1 Rehabilitation Services Integration Initiative North York General Hospital and St. John s Rehab Hospital Introduction Hospitals across Ontario have been experiencing a growing challenge in that many are increasingly unable to discharge patients in need of alternate levels of care (ALC) in a timely fashion. Patients requiring long term care, supportive housing or rehabilitation are often left waiting in acute care facilities for an appropriate bed to become available, causing backlogs that can result in increased wait times for emergency services. This inability to transition ALC patients across the continuum of care is often a symptom of a larger system capacity issue and health care partners need to collaborate to identify innovative solutions to resolve this challenge. The growing number of ALC patients, which are comprised of patients awaiting placement in longterm care facilities, short-term and long-term rehabilitation facilities, palliative care, complex continuing care, and convalescent homes, is a concern at North York General Hospital. On any given day, there are approximately 40 ALC patients in the hospital, and in NYGH s recent experience this number has ranged as high as 70 patients. This means that 12% of the acute care beds in the organization are being occupied by patients who need a different level of care, and when we experience large numbers of ALC patients, almost half our medical beds are being occupied by this patient population North York General Hospital (NYGH) functions in an integrated system with the objective of providing patients and their families with the right services, at the right time, with the right provider, at the right place and with the right cost. NYGH recognizes that it cannot be all things to all people and has made critical choices regarding its areas of clinical strength and investment by moving forward with four areas of strategic focus: cancer care, family and community medicine, care of the elderly and maternal newborn & paediatric care. St. John s Rehab Hospital (SJRH) is dedicated to rebuilding the lives of adults recovering from life changing illness or injury, by involving them in individualized rehabilitation programs focused on the whole person. SJRH is solely dedicated to rehabilitation, with a major focus on complex rehabilitation. The Central Local Health Integration Network (LHIN) has an Integrated Health Services Plan that focuses on improving access, coordination, quality and efficiency in the local system in several health service priority areas, including access to emergency services and reducing wait times. The role of health service providers should focus on both short and longer term opportunities for innovation in core processes. Under the Local Health System Integration Act, health services providers have a mandate to seek out and identify integration opportunities that will result in the provision of appropriate, coordinated, effective, and efficient health services. Proposal Ongoing discussions between NYGH and SJRH have occurred in a collaborative attempt to alleviate the ALC issue and to ensure that patients requiring short-term rehabilitation services receive optimal care. The integration proposal is the divestment of up to 15 inpatient short-term rehabilitation beds from NYGH to SJRH, and the transfer of related operating dollars to SJRH.
2 Moving inpatient rehabilitation services to St. John s Rehab would allow NYGH to redistribute resources to create a consolidated and specialized ALC unit. With the development of this unit, ALC patients can be moved away from acute care units and improve patient flow between the emergency department and inpatient acute medical beds. SJRH currently has an average occupancy of 88%. With the additional resources contemplated for transfer, SJRH could increase its occupancy, and expand its admission criteria to absorb the additional medical rehabilitation patients from NYGH. This proposal would: Facilitate a strong partnership between an acute care community-teaching hospital and a specialized rehabilitation hospital Improve the continuum of care for medical patients at NYGH that require rehabilitation services Improve access to specialized rehabilitation services for patients, enabling them to get the most appropriate care in the right place at the right time Increase capacity to provide care to acute care patients at NYGH Consolidate ALC patients on one unit at NYGH Increase occupancy at SJRH Patient Population In order to initiate this integration opportunity between NYGH and SJRH, it is essential that the rehabilitation needs of patient population currently served on the short-term rehabilitation unit at NYGH are met through this transfer. The current admission criteria for patients seeking service at St. John s Rehab are as follows: Medically stable Has rehab potential Have active, measurable and attainable rehab goals Able to tolerate increasing amount of therapy starting at least 30 minutes daily Patients with post-surgical, mild to moderate cognitive deficits will be considered Has a pre-determined discharge destination The make-up of the short-term rehabilitation patient population at NYGH can be largely characterized as de-conditioned general medical patients that include: Geriatric population with falls, failure to thrive Patients with impaired cognition (but able to follow commands and carry over learning) All weight-bearing status, e.g. NWB, PWB, etc, if appropriate Patients might have: Decreased ambulation tolerance Decreased balance Decreased exercise tolerance Decreased strength Decreased coordination Decreased mobility
3 Decreased independence ADL and IADL Geriatric syndromes Co-morbidities Mild impaired cognition Wounds NYGH and SJRH have worked collaboratively to redefine and agree on new admission criteria for patients seeking service at SJRH. The new admission criteria match the description of the NYGH patient population listed above. Alignment with Central LHIN Priorities Access Improve access to specialized rehabilitation services for patients, enabling them to get the most appropriate care in the right place at the right time Improve access to acute care services for patients by increasing bed capacity for ALC patients at NYGH Improve access to emergency services by decreasing the number of ALC patients in acute care beds Coordination Improve the continuum of care for medical patients at NYGH that require rehabilitation services Improve the referral process between SJRH and NYGH by using a Referrals Coordinator that can identify and assess patients early in their stay at NYGH who may be candidates for service at SJRH Opportunities for priority admissions Quality Increase quality of care for rehab patients receiving care at a specialized rehabilitation hospital Increase quality of care for ALC patients being consolidated on a single unit with specialized care by the right providers Efficiency Improve patient flow by using a specialized ALC unit to transfer patients out of the medical inpatient units. Improve cost per patient day for rehabilitation patients, by transferring them more quickly to a specialized rehabilitation hospital. Stakeholder Engagement Stakeholder engagement regarding the provision of rehabilitation services at NYGH began in the fall of 2005 following the completion of North York General Hospital s Strategy Map. The strategic planning process at NYGH included an interconnected process of identifying clinical areas of focus and areas for potential realignment or divestment. The goal of this process was to align the strengths of NYGH with the system s priorities and leverage the strengths of other organizations. Representatives from St. John s Rehab Hospital, Providence Health Care, North York CCAC, and the GTA Rehab Network participated in a session to identify key issues, gaps, and potential opportunities in the provision of rehabilitation services across the continuum of care. This session was organized
4 within the context of NYGH seeing a shift in rehab from musculoskeletal to medicine, and challenges associated with providing specialty rehabilitation services in an acute care environment. From this brainstorming session, several key issues were identified: Patients at NYGH have become more medically complex and lengths of stay are longer. The difficulty experienced by hospitals in following rehabilitation criteria due to the focus on acute care and the need to ensure timely access to medical beds in facilitating the flow of patients from the emergency room to inpatient units. SJRH is willing to accept more patients, but requires additional funding to expand its admission criteria, and its occupancy level. In follow-up to this system-focused meeting, NYGH and SJRH have explored the integration of shortterm rehabilitation services which would provide specialized care in specialized rehabilitation hospital that has the infrastructure and expertise to deliver optimal care. Throughout this process, staff and physicians at both organizations have been kept informed In January 2006, formal meetings were held with staff at NYGH to introduce the concept of the integration initiative. In April 2006, NYGH and SJRH staff were apprised of hospital plans to transfer 15 inpatient rehabilitation beds to SJRH. At that time staff was assured that the intention was to preserve all roles at NYGH and SJRH. Separate discussions were held with physicians that care for the patients on the unit. In May 2006, two half-day retreats were held to look at future options for the short-term stay unit at NYGH. Possible futures included designating beds for total joint patients, maintaining similar patient acuity, and increasing patient acuity. Notable highlights of the retreat were that staff: Had concerns regarding potential impact on employment Had concerns regarding the ability of SJRH to care for NYGH patients Had a wealth of experience and commitment to ALC patients In relation to the concerns regarding the impact on continued employment, NYGH and SJRH have agreed that the integration of short-term rehabilitation services would not include the transfer of human resource capital between organizations. With the shift in the focus to an ALC unit, as well as the human resource needs of other programs and services at NYGH, it was not anticipated that there would be involuntary job loss. The identified concern related to the ability of SJRH to provide quality short-term rehabilitation services to the medical patients from NYGH, has resulted in increased dialogue between the organizations to meet this challenge. While SJRH does not at present have the resources to care for some of the more acute and complex medical patients, the transfer of funds from NYGH to SJRH will provide the opportunity to increase these resources. With the infusion of increased resources, SJRH will be positioned to modify the admission criteria to its rehabilitation programs to meet the needs of this patient population. Meetings took place early in 2006 with ONA and SEIU representatives from NYGH. The representatives were advised of the proposed bed transfer. At that point, it was hoped that a non voluntary job loss would not be necessary. A further update to the unions has taken place in the summer of 2007.
5 Several Town Hall meetings have been held at SJRH over the course of the past two years, to update staff on the potential integration opportunity. Most recently, meetings have been held with Social Workers and other front line staff to discuss the types of patients that would come to SJRH as a result of this transfer. Business Case for Support Based on the expanded admission criteria identified in this proposal, NYGH will be able to transfer the entire 15 bed short-term rehabilitation service to SJRH. In order to facilitate this transfer, SJRH requires the additional resources to deliver safe and quality services to this expanded population. These human resources that are required include health professionals from the following disciplines: nursing, physiotherapy, occupational therapy, social work, speech language pathology, and pharmacy. NYGH will transfer $865,000 to SJRH which represents the annualized costs for SJRH for the additional human resource capital as well as supply costs and other expenses. In the first year, NYGH will be providing an additional $20,875 as part of the cost-sharing arrangement to extend the Referral Coordinator position for an additional six months, beyond the completion of the project approved through the Innovation Fund. Through the transfer of this service to SJRH, the capacity for short-term rehabilitation service will be remain constant in the local health system, and the capacity to care for alternate level of care patients will increase through the expansion of a consolidated ALC unit from 15 beds to 30 beds. Funding for this expansion will be supported through the reallocation of global funding by NYGH. On completion of this integration project, an additional 15 ALC beds will be available in the Central LHIN system without additional MOHLTC resources. FTE St. John's Rehab Total Total Costs Hours Total Salaries and Benefits , ,000 Total Salaries & Benefits - Referrals Coordinator ,875 Total Supplies 65,000 Total Expenses 885,875 Less: Patient Revenue - Total Direct Expenses 885,875 Beds 15 Patient Days 5,092 Separations 509 Average Length of Stay (ALOS) 10.0 Occupancy Rate (%) 93.00%
6 Implementation Plan The implementation plan associated with this integration proposal includes the recruitment of health care professionals at SJRH to care for this increased patient population, as identified earlier in this submission. NYGH will provide some assistance to SJRH in the education and training of the staff regarding this new patient population. NYGH and SJRH are planning to begin the implementation of this initiative in January 1, 2008, including the transfer of funds from NYGH to SJRH. The work of the Referrals Coordinator will be instrumental in liaising between the two organizations and assisting in the identification of patients who now meet the admission criteria. Communication Strategy Objectives Internal Communicate to staff at NYGH and SJRH how the proposed change will: Improve access to the right care, at the right place and at the right time while maintaining the high level of quality care already provided at both hospitals. Ensure a smooth transition and optimum patient care by clarifying the roles and responsibilities of staff at each organization. External Share the initiative with external audiences (patients and their families, community, other key stakeholders) and communicate: How this change will help reduce wait times and improve access to quality care for patients. How NYGH, SJRH and the Central LHIN have worked together to find innovative ways to improve integration of health care delivery across the continuum of care. Tactics Internal Ongoing Progress Reports to Central LHIN Meetings with NYGH staff directly impacted by initiative NYGH/SJRH Intranet NYGH & SJRH employee newsletters NYGH Staff Forums/ SJRH Staff Town Hall meetings SJRH & NYGH Board Updates SJRH staff Q&A document External NYGH Health Connection SJRH Community Report Potential News Release & earned media SJRH & NYGH external Web sites Communications Initiated NYGH Strategic Planning Committee has been involved in the proposal process. CEO Reports have provided updates to the NYGH and SJRH Boards. Staff working in the NYGH Short Term Rehab Unit have been, and will continue to be, engaged and consulted in this planning process.
7 Meetings with ONA and SEIU representatives from NYGH, to advise them of the proposed bed transfer, took place in early 2006 and in the summer of During the last two years, several Town Hall meetings and a Lunch & Learn have been held with SJRH staff to discuss the potential integration opportunity. NYGH and SJRH Social Workers and other front line staff have also been included in discussions regarding the types of patients that would be transferred to SJRH as a result of this partnership. update from CEO sent to all SJRH staff in April 2006 outlined that both hospitals were working together to develop options to enhance rehab services. Timing Considerations Staff directly impacted by the partnership will continue to be consulted and engaged throughout the process. Internal communications to the entire staff at NYGH and SJRH to be initiated immediately following approval from the LHIN to prepare both hospitals for the implementation of the initiative. Ongoing updates provided to staff to communicate progress and implementation. External communications to be carried out once the changes are in place at both hospitals. Evaluation and Monitoring NYGH and SJRH are committed to ensuring that the populations we serve receive compassionate and quality care along the healthcare continuum. In order to continue to monitor the goals of access, coordination, quality, and efficiency, NYGH and SJRH will be using the following performance indicators on a monthly basis for assessment and evaluation. Number of applications from NYGH accepted by SJRH Average length of stay (NYGH and SJRH) Rehabilitation ALC days (NYGH) Number of rehabilitation ALC patients (NYGH) Average days of onset (SJRH) Number of patients discharged to LTC and CCC (SJRH) FIM score at admission to SJRH Total change in FIM score Average days waiting to access a rehabilitation bed, once a patient is accepted (SJRH) Number of patients returned to Acute Care (SJRH) Next Steps Pending approval of the integration proposal NYGH and SJRH will develop a memorandum of understanding to address service level volume and quality indicators that will define how this integration will be evaluated and monitored.
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