Optimal patient flow is vital in hospitals to achieve

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1 Quality Improvement : Reducing ALC and Achieving Better Outcomes for Seniors through Inter-organizational Collaboration Leslie Starr-Hemburrow, Janet M. Parks and Susan Bisaillon Abstract Like many hospitals, those in the Mississauga Halton Local Health Integration Network (MH LHIN) have used interprofessional collaboration to maximize system processes. Process improvements previously occurring in silos have started crossing hospital programs and systems within and beyond the hospital. The challenge is that few healthcare organizations consider, never mind implement, process improvements that traverse the LHIN. This article discusses an innovation with a unique feature: concentration not only on inter-professional collaboration but on inter-organizational collaboration by professionals and providers throughout the LHIN. The approach exemplifies what is possible when culture is adapted to necessitate and enable intra- and inter-organizational collaboration and partnerships based on trust and respect. This approach has been spread and sustained successfully across the LHIN, with alternative level of care patients being reduced by 5% or greater. Optimal patient flow is vital in hospitals to achieve operational effectiveness and efficiency. Over the past decade, it has been recognized worldwide that creating acute care capacity requires change through improvements that span the healthcare system. In February 9, the Ontario Hospital Association (OHA) reported that 15,858 acute care beds (19% of acute care beds) staffed and in operation were occupied by alternative level of care (ALC) patients. (Alternative level of care is the term used by the healthcare system to describe patients waiting in one level of care but requiring another appropriate level of care.) Fifty-five percent of ALC patients were awaiting placement in long-term care (LTC). The 7 Healthcare Quarterly Vol.14 No.1 11

2 Leslie Starr-Hemburrow et al. : Reducing ALC and Achieving Better Outcomes for Seniors through Inter-organizational Collaboration chronic shortage of LTC beds in the community, coupled with a lack of adequate community resources and increased patient demand, has resulted in an increasing number of ALC patients bottlenecked in the hospital. Reducing the number of ALC patients is a provincial priority. Background A 9 OHA report identified that the Mississauga Halton Local Health Integration Network (MH LHIN) had 17% (147) of acute care beds occupied by ALC patients. This directly impacted access from emergency department (ED) admissions. At any given point, 77 patients in MH LHIN were waiting in our EDs for an acute care bed (OHA 9). Maximization of opportunities for improvement in ALC was positioned as the goal for MH LHIN as part of its ED-ALC strategy. The relationship between patient flow and ALC is clearly evident when the number of ALC patients continues to increase and the ability of the hospitals to flow all patients through the system is compromised. This in turn cripples the hospitals ability to admit and treat acute medical and surgical patients. The consequences of impeded patient flow include overcrowding in the ED, long ED waits and patient dissatisfaction. Additional impact includes opening unbudgeted beds, admitted patients waiting in the hallways for beds and surgical cases delayed or cancelled. If the issues related to patient flow and ALC are not addressed, the ability to provide quality and timely care are fundamentally compromised throughout the hospitals. Solution In September 8, the number of ALC days in Halton Healthcare Services (HHS, a community hospital in MH LHIN) nearly doubled from the previous year. A 1A Crisis designation was declared for four weeks. It quickly became evident that without some type of fundamental change, the gains made during this period could not be sustained. In partnership with MH LHIN and the MH Community Care Access Centre (CCAC), a new philosophy was born that necessitated changes in workflow, culture and communication. This initiative was established to slow the growth of ALC in hospital while at the same time supporting the province s goal to increase aging at home. Historically, in most acute care hospitals in Ontario, an ALC designation to wait for LTC placement is made very quickly after the acute care event. The answer to why this happens can be partially explained by the perception of healthcare professionals that discharge to LTC is the optimal option. However, LTC placement is a social process, and this decision was occurring in acute care hospitals rather than in the community where longer-term decisions for living should be made. The MH LHIN leadership recognized a significant need for culture transformation and capacity building across organizational structures to secure a approach and culture. Leadership and cultural change at the hospitals and LHIN were synchronized, as without the simultaneous inter-organizational culture shift, the success and sustainability of changes would not be possible. For HHS, helping healthcare professionals, providers and families to understand that going home is best practice for patients initiated significant cultural change. HHS and MH CCAC focused education and messaging why is the best practice from the perspectives of safety and quality of life. Essentially, the objective was to help the helpers (families, healthcare providers and professionals) to understand why is the optimal discharge plan (Table 1). The culture change in MH LHIN hospitals was vital to facilitate a greater use of community partnerships, resources and supports that make it possible for seniors to age at home safely. Senior leadership reviewed the entire process, structures and protocol supporting discharge practices to identify redesign opportunities to remove gaps, eliminate inefficiencies and create timelier placement of patients in the community. Subsequently, investments were made in new processes and structures that appreciated aging at home in order to increase appropriate and adequate supports in the community. Table 1. Why is the best solution Increases acute care bed capacity Reduces the risk for hospital-acquired infections Allows the patient to wait for a placement facility of choice Provides the patient with time after an acute event to attain optimal functioning prior to making a major life decision Provides the best environment (home) in which to experience a significant life transition, such as the move to a nursing home At the same time, intra- and inter-organizational partnerships based on trust and respect were leveraged. These partnerships when combined with the cultural change and improved processes will enable seniors to successfully transition back to the community where they can make longer-term decisions about how and where they wish to live. The MH LHIN commitments to create capacity in the community include the following: New programming in the community and resources that offer choices rather than defaulting to LTC A focus at MH LHIN on funding aging at home Senior leaders commitment to collaboration and change to improve the system and decrease the number of ALC patients Healthcare Quarterly Vol.14 No

3 : Reducing ALC and Achieving Better Outcomes for Seniors through Inter-organizational Collaboration Leslie Starr-Hemburrow et al. Role accountabilities and discharge processes Functioning as one team with a common purpose While quick fixes can be maintained over short periods of time, they rarely have long-term sustainability. Therefore, not only was it essential that creative and sustainable approaches be applied to flow issues, but it was also critical that these issues be considered across both systems and organizations. Thinking within closed systems or single organizations limits the potential and possibilities to improve patient flow. Seniors come to the hospital from their homes, and our preference is to use interorganizational collaboration to return them home first. The aim of was to maximize the use of LHIN investments to create better outcomes for seniors and reduce ALC. The goals were to minimize the number of post-acute patients transitioning to LTC from the hospitals and to develop a comprehensive integrated plan for appropriate inter-organizational care and placement (Table 2). The priority of patient placement is always to the appropriate service that meets the needs of the patients and their unique situations (Table 3). Table 2. objectives To implement the following: Change management processes shifting the long-standing hospital culture and processes of using long-term care as the default disposition plan from acute care Processes and structures that maximize the philosophy of and resources for aging at home A communication and education strategy teaching our patients and their families about the quality-of-life and safety benefits of Table 3. concepts In hospital, ALC to LTC should be considered only as a last resort. LTC placement is a social process, and the hospital is not the right place for this transition to occur. Legislation is designed for LTC placement from home. Right person, right place, right time must be followed. ALC = alternative level of care; LTC = long-term care. MH CCAC is the single point of access to information about LTC options if it becomes too difficult for individuals to live independently at home or they cannot return home after a hospital stay. The CCAC helps clients stay home longer by providing care in their home or by coordinating care in the community, including specialized support services. It carries out an assessment to determine eligibility and empowers clients and caregivers to make an informed decision about LTC options that suit clients needs and interests. The CCAC manages the waiting list and admissions for LTC homes. Implementation Using an inter-organizational collaborative approach, providers and professionals demonstrated that successful implementation of the approach is possible, even with unique practice models that necessitate different approaches to change management. The approach was initially launched at HHS; then, based on the experiences and best practices knowledge gained at HHS, the approach was implemented at Trillium Health Centre (THC). HHS is a three-site acute care community hospital with sites located in Oakville, Milton and Georgetown. In January 8, HHS hired a director of patient flow and projects to implement a Patient Flow Program. The HHS Patient Flow Program strategy included three broad goals with associated tactics that were targeted at patient flow improvement across the system. The Patient Flow Program successfully achieved timely and smooth patient flow by championing change management initiatives that facilitated the flow of patients: the optimization of bed utilization management; the maximization of all opportunities for improvement in appropriate level of care; and data-driven continuous patient flow improvement, including a comprehensive suite of real-time metrics. HHS s Patient Flow Program had established a solid foundation and was successfully delivering results but was challenged by the alarming growth in ALC-LTC patients. From September 7 to September 8, the number of ALC days nearly doubled, from 9.3 to 17.5%. During 8, the number of ALC-LTC patients increased monthly (on average) by 11 patients (25 new LTC patients/14 discharged). By September 17, 8, the number of ALC patients waiting for LTC placement reached 87 and acute care ALC patients reached 28%. HHS requested and received a 1A Crisis designation for its Oakville site. The 1A Crisis resulted in 23 LTC placements, representing approximately a % reduction in ALC patients awaiting placement. Given the growth of 11 patients per month, it was estimated this reduction could not be sustained. 1A Crisis is a short-term solution; it does not address any of the root causes. To decrease the number of hospital ALC-LTC patients, it was necessary to improve both aspects of the ALC-LTC growth: the number of patients placed and the number of patients newly designated LTC in hospital who subsequently wait in hospital for LTC placement. This aha moment was the beginnings of the innovation. targeted a process change wherein all 72 Healthcare Quarterly Vol.14 No.1 11

4 Leslie Starr-Hemburrow et al. : Reducing ALC and Achieving Better Outcomes for Seniors through Inter-organizational Collaboration Figure 1. Reduction in the percentage of ALC patients in acute care from 8 to 1 Data Source: Meditech open cases Midnight census last day of month From 22-28% -6% 87 LTC patients referred from hospital for LTC would be automatically reviewed by MH CCAC to facilitate discharge to their pre-hospital environment with increased supports through CCAC (Wait at Home program). Operational procedures including algorithms and hospital-ccac communication transfer forms were created and implemented. Managerial 1A Crisis sign-off was instituted to ensure that all community options were considered. HHS used rolling Plan-Do-Study-Act (PDSA) rapid-cycle improvements to implement the change. Change management followed the eight-stage process of creating major transformation outlined in Kotter (1996). At THC, the ALC patient days and cases had also been steadily increasing and were directly impacting the flow of admitted patients from the ED. In March 8, the ALC cases peaked at 135 cases (approximately 19% of our beds). The ALC pressures resulted in multiple days of ED gridlock with admitted patients kept for prolonged periods, occupancy rates over 1% and the need to create ED diversion areas for assessment. Reinforcing the need for improvement was the positive correlation between the rise in outbreaks of Clostridium difficile infections and higher ALC cases in over-time statistics. Additionally, anticipated targets in the ED Pay-for-Results Initiative (a Ministry of Health and Long-Term Care ED-ALC strategy) were not achieved despite numerous redesign strategies. Overall, providing safe and appropriate care was impacted by Sustaining Figure 2. Reduction in the total number of ALC patients awaiting placement in LTC, for all beds at all sites Sustaining 15 1 Nov-7 Dec-7 Jan-8 Feb-8 Mar-8 Apr-8 May-8 Jun-8 Jul-8 Aug-8 17-Sep-8 Sep-8 Oct-8 Nov-8 Dec-8 Jan-9 Feb-9 Mar-9 Apr-9 May-9 Jun-9 Jul-9 Aug-9 Sep-9 Oct-9 Nov-9 Dec-9 Jan-1 ALC = alternative level of care; LTC = long-term care. Healthcare Quarterly Vol.14 No

5 : Reducing ALC and Achieving Better Outcomes for Seniors through Inter-organizational Collaboration Leslie Starr-Hemburrow et al. Figure 3. Reduction in the number of ALC cases from September 8 to increased ALC patients as evidenced September 9 by the infection rates and inability to 1 provide timely access. Building on the learning at HHS, 15 1 THC s front-line staff and leadership focused on aspects that were ALC Cases 5% reduction necessary for redesign related to roles, accountability framework, protocols and processes to enhance 52 the discharge practices to improve patient flow. The teams from THC and MH CCAC were encouraged to work together as one team with the focus on a patient-centred approach 8 9 across the continuum of care from the hospital to the community. Overall, the goal was to hardwire our processes through the development of appropriate protocols and structures that support timely and appro- Figure 4. Reduction in the time in gridlock from 8 to 9 priate placement of our patients in 1 the post-acute phase of their care along with clear role accountabilities. THC seconded a director to identify operational and redesign opportunities to transform % reduction the discharge processes from the hospital to the community. THC focused on a renewal process for ALC management that supported implementation with the and MH LHIN strat- egies for managing patient care in the community. 8 9 In March 9, a command centre was established for the daily review of all ALC patients Gridlock at THC in conjunction with MH CCAC. The Figure 5. Number of ALC patients by day from March 1, 9, to June 1 ALC command centre established on March 11/ Healthcare Quarterly Vol.14 No.1 11

6 Leslie Starr-Hemburrow et al. : Reducing ALC and Achieving Better Outcomes for Seniors through Inter-organizational Collaboration Figure 6. Reduction in total ALC patient days from 8 9 to , 3, 25,, 15, 1, 5, 33,963 A decrease of 11,248 ALC Patient Days in 1 year 22,715 9/1 Annualized (Feb & March estimated) approach that was created, ensure accountability with team members and reinforce the expectation of reducing the number of ALC patients. The command centre approach to reviewing ALC patients was successful and identified the need for an ongoing daily joint discharge operation to review all patients who were designated as ALC-LTC,, chronic, chronic palliative, rehabilitation or another complex case. The end result was that the patients experienced seamless access and flow across the continuum of care from the hospital to the appropriate community setting that best met their care needs. 8/9 9/1 Figure 7. Reduction in ALC patient cases from March to August March A decrease of 68% August purpose of the command centre was to lead a purposeful review of plans of care for ALC patients with the key stakeholders to ensure that the plans of care were current and relevant to patients needs and that patients were being considered for the most appropriate level of placement. To ensure that staff were not defaulting to LTC, the team met daily to discuss discharge options for ALC patients and to remove barriers to successful discharge. Additionally, the management from THC and CCAC participated in the daily reviews to support the new 43 Analysis Halton Healthcare Services HHS s was successful in anchoring the Home First innovation into the culture of the organization. The culture change to the approach instead of LTC began with education, coaching and mentoring physicians, healthcare professionals, patients/families and the community through in-services, communiqués, community newspapers and presentations. messaging focused on safety and quality-of-life benefits for discharge home that had an appreciable influence on healthcare providers and professionals attitudes regarding LTC placement from hospital or home. Healthcare providers and professionals are motivated intrinsically to do what is best for their patients, and families want what is best for their family member. By helping healthcare providers, professionals and patients families to understand that going home is in fact best for patients, HHS was able to shift the hospital culture and reduce the number of ALC patients. Trillium Health Centre Key success factors have included the role redesign for discharge, changing our unit practices related to discharge planning and implementing utilization software along learning from FLO collaborative units. The Flo Collaborative is an Ontario Health Performance Initiative that focuses on processes to improve the timeliness and effectiveness of transitions for patients from acute care hospitals to subsequent care destinations. This work was supported by the introduction of technology and software solutions that facilitated timely and accurate information related to discharge. Ongoing review of Healthcare Quarterly Vol.14 No

7 : Reducing ALC and Achieving Better Outcomes for Seniors through Inter-organizational Collaboration Leslie Starr-Hemburrow et al. identified opportunity areas related to discharge practices will need to be considered to further achieve and sustain gains in supporting our discharged patients and families. Discussion The Approach has spread to all hospitals in MH LHIN, including Credit Valley Hospital, and has been adopted by hospitals throughout Ontario. This innovative best practice exemplifies what is possible when culture is adapted to necessitate and enable intra- and inter-organizational collaboration and partnerships based on trust and respect. Sustainable reductions have occurred in the number of new referrals to LTC, time in gridlock, number of no-bed admissions and ALC-LTC growth (Figures 1 7). There has been improved role clarity, coordination and completeness of care and standardization of discharge processes. is not a program; it represents a philosophical and cultural shift within acute care to change the focus through partnerships to ensure our seniors can age outside of acute care. Acknowledgements We wish to acknowledge the following people for their support: Patti Cochrane, vice-president of patient services and quality and chief nursing officer at Trillium Health Centre; Denise Hardenne, senior vice-president at Oakville-Trafalgar Memorial Hospital; Vida Vaitonis (former executive director of MH CCAC); and Dale Clement (former ALC strategy leader for MH LHIN). it s our readers that you want. recruit them here jobs.longwoods.com References Canadian Institute for Health Information. 9. Alternate Level of Care in Canada. Ottawa, ON: Author. Retrieved January, 1. < Kotter, J Leading Change. Cambridge, MA: Harvard Business School Press. Ontario Hospital Association. 9. ALC Survey Results. Alternate Level of Care. Toronto, ON: Author. About the Authors Leslie Starr-Hemburrow is the Patient Care Program director for the Regional Cancer Program and Renal Program at the Credit Valley Hospital, in Mississauga, Ontario (Formerly director, patient flow and projects, Halton Health Services). Janet M. Parks is the director of client services at the Mississauga Halton Community Care Access Centre, in Mississauga, Ontario. To reach our 31, visitors* contact Susan Hale, shale@longwoods.com, Executive and Nurse Recruiting. *over seven months ending January 1, 11 Susan Bisaillon, RN, BN, MSc (Nursing), CHE, is the executive director of clinical operations at Trillium Health Centre, in Mississauga, Ontario. 76 Healthcare Quarterly Vol.14 No.1 11