Central East LHIN Assess and Restore Status Update

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1 Central East LHIN Assess and Restore Status Update Indra Narula, System Design and Implementation July 2014

2 Presentation Objectives Assess and Restore Policy o Background and Rationale o Funding Overview Share and reflect on Central East LHIN Assess and Restore projects 2013/14 o Overview and Key features o Successes and Lessons Learned Recommendations Questions and Discussions 2

3 Patient Story Susan*, a patient over the age of 65, was admitted to Assess & Restore directly from emergency after presenting with leg pain. She had had 13 hospital visits in 12 months with various somatic symptoms. She was examined by the emergency physician and he felt she did not require acute care admission. Nevertheless, after three visits to emergency that same week, she was referred to the gerontology Nurse Practitioner (NP) for assessment. Her self-expressed goals were to become more social and that she struggled with anxiety. The NP identified she was dealing with a number of complex issues and because of the frequent visits to emergency, felt that the root of Susan s problems had not been previously managed. She was admitted to Assess & Restore where a Comprehensive Gerontological Assessment was completed by the interdisciplinary professional team during her hospital inpatient stay. Ten different gerontology syndromes were identified, including anxiety, frequent falls, Polypharmacy and COPD. 3

4 Patient Story A comprehensive treatment plan of care for each of the Gerontology Syndromes identified was developed based on Susan s own goals, including changes to medications which had contributed to her anxiety, tools to assist with memory, physiotherapy, and assistance from a social worker. In addition, a comprehensive transition plan was developed with her caregivers in the community. * name changed for patient confidentiality 4

5 Assess and Restore Policy BACKGROUND AND RATIONALE 5

6 Background and Context Ontario s 1.9M seniors account for 14% of the population but utilize 45-50% of health care resources. o Only a small percentage of the seniors in Ontario are frail (~ 8%, or 150,000 persons), but their health care costs are significant. An estimated 40,000 of this frail cohort are estimated to have reversible functional loss Even when preventative programs are in place (e.g. community exercise and falls prevention classes, Senior Friendly Hospitals initiatives, Rapid Response Nursing Programs, Nurse-Led Outreach Teams, Home First, Health Links), frail seniors are vulnerable to stressors that can lead to hospitalization and rapid functional decline Unaddressed, this functional decline can lead to permanent loss of selfcare abilities in Activities of Daily Living (ADLs) (esp. toileting, bathing, and ambulation) and result in the need for long-stay Long-Term Care Home (LTCH) placement 6

7 Background and Context The Assess and Restore approach to care targets: Community-dwelling high-risk frail seniors with restorative potential who have experienced reversible functional loss and for whom home- and/or ambulatory-based rehabilitative care alone is not a safe and effective option; and Involves the use of standardized processes for assessment and system navigation for frail seniors to sub-acute beds in hospitals and LTCHs to restore their strength and mobility and enable them to return home The Central East LHIN serves 1.5 M residents which includes 200,000 seniors; 92,000 seniors that are 75+ and 9,200 frail seniors (using a 10% definition) 7

8 Assess and Restore - System of Senior Care 8

9 Policy Directions The five essential elements of an Assess and Restore approach to care are: 1. Screening: of at-risk seniors in community, primary care, and hospital settings 2. Assessment: to determine whether a person is at high risk for loss of independence, has restorative potential, and requires facility-based (inhospital or in-ltch) care (vs. in-home- and/or ambulatory-based care) 3. Navigation & Placement: to the appropriate home and/or ambulatory care and only as necessary, to facility-based Assess and Restore care 4. Assess and Restore interventions: based on best-practice assessments, therapies and treatments 5. Transition home: to ensure gains made are retained 9

10 Assess and Restore Policy Directions Alignment with Central East LHIN Initiatives Assess and Restore Policy elements Central East LHIN Initiatives Early Risk Identification Exercise and Falls Prevention Programs Hospital Geriatric Activation Standardized Assessments Sector-wide implementation of RAI-Community Homecare (CSS), RAI-Home Care (CCAC), RAI-Long Term Care assessments Enhanced CCAC role GAIN Clinics Timely Navigation Home First Implementation Resource Matching and Referral (RMR) Community Enhancements Standardized Care Central East Regional Specialized Geriatrics Senior Friendly Hospital Initiatives (LHIN-wide) Geriatric Activation and Hospital Transitional Care programs Enhancement to LTC Convalescent Care Programs GAIN Community Clinics Coordinated Transition Home Home First Rapid Response Nursing Virtual Ward 10

11 Assess and Restore FUNDING OVERVIEW 11

12 Funding Overview The Ministry provided the LHINs with one-time targeted funding in 2013/14 to support implementation of Assess and Restore On December 16th, 2013, the Ministry allocated $8M one-time targeted funding to Ontario s LHINs to expand Assess and Restore capacity and access. The Central East LHIN allocation was $ 947,100. The Central East LHIN provided funding to the hospitals investing in expanding capacity (including: education, planning, home adoption, increase ambulatory or home services), access and development of provincial standards 12

13 Funding Central East LHIN Assess and Restore Projects RVHS Ambulatory Rehab $32,000 CMH Ambulatory Rehab $18,500 PRHC - Ambulatory Rehab $18,825 TSH - Ambulatory Rehab $190,000 RMH - Ambulatory Rehab $14,805 RMH - Education $47,810 HHHS - Education $15,000 NHH - Education $41,000 NHH Care Coordination $203,800 LH Care Coordination $365,360 13

14 Assess and Restore CENTRAL EAST LHIN 2013/14 ASSESS AND RESTORE PROJECTS 14

15 Assess and Restore Projects Overview/Successes/Lessons Learned Hospital - Project CMH Enhancement of Physiotherapy Services PRHC Assess and Restore: Increased Physical Therapy Weekend Overview/Key Deliverables Functional decline will be reduced by promoting continuity of physical services. Therapy services to be increased on weekends Rehabilitation Service would be enhanced to provide weekend coverage on the Medical Units during Q4 January April 2014 Successes More patients in the Northumberland, Peterborough and Hastings County were assessed and assigned appropriate physical care. Patients received service on all days of the week including weekends 7 day rehabilitation model improved patient outcomes, reduced length of hospital stay and increased rehabilitation workload, demonstrating increased efficiency and access to care Lessons Learned Continuity of physical services on all days of the week allowed physiotherapists more time for admission assessments. Early mobilization improves patient outcomes and the patient s readiness for discharge. 15

16 Assess and Restore Projects Overview/Successes/Lessons Learned Hospital - Project HHHS MOVE ON 3 Moments of Mobility RVHS - Additional PT services delivered on weekends Overview/Key Deliverables Successes Lessons Learned Explore, develop and implement the evidenced based strategy MOVE ON related to interprofessional practice that supports 3 moments of purposeful activity per day per patient- (geared to patients over the age of 65) Increase physiotherapy services provided to inpatients on the weekend with a focus on those who would significantly decline in function if not seen, specifically the frail elderly population Early mobilization focused on an interprofessional approach helped prevent 3 serious complications of hospitalization that affects older adults (delirium, functional decline and falls). All patients benefited from this initiative being imbedded in the care plan as a standard of care Patients seen sooner after admission or surgery, timely assessments, increase in physiotherapy and assistant resources, enabled patients to mobilize more timely to prevent deconditioning resulting in the activation of a greater number of patients. 16 Good collaboration with regional partner RMH and staff helped to build capacity and knowledge. This model helped build capacity amongst staff teams and reduced education costs The ability to provide additional therapy on the weekend enabled more timely assessment and treatment to prevent deconditioning on the inpatient units which is especially important during the winter months when there are many admissions from illness and/or falls

17 Assess and Restore Projects Overview/Successes/Lessons Learned Hospital - Project NHH a) Norms of Gerontology Best Practice and b) Assess and Restore Overview/Key Deliverables Building a gerontological foundation to create culture change with new care processes and service delivery changes Optimizing seniors remaining in their homes using an assess and restore model of care that TSH - Increase focuses on functional and Assess and cognitive abilities and Restore Capacity integrates acute care and community services in the transition of care from hospital Successes Assess and Restore was Gerontological NP led involving collaboration with GEM. Gerontological NP led Assess and Restore provided the role of comprehensive gerontological assessments and provided opportunity to address geriatric syndromes that accompany chronic disease and ageing Decreased length of stay for ACE patients to integrate back into the community. Increased collaboration and understanding between hospital and community sectors 17 Lessons Learned Significantly positive effect on patient flow, decreased utilization of acute care. Use geriatric syndrome to improve length of stay, re-admission rates, patient flow and ALC rates. Admitting from emergency directly to Assess and Restore was ideal Integration of services is enabled through a continuum not a hand off. The value of onsite support increased integration outcome for patients. Collaboration across the interprofessional team supported care plan into the community.

18 Assess and Restore Projects Overview/Successes/Lessons Learned Hospital - Project LH - Medicine Patient Care Navigator and Assess and Restore Team RMH a) Increase Assess and Restore Capacity and Interventions Overview/Key Deliverables Early connection with patients at risk for challenging discharge as defined by the Triage Risk screening tool (TRST) to support earlier intervention in care and care planning Extend Rehabilitation Assistant coverage on weekend for the walking program. Improve accessibility to timely assessment and therapy treatment time through provision of full complement of physiotherapy coverage Monday and Tuesday Successes Support in navigation of the patient s journey supported timely interventions in care and assurance that education and resources required by the patient for successful discharge were identified and reviewed with the patient and family as appropriate. Increased patient access in acute and post-acute care to the existing walking program on weekends with the goal to maintain patient functional gains and reduce functional decline. Increased timely access to physiotherapy services on Mondays and Tuesdays 18 Lessons Learned Better understanding of community resources and ability to access these is foundational to supporting successful transition to home/community. Further work with community partners and outcomes from Health links will support successful transitions. Mobilization is essential to maintain vulnerable elders function and strength. Access to appropriate mobility equipment (including bariatric) 7 days per week is required

19 Assess and Restore Projects Overview/Successes/Lessons Learned Hospital - Project RMH b) Increase Assess and Restore Capacity and Interventions Overview/Key Deliverables Explore, develop and implement program format and interprofessional care path for 3 Moments of Mobility. Work in partnership with HHHS for education rollout Successes Lessons Learned Early mobilization helped prevent 3 serious Secure Senior leadership support = complications of clear direction to all staff that this is hospitalization that affects a priority. Patient and family older adults (delirium, education and community functional decline and awareness of this initiative is key for falls). Awareness built and engagement expanded nursing role in mobilization 19

20 Key Lessons Learned Referral/Early Activation/Increased Coverage: o Early mobilization improved patient outcomes and the patient s readiness for discharge o The ability to provide additional therapy on the weekend enabled more timely assessment and treatment to prevent deconditioning on the inpatient units o The addition of increased physiotherapy services in the emergency department needs to be considered as an area for future expansion NP Roles for Assess and Restore o NP led Assess and Restore in collaboration with the GEM maximized efficiencies, capacity development and patient outcomes o NP led Assess and Restore provides a similar clinical foundation to Geriatrician services. NP led Assess and Restore was a critical support for primary care physicians and the broader health care team 20

21 Key Lessons Learned NP Roles for Assess and Restore o The NP led programs provided comprehensive discharge summaries to patients, family physicians, and caregivers such as retirement homes, nursing homes, and social workers and patients achieved smooth transitions to the community Supporting the continuum of care with a focus on quality o Assess and Restore is an appropriate component on the Central East LHIN Geriatric Assessment and Intervention Network (GAIN) continuum o Patient and family education and community awareness of this initiative is a key for engagement o The LEAN approach to system design was fundamental to developing a service model that is patient centred while considering hospital and community provider perspectives o Secure Senior leadership support = clear direction to all staff that this is a priority 21

22 Assess and Restore CENTRAL EAST LHIN CURRENT CONTEXT AND FUTURE RECOMMENDATIONS 22

23 Central East LHIN context The Central East LHIN has made significant investments towards improving outcomes for seniors The investments along with the Assess and Restore programs are collectively intended to achieve optimal health for seniors Home First and investments in Home Care services Assisted Living for High Risk Seniors Adult Day Programs GAIN Community Teams Senior Friendly Hospitals Behavioural Supports Ontario Nurse Practitioners Supporting Teams Averting Transfers (NPSTAT) 23

24 What are the recommendations provided by the Central East LHIN to the MOHLTC? The implementation timelines were very short to address the questions related to positive patient outcomes Service delivery design of Assess and Restore needs to be established and expanded including the development of standardized outcome measures i.e. functional decline MOHLTC needs to consider funding timelines and nature of funding (onetime vs. ongoing). Ongoing funding commitment can increase the scope of services and could lead to best evidenced based gerontological practice for frail seniors Standardized Comprehensive Geriatric Assessments (CGA) should be used and encouraged for patients that are at risk for functional decline during hospitalization. Based on the results of CGA, interventions can be targeted to address the needs of seniors during hospitalization 24

25 Questions, Comments, Discussion THANK YOU! 25

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