelph (Long-Term Care Home TBD) Up to $325,000 annualized based funding starting in 2014/15 to provide 10 beds of convalescent care through existing long-term care stock in the Guelph area developed through a Request for Service process The Convalescent Care Program is a short-stay (maximum 90 days) program that assists people who have undergone surgery or who were ill, to recover their strength with the goal of returning back to their home to live independently. The CCP program provides 24-hour nursing care as well as access to an on-call physician, physiotherapy and occupation therapy services. In 2013 the WWLHIN increased capacity for convalescent care program (CCP) beds by adding an additional 10 beds to the system for a total of 25 convalescent care beds. This recognized that there are some individuals who can benefit from a period of time to convalesce after being discharged from hospital in order to return home. However, all 25 beds are currently located at Sunnyside in Kitchener, and none exist in the Guelph/Wellington area. The expansion of an additional 10 CCP beds advances the LHIN s strategic priority to improve coordination and transitions in care across the health system, by enabling residents to return to independent living at home after an acute health episode. To identify interest in delivering this service, the WWLHIN will issue a call for applicants from existing health service providers in the Guelph-Wellington area. It will be expected that the successful health service provider will integrate the convalescent care program into the wider continuum of transitional care services available in the WWLHIN. This includes sharing a common intake and assessment process with other WWLHIN funded transitional services, including Complex Continuing Care and Rehabilitative Care, in the same way that the program was expanded in

5 An additional 10 CCP beds would be found through a conversion of 10 existing long-term care beds, however it is anticipated that this opportunity will result in an impact to ALC by helping to transition residents to independent living back at home faster, and in a more appropriate care environment. Nurse-Led Outreach Program (St Joseph s Health Centre, Guelph) Up to $21,500 annualized base funding starting in 2014/15 to St Joseph s Health Centre, Guelph to enhance the nurse-led outreach program The Waterloo Wellington Nurse-Led Outreach Team (NLOT) was established in 2009 with three goals: Reduce resident transfers from Long-Term Care (LTC) to Emergency Departments/Hospitals for conditions which can be treated in LTC Home/community; Reduce hospital admissions for conditions which can be treated in the LTC Home /community; and Reduce hospital Length of Stay (LOS) for residents/patients who can be discharged to a LTC with support provided by the NLOT. The NLOT programs which are funded through a MOHLTC initiative are implemented in different ways across LHINs. The WWLHIN NLOT program operates and supports all 35 Long Term Care homes across the LHIN. The WWLHIN has recently reviewed the NLOT program compared to other NLOT programs and a further review with St. Joseph s Health Care, the lead on this program for services across the LHIN, is currently underway. Traditionally, funding for NLOT has been through one-time funding; however, in May 2014 the MOHLTC renewed its commitment to the NLOT strategy and program across the province by rolling this funding into base funding. The program and services (salaries) are funding through this initiative however other operating costs (travel, training, IT) are not and have been supported through one-time funding at the end of each fiscal year. As these system resources are now permanent, this additional funding for the operating costs for 5 nurses should also be permanent and rolled into base funding. 5

6 Community-Based Geriatric Specialist Nursing (CMHA WWD) Up to $240,000 annualized base funding starting on 2014/15 to Canadian Mental Health Association Waterloo Wellington Dufferin (CMHA WWD) to expand access to community-based geriatric specialist nursing Two separate pilot projects have been run in Waterloo Wellington to assess the opportunity and impact of geriatric-specialist nursing in the community on access and outcomes regarding geriatric assessment and care. In one pilot, a Nurse Practitioner (NP) worked in collaboration with local geriatricians, conducted comprehensive geriatric assessments, developed care plans, supported primary care to implement the identified care plans and monitored progress and/ or adjusted medications as needed. In addition to patients served in clinic, this NP Geriatric service included home visits as a core community service. In a separate pilot, two Geriatric Emergency Management (GEM) Nurses operating out of Cambridge Memorial Hospital alternately led a weekly geriatric assessment clinic out of the Grandview Family Health Team (FHT). This clinic was developed in response to the high number of patients who were being sent to the ED by their primary care provider to access a comprehensive geriatric assessment. As a result of these two programs, significant reductions in geriatric wait times were seen: Guelph and Cambridge wait times decreased from 5 months to 6 weeks, Kitchener wait times decreased from 18 months to 3 months, and urgent referrals were seen in hours instead of 1-3 weeks. An ongoing investment in geriatric nurse specialists in the community built on best practices will enhance access to geriatric services in the community while saving cost in acute care settings and decreasing wait times to access geriatricians. This disbursement aligns well with our annual business plan priorities of strengthening and maximizing the quality and capacity of community services, improving health equity by improving access to care close to home, and improving care for seniors by implementing key recommendations of the provincial seniors strategy. 6

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