1 Hamilton Niagara Haldimand Brant LHIN Rehabilitation/Complex Continuing PAG Service Delivery Model Review April, 2009
3 Service Delivery Model Review Introduction This document presents a summary of peer practice service delivery models researched across published sources and through first-hand knowledge of other health organizations. Although outcomes are not available in many instances, the models and considerations that are provided in this summary give insights into the options and principles other health organizations are using to coordinate clinical service delivery. They are intended to inform the Planning Advisory Group (PAG) as it designs the future model of service delivery for the Hamilton Niagara Haldimand Brant (HNHB) LHIN. To support initial planning discussions, an orientation to a common typology of service delivery models is provided below, which can be used as a foundation for discussion. An orientation to broader work underway in Ontario with respect to chronic disease prevention and management (CDPM) is also provided in the Appendix. This summary document is intended as one input to the planning process. As the PAG considers future service delivery models that are LHIN-wide and result in quality care, equitable access, and efficient delivery, members will also draw on the expertise of the group and colleagues, as well as any other leading practices with which they are familiar. Summary of General Service Delivery Models In examining the type of service delivery model to consider for a specific clinical area, there are three generic models of service delivery presented for consideration at the local, district and LHIN-wide levels. Depending on the clinical focus, each option may present different benefits and challenges. Each of the models presented below is intended to depict providers across the full continuum of care and across health sectors: providers may be hospitals, long-term care facilities, community care agencies, individual physicians or others. As a frame of reference, a graphical representation of the continuum of care and patient movement across the continuum is provided below. Examples of Involved Across Health Sectors Long-Term Meals on Wheels Physician CCAC Hospital Community Agencies Health Promotion and Prevention Public Awareness and Education Primary Emergency Medical Services Acute Rehabilitation Home Long Term Palliative As the generic service delivery models on the following page are reviewed, several key considerations are noted for PAG members: Critical mass volumes, technology intensity, level of specialized knowledge, availability of health human resources, and access to service availability are parameters to consider across all models. In modelling local vs. district vs. LHIN-wide care provision, multi-direction flows of providers and patients should be considered. For example, the PAG may consider a two-way flow of practitioners between a specialized hub of service delivery and local community service delivery where community-based physicians have access and opportunity to deliver specialty services in the hub, and specialist hub-based physicians are involved in care delivery in the local community. Principles from Lean service delivery in health care may be helpful for the PAG to consider as it begins its work: lean principles suggest service delivery design should focus on being patientcentered to maximize the value from the patients perspective. This includes focusing on connection points between care providers at the organization and individual levels and ensuring seamless coordination to eliminate waste in duplication of efforts across the service model. 3 Deloitte & Touche LLP and affiliated entities.
4 Common Service Delivery Models Community A Community C Service Provision Community B Service Provision: Services needed by the local population are provided locally through the local hospital, community care agencies, individual physicians or others, with locally-based utilization of resources and expertise pertinent to patient needs. Although some information or best practice sharing between local communities may exist, there is limited service coordination. This model provides care close to home, but may create duplication in services and redundancies in infrastructure across hospital and community providers, and may be challenging to deliver because of the intensity of human resource and funding requirements. District Service Provision: Services are organized with a district provider institution for populations across select communities within the LHIN, supported by local providers in each community. This model effectively creates a network of large and small hospitals, community care agencies, physicians and others, where multi-directional flow of providers and patients across the continuum of care is coordinated at a sub-lhin level. The district provider will capture a large proportion of residents who may require certain types of subspecialty programs, yet do not need to travel to a regional site. This can create additional efficiencies for human resources (depending on the level of specialization of skills), technology requirements (depending on complexity of technology required to support the service), and cost effectiveness, but may create access challenges for patients who are required to travel to the district site. Community A District Provider District and Service Provision Community C Community B Community A Community D LHIN-Wide Centre LHIN-Wide Centre Provision Community B Community C District Provider Community E LHIN-Wide Centre Provision: Highly specialized services that will promote access LHIN-wide are consolidated into centralized service provider site(s). These sites will have the critical mass required to sustain quality standards of care and clinical efficiencies for specialized services. This model creates a LHIN-wide network of large and small hospitals, community care agencies, physicians and others, where multi-directional flow of providers and patients across the continuum of care is coordinated at a LHIN level. One or more district and local models may exist within this LHIN-wide model to ensure appropriate balance of LHIN-level vs. local care, all coordinated in a central manner. From a patient perspective, this will mean requiring travel to the LHIN-wide centre for select services, but the need for specialization, economies of scale for academic programs, and appropriate critical mass make this necessary. 4 Deloitte & Touche LLP and affiliated entities.
5 Applying the General Service Delivery Models To provide a tangible example of how the generic service delivery models can be applied to HNHB LHIN s clinical service planning, the table below presents a sample of different levels of sites providing services across specific points along the continuum of care (highlighted).* Health Promotion and Prevention Public Awareness and Education Primary Emergency Medical Services Acute Rehabilitation Home Long Term Palliative While this table only presents a sample of facility/site-based services, it provides an additional frame of reference for PAG members to consider. The integration of these site-based services with broader community-based services will also be a critical component of planning by the PAG. Service Components Level 1: Regional Centre Level 2: Area Centre Level 3: Affiliate Site Level 4: Satellite Site Level 5: Basic Site Screening Services Manages and participates in all screening services. Participates in all screening services. Participating in screening programs is desired, but optional. Participating in screening programs optional. Participating in screening programs optional. Assessment & Diagnostic Services Full range of assessment & diagnostic services Provides selected range of assessment and diagnostic services. Refers to Level 1 when appropriate. May have limited set of basic assessment and diagnostic services. Likely to refer to Level 2 or 1 as appropriate. Basic assessment & diagnostic services are optional. Expected to refer to Level 2 or 1 as appropriate. No assessment & diagnostic service necessary. Expected to refer to Level 2 or 1 as appropriate. Treatment Services Full range of treatment services across. May refer to another Level 1. Intervention and therapy for defined set of patient types. Provides pre & post treatment care. Intervention care Provides limited and may provide intervention and therapy for limited therapy. Provides pre set of patient types. & post treatment care. Provides pre & post treatment care. May provide pre & post treatment care. Pre/Post Treatment, Supportive, Symptom Management & Palliative Services Full range of Full range of specialized services available to all patients. Includes complex pre & post treatment care, symptom management & palliative care. services, for patients available in the hospital or local community. Can provide pre/post treatment care for most patients treated at Level 1. Core range of services available in hospital or local community. Able to provide routine pre/post treatment care. Essential range of services available in hospital or local community to be able to provide routine pre/post treatment care as well as basic supportive & palliative care. Services not required to be available within the hospital other than for emergent / urgent care. Specialization Provides a full range of specialized services across all of the recognized disease-related areas. Provides full range of services for the high volume and less complex patient types. Patients go to Level 1 for complex treatment. Provides specified set of services for the high volume and less complex patient types. Provides pre and post treatment care for patients from catchment area. Provides specific screening and therapy treatment along with selected pre and post treatment care for patients from catchment area. * This framework is adapted from a draft developed by Brian Orr, Regional Vice President, London Regional Cancer Program. Unscheduled urgent / emergent pain and symptom management care for patients from catchment area. Limited pre & post treatment care. 5 Deloitte & Touche LLP and affiliated entities.
6 Rehabilitation/Complex Continuing Specific Models of Service Delivery A summary of research into peer practice rehabilitation/complex continuing care service delivery models is presented below. Models have been selected based on a review of forward-looking service delivery practices in other jurisdictions and models identified by advisory groups. The models presented below provide an overview of areas where service delivery models have been developed and documented, and are not intended to limit the PAG in terms of focus. In some instances, models also highlight where there are linkages to other PAGs (i.e. oncology or paediatrics). We recognize that there are other areas within rehabilitation/complex continuing care services that are not included in the models provided; particularly as there are many patient population specific rehab streams to consider (i.e. stroke, cardiac, neuro, etc) however the models presented share common elements to what is demonstrated in these other areas. For these reasons PAG members will be asked to provide insight into the most appropriate service delivery models for the LHIN. Models presented are intended to give insights into the options and principles other health organizations are using to coordinate clinical service delivery. For each model, a summary of the key attributes of service delivery along the continuum of care and outcomes achieved is provided as available. Literature or web-based references are also provided, so that PAG members may obtain additional information. Key Success Factors As the PAG plans future service delivery models for the HNHB LHIN, it will need to reflect on several inputs including items outlined in the PAG guide, in addition to the enablers and barriers to service delivery that must be considered for implementation. Insights gained from the peer practice service delivery models identified on the following pages as well as general service delivery model enablers suggest several implications for Rehabilitation / Complex Continuing Services that can serve as an input into PAG planning. Recognition for the need to plan for services (i.e. appropriate type of services, associated support serves such to support cognitive and behavioural issues, and location of rehab and CCC resources) using a coordinated system of access across providers. Services are most successful when they are focused on the patients needs and adding value from a patient s perspective (and not being provider focused). Being mindful of equitable access to high quality services and locating services strategically to minimize the impact of distance on patient access to services. Need for standards of practice and role clarity in provider responsibilities within the service model to help improve care coordination across the continuum, improves the patient experience, and provides accountability. This includes identification of multi-directional provider flow across urban and rural centres, where appropriate. Establishment of communications and feedback loops for program evaluation and information sharing across the LHIN. Need to enhance communication between providers across the continuum of care particularly at transition points including standardized admission and discharge processes and individualized care plans. This may be enabled by shared patient information where feasible. Need for integration between health professionals along the continuum, with support for resource tools and communication mechanisms. Need to secure and maintain adequate health human resources to meet the needs for the LHIN, balancing local, district and LHIN-wide service delivery (e.g. specialized psychiatrists and interprofessional teams). Networking and information systems to help ensure efficient, effective care for patients and creating an up-to-date inventory of resources/community supports for the LHIN, opening the information loop and support services further for rural and remote patients. Maintenance of a central registry for select services and chronic diseases (e.g. diabetes) to support service access and population health. 6 Deloitte & Touche LLP and affiliated entities.
7 Delivery Framework for Adult Rehabilitation 1 NHS Scotland The delivery framework for adult rehabilitation in Scotland identifies early intervention for the selfmanagement group where emphasis is placed on self management and health promotion utilizing community culture and leisure centers, lifelong learning opportunities and voluntary agencies services. The framework for adult rehabilitation is organized into four phases: The condition management phase into which an individual can self refer when appropriate to a rehabilitation team via a single point of access to enable specific needs, either social or health, to be addressed. In the acute phase vital specialist interventions are undertaken by hospital rehabilitation teams with the aim of stabilizing the patient and ensuring a timely, seamless discharge process. The longer-term rehabilitation phase calls for community rehabilitation teams to work in partnership not only with acute rehabilitation teams, but also across all health, local authority, independent and voluntary sectors and, crucially, with individuals, carers and communities. The vocational rehabilitation phase outlines the support structures that should be available to individuals in workplaces to promote health and well-being at work. It then identifies a rapid access referral process through which individuals should be able to secure support and specialist advice from a dedicated vocational rehabilitation team consisting of a range of professionals using case management approaches. Settings in which rehabilitation teams work include GP practice, care homes, client homes, day hospitals/centres, community hospitals, community pharmacies, mental health services, specialist outreach services, community nursing services, sheltered housing, community resource centres, job centres, etc. The highlights of the model satisfy the need to: Develop person and carer-centred rehabilitation services; Create direct access to rehabilitation services, where appropriate; Create a single point of access to rehabilitation services, where appropriate; Promote a focus on maximizing individuals autonomy and enablement; Provide rehabilitation services closer to individuals homes, when appropriate; Encourage multi-disciplinary, multi-agency teams genuinely to work together in whole-systems approaches; Adopt a holistic model of rehabilitation encompassing physical, psychological, emotional and social needs; Strengthen the Single Shared Assessment system (streamlining the assessment process to reduce duplication of activity in the area of needs assessment).on accessing services; Provide the same quality of treatment for all, regardless of class, age, culture or geographical location; Review and analyze outcomes on an ongoing basis, with a particular focus on feedback from individuals and carers. 1 A Delivery Framework for Adult Rehabilitation in Scotland, Scottish Executive, Deloitte & Touche LLP and affiliated entities.
8 Delivery Framework for Adult Rehabilitation 8 Deloitte & Touche LLP and affiliated entities.
9 Acquired Brain Injury Service Pathway 2 (HNHB LHIN) The HNHB LHIN Acquired Brain Injury Service Pathway was developed to provide a pathway for expanded, accessible and efficient provision of coordinated Acquired Brain Injury (ABI) management services. As noted in the in the model s documentation 3, the guiding principles of the ABI Network are used in planning the provision of care to ensure that ABI services are optimally configured to: Provide client centered services that are responsive to individual needs; Provide equitable and timely access to services regardless of location; Provide universal accessibility of environment and language; Provide seamless transition across the health continuum; Provide specialized services; Establish specific discharge and admission guidelines for all services that direct where people go to ensure access for those who cannot advocate for themselves; To maximize existing technology to offer training and consultation opportunities through videoconferencing or telemedicine; and Establish a common evaluation tool to measure outcomes The supporting service delivery model / model of care for ABI looks at the continuum of care from the patient being ready for discharge from an acute care setting to discharge in a private or public residence. The model takes into account: bed availability, long term care needs, availability of community supports, crisis management, funding and ongoing outreach services. The ABI Service Pathway is aimed at assisting service delivery and integration of ABI patients into the community. Key components of the model are: A transfer process from hospital to community and vice versa; A transition process from paediatric to adult services; Navigational supports for the individual to facilitate access to services; Community supports to minimise hospitalization; Coordinate services among sectors to address multiple issues e.g. ABI, mental health and addictions; Long term facilities that are willing to admit individuals with ABI and behavioural challenges; Age appropriate services in long term care facilities for younger adults; Community transitional services to facilitate return to independent living and allow earlier discharge from acute and specialized rehabilitation beds; Transportation services; Affordable housing; Timely access to acute care mental health beds for crisis or medication review; Specialized supports for rehabilitation or behavioural programming for individuals transferred to local hospitals; An on call system to support individuals in the community; Respite opportunities; and Discharge planning started while in acute care to facilitate timely access to funding, equipment, services and to start the application to long term care if appropriate. 2 The HNHB LIHN ABI Service Pathway, March Clinical Planning and Integration, HNHB Community Support Services Network and the HNHB ABI Network 9 Deloitte & Touche LLP and affiliated entities.
10 ABI Service Pathway 10 Deloitte & Touche LLP and affiliated entities.
11 Bruyère Continuing 4 (Ottawa, Ontario) The Complex Continuing (CCC) program is a goal-oriented program for people who require medical management, skilled nursing care and a range of interdisciplinary diagnostic and therapeutic services and technologies either for a continuous or an extended period of time. The inter-professional health care team work closely with patients and families to develop an individualized care plan. Complex Continuing has three major care streams: Specialized Complex. Patients in the Specialized Complex stream have a progressive disease and multiple medical conditions requiring ongoing monitoring by an interdisciplinary team. Restorative. Patients in the Restorative Stream may require inpatient treatment by an interdisciplinary team for functional improvement over an extended period of time, with the goal to be discharged to another program, home or to the community. Supportive. Patients in the supportive stream have severe functional impairment requiring care above what can be provided from community agencies or long-term care facilities or an improved condition, or are maintaining their health status, or are good candidates to be transitioned to the community. Patients will be moved from stream to stream as their care requirement improves or changes. Once a patient no longer needs Complex Continuing, the inter-professional team will ensure efficient and appropriate discharge into the community Deloitte & Touche LLP and affiliated entities.
12 Appendix: Ontario s Chronic Disease Prevention and Management Framework Summary Ontario s Chronic Disease Prevention and Management (CDPM) framework is provided below to highlight some general principles for the PAG to consider as it approaches the task of designing an optimal future service delivery model. The purpose of the CDPM framework is to provide a common policy framework to guide efforts toward effective prevention and management of chronic diseases (e.g. diabetes, COPD). System Design Elements of the Ontario Framework for Chronic Disease Prevention and Management CDPM System Design Elements Increased interdisciplinary care teams with defined roles and responsibilities 5 Description An interdisciplinary mix of specialty care professionals, working either collaboratively or in an organized team, has been shown to improve care for the chronically ill, and provide effective prevention. One factor found to be important to interdisciplinary teams success is a shared vision and commitment among members to patient-centered care. Prevention and health promotion experts in the community extend the breadth of the primary health care team, delivering prevention, health promotion and self- management supports to a practice s individual clients as well as to the population as a whole. 5 Preventing and Managing Chronic Disease: Ontario s Framework, Ontario Ministry of Health and Long-Term, May p Deloitte & Touche LLP and affiliated entities.
13 CDPM System Design Elements Innovative patient interactions 6 planning, care paths and care management 7 Enhanced health promotion and prevention 8 Description A variety of interventions patient reminders, outreach workers, physician reminders, or patient orientation have been shown to be effective in maintaining ongoing client contact, which can take the form of return visits, home visits, s, or telephone calls. Regular planned visits anchor the planning and coordination of clients care which is based on a patient-centred care plan tailored to the client s specific needs, capacities, circumstances and wishes. Activities in care plan include: risk assessment, education and skills training to prevent/manage chronic disease; screening, diagnosis, testing to detect early onset of disease or onset of co-morbidities; and treatment, rehabilitation, medication management and counselling for chronically ill patients. Effective execution of the plan requires use of care paths that plot the sequence of care, and next steps for each point in disease management. Emphasis on prevention in risk assessments (for genetic, environmental, behavioural, social factors, for example) and pro-active follow-up for screening and tests to detect disease early, and information, education, skills training, and supports to stay healthy. The prevention and health promotion services that clinical team members deliver may need to be expanded by drawing upon, or developing services with community organizations. Outreach and population-needs based care and cultural sensitivity 9 Recognition of the role of culture, income and other determinants of health in shaping individuals health and access to health care is critical. This includes ensuring equal access and sensitivity to the cultural and linguistic needs. Can also include supporting community organizations in making health services, information and education accessible to all sub-populations in their catchment area. e.g., aboriginal population, Francophones and marginalized or cultural/linguistic minority populations. The framework components include: Health Organizations: to make systematic efforts to improve prevention and management of chronic disease; Delivery System Design: focused on prevention and improving access, continuity of care and flow through the system; Provider Decision Support: to integrate evidence-based guidelines into daily practice; Information Systems: for enhancing information for providers to provide quality care; for clients to support them in managing their disease on a day to day basis; and for integrating services across health system; Personal Skills & Self-Management Support: to empower individuals to build skills for healthy living and coping with disease; Healthy Public Policy: to develop and implement policies to improve individual and population health and address inequities; Supportive Environments: to remove barriers to healthy living and promote safe, enjoyable living and working conditions; and, Community Action: support for activities undertaken collectively to improve the health of the residents. 6 Ibid. p Ibid. 8 Ibid., p Ibid. 13 Deloitte & Touche LLP and affiliated entities.
14 Deloitte, one of Canada's leading professional services firms, provides audit, tax, consulting, and financial advisory services through more than 7,700 people in 57 offices. Deloitte operates in Québec as Samson Bélair/Deloitte & Touche s.e.n.c.r.l. Deloitte is the Canadian member firm of Deloitte Touche Tohmatsu. Deloitte refers to one or more of Deloitte Touche Tohmatsu, a Swiss Verein, and its network of member firms, each of which is a legally separate and independent entity. Please see for a detailed description of the legal structure of Deloitte Touche Tohmatsu and its member firms. Deloitte & Touche LLP and affiliated entities. TM 2006, VANOC.
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Complex Continuing Care Restorative Care (Combined Functional Enhancement and Restorative Care Programs) Description: The Restorative Care program provides a moderate to low intensity goal-oriented rehabilitation