Urology - Chronic Kidney Disease (CKD)

Transcription

1 Urology - Chronic Kidney Disease (CKD) Planning Advisory Group Summary of Meetings HNHB LHIN Clinical Services Planning Project

2 PAG Membership Rick Badzioch Dr. Ian Brown Dr. Euan Carlisle Jane Cornelius Terry Dalimonte Maureen Kitson Dr. Bill Love Dr. Frank Scallan Maureen Shantz Dr. Bobby Shayegan

3 PAG Deliverables Describe the strengths & challenges within the existing health care system in addressing population health care needs Identify leading factors that may influence the future demand for health care Develop a high level, HNHB LHIN wide, ideal services delivery model for the PAG population Identify pre-requisites & challenges of implementation of the ideal service model

4 Urology & CKD At the start of the project the PAG concurred that urology and CKD are distinct services with little overlap and need to be reviewed separately.

5 Meeting 1 Strengths & challenges within the existing health care system Leading factors that may influence the future demand for health care Ideal delivery model (high level)

6 Urology - Strengths & Challenges of Current Health Care System Strengths Good distribution of urologists across the LHIN. Access to urologists not an issue HNHB LHIN Urologists cohesive group Readiness of LHIN urologists to develop quality working group to review and improve services in LHIN Majority of urology related care available in LHIN, only need to transfer outside LHIN for special technology i.e. lithotripsy. Nurse practitioners in LTCH can increase capacity by performing minor care procedures i.e. changing suprapubic catheters CCAC provides continence referrals Hamilton training program for physician assistants Less subspecialty among urologists. Challenges Access to interventional urology in Brantford, requires transfer to Hamilton, often needing an overnight stay Access & support for new technology i.e. lithotripsy, robotic Aging population with limited access to continence support Transportation especially with aging population Agreement & standardization of Nurse Practitioner practice within LTCH across the LHIN Centralized model may limit recruitment, impacting health human resources in smaller sites. Need to access urologist on urgent basis makes regionalization of specialty challenging. Inability to share information across sites (each sites has meditech and PAC system but cannot share information online between sites) Wait time to operative time Maintain & replace capital equipment Lack of level 1 evidence for screening in urology. If evidence supports screening potential for increased demand. Increase pressure to teach residents. Access to operating room time

7 CKD - Strengths & Challenges of Current Health Care System Strengths Ready access to specialists No wait lists (except for transplant) Immediate access to hemodialysis (hemo) Hub & spoke service delivery model satellites across the LHIN CCAC support for home dialysis Pre-dialysis clinic care > reduce or delay need for dialysis (medical preventive care nephrology clinics) Range of hemo dialysis modalities LTC access for clients on hemo MOH PD in LTC Initiative MOH increased support for transplant services Challenges Access to timely surgical, vascular & interventional radiology support - (for peritoneal dialysis catheter insertion/replacement, vascular access/complications, & nephrology tubes) Access to interventional radiology only in select areas of LHIN CCAC staff turnover has resource implications for regional centre to retain for home and LTC support Regional referral role - pressure to accept transfers from satellites and from other centres for transplant Access to LTCH for seniors on PD Costs of different modalities i.e. daily, nocturnal absorbed by regional centres LTCH capacity to care for individuals on dialysis i.e. staffing model Lack of dedicated funding to support pre-transplant treatments i.e. plasmapheresis, tissue typing Management of CKD programs that cross LHIN boundaries i.e. Halton/Burlington Maintenance of knowledge/skills at non CKD centres to facilitate repatriation (critical mass). Resources/costs associated with supporting dialysis offsite at other tertiary centres (Hamilton)

8 Factors Most Likely to Increase or Decrease Demand common to both *Aging population * Increase in comorbidities in aging population & starting earlier in younger population i.e. type 2 diabetes, obesity * Social economic profile of the LHIN * Increase availability of primary care > increase demand Access to transportation will increase demand for services close to home Medical advancements, both in skill & technology (urology, transplant, continual renal therapy, cancer treatment options) Client/family expectations Competition for limited health human resources Note: * Denotes factors identified as having a significant impact

9 Factors Most Likely to Increase or Decrease Demand Service Specific Urology Increase demand None identified Unknown evidence supporting cancer screening Projected increased oncology demand CKD Increased Demand Increase in individuals with end stage heart disease Transplant population long term use of anti-rejection medication Diabetes Decreased Demand Increased access to physician assistant or nurse practitioner may increase result in increased productivity Decreased Demand Increase prevention Best practice standards for hypertension, diabetes Increase client s knowledge of health risks and status and success with self management. Increase access to nephrology clinics/care to prevent or delay need for dialysis

10 Urology Components of Ideal Service Delivery Model Component Services associated with this component Clinical & non-clinical interdependencies Linkages to community services Health promotion/disea se prevention Increased education re on prevention of cancer Increased education on stone prevention Global media marketing of health Link to CCO for prevention Link to public Health Primary & Community Care Pre & post hospital Continuity in primary care Primary care capacity to meet population access requirements in all areas of the LHIN Standard care paths Timely access to urologist, other allied health, diagnostic services in the most appropriate place (does not need to be done at academic centre) Integrated information system Coordinated care with community services Access to funded stoma/catheter therapy training Early detection, assessment and follow Access to multidisciplinary team for complex cancer cases \ Role of pre-cancer screening identified Integrated information system Diagnostic services Outreach multidisciplinary team Interventional radiology Access to specialists Access to end of life care identification of what services are needed to provide end of life care CCAC for follow up care Community based continence care keeps people home Link to rehab services Link to end of life care Stoma/catheter support

11 Urology Components of Ideal Service Delivery Model Component Services associated with this component Clinical & nonclinical interdependencies Linkages to community services Acute Care Hub and Spoke Model Tertiary care Community hospitals Community Clinics Hub (everything plus) Complex cancer services Multidisciplinary team Interventional radiology Timely access to tertiary care beds Access to evidence based technology Community Hospitals Most oncology cases, the majority of stones cases, most male and female voiding dysfunction, most infectious diseases, most erectile dysfunction, much of pediatrics, most andrology, basic infertility Access to urology services at multisite hospitals Access to interventional radiology Clinics Simple basic surgical procedures Primary & Specialist care services Early urological screening & diagnostics Monitoring and follow up Outreach team Integrated information system Cross site urology work group to monitor quality of care and outcomes Interventional radiology Supportive specialists i.e. cardiology Education across sites Videoconferencing/w eb based education CCAC & community care Continence, catheter and stoma care & support

12 CKD Components of Ideal Service Delivery Model Component Services associated with this component Clinical & non-clinical interdependencies Health promotion/ disease prevention Primary & Community Care - Pre and post acute Strong, integrated primary prevention system to prevent diabetes, high blood pressures & obesity Increased coordination & integration of all diabetes education programs Education provided by mixture of health care professionals. Flexible models Best practice guidelines for screening Early detection of high risk population. Continuity in primary care for assessment, monitoring & follow up Staffing model standards/regulations for community & LTC (Default mech) CCAC maintain home PD & hemo. Access to rehab/ltch/end of life/basket of services for dialysis clients Pre-emptive transplant care Established ongoing communication system between regional centre/ltc/community sector Designated number LTCHs adequately resourced to care for the CKD population Link to Public Health/Min Health Promotion, CDPM, Diabetes strategy Heart and stroke strategy to reduce cardiac and HTN events Integrated information system Access to other specialists, endocrine, cardiac etc Ongoing education for community and LTC Public health/primary care vaccinations for hepatitis Ongoing education to maintain expertise - across health professionals and EMS Linkages to community services Municipalities planning Other ministries i.e. education CDPM CHCs Role of community support for brittle diabetics Diabetes education programs CCAC for home dialysis support Access to rehab, LTC Link to rehab services Link to end of life care Accessible transportation Partnership with kidney foundation

13 CKD Components of Ideal Service Delivery Model Compone nt Acute Care Hub & Spoke Model Regional centres Satellites IHF Defined by MOH CKD model Services associated with this component interdependencies Linkages to community Hub/Regional Centre Tertiary centre: Transplant & dialysis to other tertiary centres Vascular & interventional resources for vascular access. Access to interventional radiology services at the regional centre or formalized linkages to access service in a timely manner Timely body access Dedicated OR time for Vascular & PD Primary level 2 & 3 dialysis Pre & Post dialysis clinics, nephrology clinics Home dialysis & training Access to surgeons all hemo patients surgeon consult Nephrology clinics referral based on GFR Express protocol for admission to regional centre established (with repatriation agreements) Optimize ambulatory services and supports to reduce inpatient stays Dedicated resources for plasmapheresis Maximize transplant program along the transplant continuum Home dialysis targets appropriate for the demographic and geographical area Satellites Level 1 2 dialysis Post dialysis and nephrology clinics Predialysis clinics based on critical need (mobile clinics) Selective home dialysis training. Integrated information system Services for vascular access link to vascular PAG Interventional radiology Urology re PD insertion Access to resources/specialists to treat peripheral vascular disease Combine treatment clinics (diabetes, nephrology, stroke/htn) Videoconferencing/ web based conferencing CCAC community support Access to rehab, LTC End of life care education and support Link to Critical Care Lead to identify dialysis needs at LHIN critical care units. Diabetes clinics

14 CKD Components of Ideal Service Delivery Model Component Services associated with this component interdependencies Linkages to community Hub and Spoke Model Regional centres Satellites IHF IHF - Level 1 dialysis Reevaluate the necessity of IHF through expansion of home dialysis Regional CKD Centre Defined by MOH CKD model

15 Meeting 2 Incorporate PAG colleagues feedback Diagram of PAG ideal service delivery Model Describe PAG Ideal Model using LHIN Criteria Describe prerequisites, enables and challenges to the implementation of the ideal service model

16 Urology Ideal Service Delivery Model Heath Promotion Cancer prevention education Stone prevention Global media marketing of health Primary & Community Pre & Post Acute Care Primary Care Assessment and early detection Consistency in referrals (care paths & regular knowledge sessions) Follow up care & monitoring Coordinated & integrated with community providers care (including palliative) Community Care Coordinated by CCAC Continence care Pre and post acute care education/support for stoma and catheter care Pallative care (hospice/outreach) Pain Clinics Patient Accesses & Moves Across Levels of Care Based on Need Community Community Tertiary Centre Complex Cancer & other urology cases Multidisciplinary outreach, Most oncology, stone, voiding infertility, erectile dysfunction pediatric and basic fertility, andrology cases. Hospitals Medical oncology & multi-disciplinary cancer care (oncology, palliative car etc. ) Simple basic surgical procedures Assessment, monitor, follow up Diagnosis, Access to Primary Care & Urologist Outreach team Clinics Integrated & Coordinated Care Across the Continuum

17 CKD Ideal Service Delivery Model Heath Promotion Strong, integrated primary prevention system to prevent diabetes, high blood pressures & obesity Increased coordination & integration of all diabetes education programs/clinics, nephrology and cardiac/stroke/ HTN clinics Primary & Community Pre & Post Acute Care Primary Care Education provided by mixture of health care professionals. Best practice guidelines for screening Early detection of high risk population. Continuity in primary care for assessment, monitoring & follow up Pre-emptive transplants Community Care Staffing standards/regulations for community & LTCH (Default mech) CCAC maintain home PD & hemo. Access to rehab/ltch/pallative care for dialysis clients Tertiary Regional Centre Role Renal Transplant services Dialysis services to other tertiary centres CKD Regional Centre Defined by MOH CKD Model Body access Vascular and PD Dedicated OR time for PD Interventional radiology Dialysis level 2 & 3 Pre & Post dialysis clinics, nephrology clinics Home dialysis including training LTCH Supporting tertiary Specialties i.e. Cardiac, neuro Home Satellites A,B, C Level 1 & 2 Dialysis Post dialysis and Nephrology clinics Outreach Pre-dialysis clinics IHF? Integrated & Coordinated Across the Continuum

18 PAG Ideal Model -LHIN Criteria Domain Criteria Assessment Strategic Fit Population Health Aligns with LHIN priorities for health improvement, health care needs and system transformation Heath Status clinical outcomes Prevalence Health Promotion and disease prevention Promotes patient flow and integration across the continuum of care Builds on existing infrastructure & optimizes use of health human resources Responds to health care needs of population i.e. close to home Strong emphasis on integrated prevention across the continuum of care (screening case finding in early stages) Supports quality outcomes The hub and spoke model can quickly respond to variances in prevalence and incident.

19 PAG Ideal Model -LHIN Criteria Domain Criteria Assessment System Values Client Focused Partnership & Community Engagement Innovation Equity Efficiency Promotes prevention, early detection, close to home and in the home Focused on patient safety Hub and spoke model depends on partnerships between hospitals, community and primary care Greater integration with community which will build confidence between teams LHIN model promotes integration ideas and centres, which is innovative Does not considered IHF model for urology (stand alone centres i.e. Alberta) Integration of knowledge Equity of services through hub/spoke model Access to advanced technology limited i.e. lithotripsy Integrated information system needed, to reduce duplications of tests i.e. labs, xray (model has potential to gain efficiencies)

20 PAG Ideal Model -LHIN Criteria Domain Criteria Assessment System Performance Access Quality Sustainability Integration Model improves access promotes quality is feasible. sustainable and does not require substantial new investments optimizes health care professionals and supports training promotes and depends on integration across the continuum. Promotes integration

21 Ideal Service Model - Prerequisites, Enables & Challenges to Implementation Category Prerequisite Enables Challenges Policy/legislation Changes in legislation/policy re staffing models LTCH- community CCO guidelines for urology PD policy in LTCH Funding policy for CKD Funding policy for CKD in LTCH Policy change re use of creatine vs GFR for nephrology clinics Resources Existing infrastructure, formal hub and spoke model for CKD LTCH PD Dialysis resources for dietician Transportation Lack of integrated information system communication with regional centre Transplant resources Preemptive transplant resources

22 Ideal Service Model - Prerequisites, Enables & Challenges to Implementation Category Prerequisite Enables Challenges Community readiness Availability of resources (funds & HR) in community Standard medical directive/orders for nursing Community support LHIN based interactive IT Transportation Lack of supportive housing/assisted living Home maintenance/adaption Services ehealth transfer of information Partnerships/ linkages Enhanced communication process between acute, LTC and community Urology cohesive collaborative group CKD model Standardized MD credentialing across the LHIN Timely affordable transportation Readiness of ancillary resources

23 Meeting 3 Discuss Input from PAG Colleagues Finalize All Templates for Submission to Committee

24 PAG Colleague Feedback Suggested feedback incorporated or strengthened in model: Greater emphasis on need for vascular support for CKD (Dependency on plastic i.e., catheters increases infection rates/sepsis, in-patient admissions and mortality) Physician PD catheter insertion compensation Promote more ambulatory care Strengthen rehab & Pallative care services Funds need to move with patient Timely access to short term beds (24-48 hours) Support centres of excellence

25 PAGs with Direct Links to UR/CKD Vascular Surgery Rehab Pallative Care Critical Care Emergency Services