NE LHIN Rehabilitation (Rehab) and Complex Continuing Care (CCC) Systems Review

Transcription

1 NE LHIN Rehabilitation (Rehab) and Complex Continuing Care (CCC) Systems Review June 1, 2012

2 June 1, 2012 Ms. Louise Paquette Chief Executive Officer North East Local Health Integration Network Dear Louise, I am pleased to submit the Report of the Rehabilitation (Rehab) and Complex Continuing Care (CCC) Systems Review to the North East Local Health Integration Network (NE LHIN), conducted between November 2011 and January This report will be followed by two additional, shorter reports, flowing from the first phase of the work. These consist of: An evaluation of the congruence with Best Practices for hip and knee replacements, hip fracture and stroke in the community; and A mapping of current programs for specific organizations for hip and knee replacements, hip fracture and stroke within the Rehabilitation and Complex Continuing Care Expert Panel framework/matrix. The work was supported by a Core Stakeholder Group created by the NE LHIN for the purpose of this project and was chaired by Terry Tilleczek, Senior Director, Emergency Department (ED)/Alternative Level of Care (ALC). The mandate of the Core Stakeholder Group was to review and advise on each step of the process in terms of content, methodology and timelines, including the final report. In addition, Erika Espinoza provided support throughout the process and with Rebecca Ducharme in the preparation of the reports. Stakeholders within the NE LHIN, including all the hospitals and the North East Community Care Access Centre, as well as other staff within the NE LHIN, were most helpful in providing the necessary data and information. The collaboration of the NE LHIN staff and stakeholders was a key factor in the completion of this project. It has been a privilege to engage in this work. Sincerely, Rika Vander Laan, RN, MScN Rehabilitation and Complex Continuing Care Officer 2

3 E X E C U T I V E SU M M A R Y 7 B A C K G R O UND 15 REHABILITATION AND COMPLEX CONTINUING CARE EXPERT PANEL 15 CARING FOR OUR AGING POPULATION AND ADDRESSING ALTERNATE LEVELS OF CARE 18 ENHANCING THE CONTINUUM OF CARE: REPORT OF THE AVOIDABLE HOSPITALIZATION ADVISORY PANEL 19 CCAC EXPANDED ROLE 20 M E T H O D O L O G Y 22 F INDIN GS 22 THE NE LHIN 22 CHARACTERISTICS 22 REHABILITATION AND COMPLEX CONTINUING CARE SYSTEM 23 DESIGNATED INPATIENT REHABILITATION BEDS 26 ALTERNATIVE LEVEL OF CARE (ALC) 28 TYPES OF PATIENTS SERVED 28 ADMISSION FUNCTIONAL INDEPENDENCE MEASURE (FIM) SCORES 30 OUTPATIENT REHABILITATION 32 UTILIZATION 32 CHALLENGES AND RECOMMENDATIONS 33 COMMUNITY REHABILITATIVE CARE CCAC 35 UTILIZATION 35 CHALLENGES AND RECOMMENDATIONS 36 COMMUNITY SERVICES (OUTPATIENT AND CCAC) 36 TRANSITIONAL CARE BEDS 36 COMPLEX CONTINUING CARE 37 HUB HOSPITALS AND ST. JOSEPH S CONTINUING CARE CENTRE (SJCCC) 37 UTILIZATION 37 ALC 38 COMMUNITY/RURAL HOSPITALS WITH CCC BEDS 39 LOS 39 UTILIZATION AND ALC 40 CASE MIXED INDEX (CMI) 41 CHALLENGES AND RECOMMENDATIONS 42 CONVALESCENT CARE 42 UTILIZATION 43 3

4 PR O G R A M D E F INI TI O NS A C R OSS T H E R E H AB A ND C C C SYST E M 43 CHALLENGES AND RECOMMENDATIONS 44 A C C ESS A ND R E F E RR A L 45 CHALLENGES AND RECOMMENDATIONS 49 C C A C E N H A N C E D R O L E 50 CHALLENGES AND RECOMMENDATIONS 50 R ESO UR C ES A ND C OST IN G 51 E N A B L E RS A ND B A RRI E RS 55 NORTH EAST REHAB NETWORK 55 PR OJE C T A C C O MPL ISH M E N TS T O D A T E A ND A C T I V I T I ES O U TST A NDIN G 56 N E X T ST EPS A ND IN F R AST RU C T UR E 58 NEXT STEPS 58 INFRASTRUCTURE 58 SU M M A R Y O F C H A L L E N G ES A ND R E C O M M E ND A T I O NS 59 INPATIENT REHAB 59 OUTPATIENT REHAB 60 COMMUNITY REHABILITATIVE CARE (CCAC) 61 CCC 62 PROGRAM DEFINITIONS ACROSS THE REHAB AND CCC SYSTEM 62 CCAC ENHANCED ROLE 63 NEXT STEPS AND INFRASTRUCTURE 64 4

5 APPE NDI C ES A. Project Charter B. Expert Panel Conceptual Framework Matrix C. Future State of Rehab D. Overview of services E. Rehab Inpatient Utilization F. Rehab Inpatient LOS G. Rehab Inpatient FIM scores H. Outpatient Utilization I. Community Hospital Outpatient services J. NE CCAC Data K. CCC Data L. CCC in Community Hospitals M. Admission Criteria and Staffing Ratios N. Rehab Inpatient Staffing O. CCC Staffing P. Convalescent staffing 5

6 NE LHIN Rehabilitation (Rehab) and Complex Continuing Care (CCC) Systems Review Executive Summary June 1,

7 As part of overall system planning and its Emergency Department (ED)/Alternate Level of Care (ALC) initiatives, the North East Local Health Integration Network (NE LHIN) initiated a project to review the Rehabilitation (Rehab) and Complex Continuing Care (CCC) system with a long-term goal of developing a comprehensive service delivery model. In the fall of 2011, a project plan and timeline was developed. In October 2011, a Core Stakeholder Group was formed to work with the NE LHIN and the Rehabilitation and Complex Continuing Care Officer to review and advise on each step of the review process in terms of content, methodology and timelines, including the final report. The group met for the first time on November 1, The scope of the work included a review of the four hub hospitals, (Health Sciences North (HSN), Timmins and District Hospital, North Bay Regional Health Centre and Sault Area Hospital (SAH)), West Parry Sound Health Centre, St. (SJCCC) and the North East Community Care Access Centre (NE CCAC). The smaller rural hospitals were also surveyed, although in a more limited way. One hundred (100) percent of facilities and agencies returned the surveys. Information was collected to determine: current capacity; utilization of beds (inpatient rehab and CCC); service volumes (outpatient rehab and CCC) over the past 3 years; patient criteria (Functional Independences Measures (FIM) scores); LOS; referral processes, sources and waitlists; and resources (staffing). Results The results and analysis revealed the following general findings: Population in the NE LHIN is older, spread out over a wide geographical area with poorer overall health when compared to the province Rehabilitative services are The role of smaller, rural hospitals is unique and unclear There are differences in practice, especially in musculoskeletal (MSK) across the system Limited data exists about the population in rehab Lack of outpatient services (and data) across the NE LHIN impacts inpatient stay, outcomes for patients and as a result, subsequent use of services Duplication of effort exists in some areas between CCAC and outpatient services Some overlap, inconsistency of program definitions and streamlining exists across the system Internal referrals are faster, more efficient than external referrals with inadequate access to rehab from smaller rural hospitals 7

8 Standardized referral processes and documentation are in place for inpatient rehab across the NE LHIN, although not consistently understood There are differences in wait times for inpatient rehab for different institutions (from NE Rehab Network audit), although current data is limited. Future audits will include all hub hospitals. Current process for external referral to CCC is cumbersome and slow There is inadequate data about wait times and targets are unclear Enhanced collaboration is needed from all sectors involved in rehabilitative care Summary of Challenges and Recommendations Following is a summary of the specific challenges and the subsequent recommendations that will move the system forward. Also included are specific actions and timelines that can serve as a future work plan. Specific parties who could/should assume responsibility for each action item are also identified. Inpatient Rehab Challenges Recommendations Action Responsibility Differences in practice, specifically around MSK and utilization of inpatient beds 1. Determine congruence with Best Practices in rehab for MSK and stroke as endorsed by the Expert Panel. Develop and implement a template for measuring congruence and complete by March 31, Core Stakeholders and Rehab and CCC Officer Limited Availability of PT, OT, SLP 2. Expand the concept of the rehab team to include a more enhanced role for nursing and provide training opportunities (i.e. Rehab certification through Canadian Nurses Association (CNA)) and training for the team to include a more enhanced role for nursing. This will enable a more around the clock/7 day a week approach to rehab. Disseminate information about CNA certification North East Rehab Network to facilitate with hub hospitals and core stakeholder group. March to November Follow up re: uptake January North East Rehab Network Core Stakeholders in rehab and CCC 8

9 Challenges Recommendations Action Responsibility Identification of ALC within rehab 3. Wherever possible clarify and create standard approach to classifying patients as ALC in rehab and CCC so data can be interpreted consistently and compared. Expand the mandate of LHIN group currently addressing classification of ALC in acute care to include rehab and CCC. March to May LHIN and Core stakeholders in rehab and CCC Limited data describing the population 4. Collaboration between NE LHIN, North East Rehab Network and the hub hospitals to develop and apply a template for system monitoring and comparisons across the rehab facilities and reduce duplication of effort to monitor the data. The template should include at least: o FIM Median and range as well as means o FIM Efficiency scores o ALC across rehab sites o Wait times o Key questions s re: shifts in outpatient changes in volumes and shifts in staffing between inpatient and outpatients Develop and apply a template, building on the North East Rehab Network template and this report, enabling system monitoring and ensuring congruence with the Expert Panel Data recommendations. Utilize existing systems (NRS). Determine a reporting schedule. Template to be completed by June 30, NE LHIN and North East Rehab Network First report ready June Outpatient Rehab Challenges Recommendations Action Responsibility Outcomes in outpatient programs, especially for MSK patients, are better than in home services as services can be more frequent and intense. 5. Review congruence with best practices for MSK, especially hip and knee replacements (together with recommendation #1) Develop and implement template for measuring congruence and complete by March 31, Core Stakeholders and Rehab and CCC Officer 9

10 Challenges Recommendations Action Responsibility Lack of outpatient services impacts inpatient stay Include questions in the rehab data template. June Shifting of staff from outpatient to inpatient services, resulting in decreasing the amount of outpatient service available 6.Add some key questions to the rehab template (R#4) to monitor : o longer inpatient stays related to lack of outpatient services o overall shifts in outpatient services o when outpatient services/volumes decrease because staff is reassigned to inpatient services. North East Rehab Network and LHIN Lack of knowledge about availability of rehab services in community hospitals 7. Disseminate information to providers about services available and about the NE Rehab Network web site. Develop communication about information available March 31, North East Rehab Network with LHIN communications Accessing rehab in rural and remote communities 8. Explore the possibilities for integrating Telemedicine in providing/accessing care as part of developing a comprehensive rehabilitative model. Engage with NE LHIN Telemedicine lead in preparation for model development to determine their capacity. Build on the experience of stroke and ABI. Initiate by March 31, Core stakeholder Group and NE LHIN Telemedicine lead Community Rehabilitative Care (C C A C) Challenges Recommendations Action Responsibility Variations in visits for specific diagnostic groups across branches 9. Review and apply best practices for MSK and stroke, together with recommendation #1. Develop and implement template for measuring congruence and complete by March 31, Core Stakeholders and Rehab and CCC Officer 10

11 Reduce duplication of effort between CCAC and outpatient services. 10. Work collaboratively with outpatient services in the various communities to leverage access to services. Partners within the North East Rehab Network to explore current collaborations across communities and identify opportunities such as sharing staff. In progress and ongoing. CCAC and outpatient providers Complex Continuing Care (C C C) Challenges Recommendations Action Responsibility Program definitions and streaming across settings To be addressed in program section (Recommendation #11) See action in program section. Classification of CCC patients as ALC See Recommendation # 3. Program Definitions across the Rehab and C C C System Challenges Recommendations Action: Responsibility Overlap in program descriptions, criteria for admission 11. Streamline programs, definitions and criteria across the system from rehab to CCC to convalescent care, utilizing the Expert Panel framework to inform the process. With core stakeholder group, using the Expert Panel Template, clarify and streamline definitions, where programs fit. Core stakeholder Group and Rehab and CCC Officer clinical data, including the Alpha FIM (for acute care) FIM (for rehab), and the RAI (for CCC and Convalescent elements and the clinical level intensity of care required. Utilizing the work of the Expert Panel, develop a clearer process across the NE LHIN for determining overall need and the data elements required to identify needs of individual patients. March to September NE LHIN and Transitional Care Units and Core Stakeholder Group 11

12 Access and Referral Challenges Recommendations Action Responsibility Development of a process for transition to rehab and CCC that meets the needs of patients and referring and admitting facilities 13. Evaluate the current process in place for CCC admissions to SJCCC and SAH as a pilot/test for future process. Process currently being undertaken to address the challenge. Report expected by February 29, CCAC and SJHC and HSN Improve wait time tracking Matching actual practice to targets for referral to assessment to decision to admission. Reduce wait times 14. Develop more specific tracking methods to measure: a) actual to targets for processes for all external referral transition points: to inpatient rehab; to CCC; and to the CCAC. b) Actual wait times. 100 % participation by hub hospitals with designated rehab beds in the North East Rehab Network External Referral Audit. Include data in the regular reporting template (See Recommendation # 4). North East Rehab Network and hub hospitals Initiate specific tracking of referrals through the CCAC to CCC and convalescent care of actual to targets. September 30, Monitor actual wait times. CCAC All core stakeholders Collaboration already in progress with ALC RM&R processes. 12

13 C C A C Enhanced Role Challenges Recommendations Action Responsibility Transition to enhanced CCAC role for CCC and rehab CCAC and Stakeholders 15. Support the CCAC initiative to develop case managers with particular expertise in rehabilitative care to manage transitions to rehab and CCC. Include rehab and CCC stakeholders as processes are being developed and tested. To November Create mechanism for CCAC collaboration with acute care, rehab and CCC as new processes are developed. Ongoing Next Steps and Infrastructure Challenges Recommendations Action Responsibility Collaboration from all the sectors involved in rehabilitative care LHIN and Core Stakeholder Group 17. Create a group that includes representation of all stakeholders involved in rehabilitative care across the NE LHIN, including all hospitals, NE CCAC, geriatric services and convalescent care, that will follow-up on this review and drive the development of a comprehensive service delivery model for rehabilitative care. April Create a strong stakeholder group under the NE LHIN umbrella with enhanced membership and mandate. Create NE LHIN rehabilitative care. 13

14 NE LHIN Rehabilitation (Rehab) and Complex Continuing Care (CCC) Systems Review Report June 1,

15 Background As part of overall system planning and its Emergency Department (ED)/Alternate Level of Care (ALC) initiatives, the North East Local Health Integration Network (NE LHIN) initiated a project to review the Rehabilitation (rehab) and Complex Continuing Care (CCC) system with a long-term goal of developing a comprehensive service delivery model. In the fall of 2011, a project plan and time line was developed as part of the NE LHIN Rehabilitation and Complex Continuing Care System Review Charter. The charter outlines the scope, activities, structure and a process for engaging stakeholders, including the identification of recommendations and an implementation plan to enhance access and patient flow to rehab and CCC occurring in the NE LHIN. The full charter and membership is found in Appendix A and B of this report. The initiative in this document supports the NE LHIN ED and ALC priorities. The project is also taking place alongside and concurrent with the work of a provincial Rehabilitation and Complex Continuing Care Expert Panel. A challenge to this project is the timing of both the Ministry of Health Long-Term Care (MOHLTC) Expert Panel and the recommendations of the NE LHIN in moving forward with their plan around rehabilitative care, in that the Expert Panel will not be completed its report until the fall of Rehabilitation and Complex Continuing Care Expert Panel The MOHLTC Rehab and CCC Expert Panel was formed in December 2010 as a sub-committee of the province ED/ALC Expert Panel. The purpose of the Rehab and CCC Expert Panel is to -think the delivery of rehabilitation and complex care across the acute and post- acute continuum including community settings, hospitals, transitional and convalescent care settings and in long-term 1 Phase I of the Expert Panel report focused on providing advice and guidance to the ED/ALC Expert Panel on how best to reduce ALC lengths of stay (LOS) throughout the system by properly utilizing the capacity, role and expertise available in rehab and CCC resources. Key recommendations for immediate action included endorsement of best practices for stroke, hip and knee replacement and hip fractures across the full continuum of service (acute, rehabilitative care and community) and for the LHINs to evaluate current congruence with best practices. 1 Rehabilitation and Complex Continuing Care Expert Panel: Phase I Report, June, 2011, p

16 A second phase, nearing completion, focuses on describing a framework for rehabilitative care. The framework is governed by the following foundational principles: Early access to rehabilitative care should be equitable; All of these programs and services can be described or measured by data elements; Every program or service can be mapped to a Canadian Institute for Health Information (CIHI) National Rehabilitation Reporting System (NRS) category or Continuing Care Reporting System (CCRS) category and to a Ontario Healthcare Reporting Standards (OHRS) category; The care delivered to every patient/client group, diagnostic cluster and in every location would be guided by best practices where they exist; All programs and services would be delivered in an age appropriate manner (e.g. seniors focused, developmentally appropriate); Within each program or service there is flexibility to care for patients/clients as their tolerance for treatment changes to minimize transitions; and There is recognition that clustering patients with similar care needs allows for care delivery by dedicated inter-professional teams which, in turn, leads to better outcomes. Key components of the framework focus on rehabilitative care rather than rehab and CCC beds. The desired outcomes of rehabilitative care will include one or more of: Maintenance or sustaining of functionality; Restoration of functionality; and Developing of adaptive capacity. The Expert Panel has developed a conceptual framework matrix that brings together five (5) functional groupings, best practices and locations of care. This conceptual framework describes the spectrum of programs and services that, in a future state, will be available to patients/clients who require rehabilitative care. The framework has been field tested in various settings for a variety of populations. The framework consists of the following three (3) elements: Element 1 Level of patient/client functioning, capacity for improvement and expected speed of recovery This concept is to distinguish between categories of patients/clients based on initial level of function, capacity for functional improvement, complexity and predicted speed of recovery. 16

17 There are five (5) groupings. This element describes for each of the five groups where (provincial, regional, local) care would be delivered (see Appendix B). Element 2 Patient/client clusters Placement in a cluster would be by most responsible rehabilitative diagnosis from the following 13 groups: Medically Complex, Stroke, Spinal Cord, Oncology, Acquired Brain Injury (ABI), Cardiac Rehab, Amputee, Pulmonary, Burn, Musculoskeletal (MSK) (Orthopaedic), Neurology, Geriatric and Paediatric. It is recognized that there may be overlap between clusters. The purpose of clusters is to enhance best practice and allocation of health human resources (HHR). The clusters also map well to existing CIHI and OHRS categories. Element 3 Locations of care and best practices (local, regional, provincial) In each box, the best practices each type of patient/client will receive in each location will be described (see Appendix B). There will be one matrix for each of the 13 clusters from Element 2. Completion of the matrix is based on best practices and conducted by content experts. Depending on the best practice, there may not be a role documented/noted for each location (e.g. local, regional, and provincial). An example might be stroke care delivered to a Group 4 patient/client, which would include acute care rehab, secondary prevention clinic and/or a community-based day program that is only available locally. It is recognized that the matrix may be different in different LHINs depending on resource availability. A map of a future state of rehabilitative care can be found in Appendix C. Work still in progress Once complete, the Conceptual Framework and corresponding Data Elements to be identified can be used to measure existing systems against systems defined by best practices. This work is expected to be completed by the Definitions Working Group in the spring of The last phase of the MOHLTC the size and site of the rehabilitative system, using the conceptual framework. A timeline of fall 2012 has been tentatively identified by the Expert Panel for completion of this phase. 17

18 Other Reports/Initiatives A number of other reports and initiatives are also informing the work of then NE LHIN Rehabilitation and Complex Continuing Care Systems Review Project. Highlights of each of these reports are summarized below. Caring For Our Aging Population and Addressing Alternate Levels of Care In June 2011, Dr. David Walker submitted his report, Caring for Our Aging Population and Addressing Alternate Levels of Care. 2 to meet the needs of an increasingly aging population who will live longer in states of both health and illness. To meet these needs, the system must shift to address six transformational pillars of care, by realigning, refocusing, and targeting investments, improve patient flow across the system and optimize an 3 A summary of the pillars and recommendations around each of the pillars from the report follows. Improve Access to the Right Care Through Community Investments Primary Care management of high-risk frail seniors sector NE LHIN Primary Care Lead Community Care Continuum of NE CCACs and CSS e Virtual Wards Improve Patient Flow Across the System Acute Care Hospitals Senior Friendly principles planning Assess and Restore Assess and Restore in CCC/Rehab and long-term care home (LTCH) pathways Optimize and differentiate Capacity Long-Term Care (L T C) Capacity capacity needs patients and complex care preferred beds LTCH 2 Caring For Our Aging Population and Addressing Alternate Level of Care, Report submitted to the Minister of Health and Long-Term Care, Dr. David Walker, Provincial ALC Lead, June 30, Caring For Our Aging Population and Addressing Alternate Level of Care, Report submitted to the Minister of Health and Long-Term Care, Dr. David Walker, Provincial ALC Lead, June 30, 2011, p

19 Improve Access to the Right Care Through Community Investments Improve Patient Flow Across the System Optimize and differentiate Capacity Special Needs Populations ialized units in community and LTC System Enablers: Governance and Accountability, Health Human Resources (HHR), Information Technology (IT), Health Professional and Public Education and Awareness, Process and Patient Flow Efficiency While all aspects of this report are relevant, the key element of the report for this project is around the ssess and Restore recommendations. Assess and Restore is seen as both a philosophy and func level of functioning and creating opportunities for them to be transferred home with enhanced, appropriate supports. The vision is to have Assess and Restore programs accessible within CCC, rehab or in short-term transitional programs in LTC and perhaps even acute care. The goal is to provide such services as quickly as possible, rather than risk deterioration. This could involve direct admission to an Assess and Restore Program from the ED, thus bypassing admission to an acute care bed. Enhancing the Continuum of Care: Report of the Avoidable Hospitalization Advisory Panel In November 2011, Dr. Ross Baker et al. 4 submitted a report focused on improving quality of care, sustainability of the health system and more effective use of health care resources in Ontario by reducing avoidable hospitalizations. The report calls for: Better planning for discharge; Improved communication between clinicians in different settings, as well as clinicians and patients; Medication reconciliation and management when patients return home; Patient and caregiver education; and Timely primary care follow-up in the community. 4 Enhancing the Continuum of care: Report of the Avoidable Hospitalization Advisory Panel Submitted to the Ministry of Health and Long-Term Care. November,

20 The report identifies clinical strategic partnerships across the health care system and collaboration across organizational boundaries as an essential element for reducing poor outcomes. It also states that efforts to improve care transitions need to be integrated into the system without adding unnecessary complexity or introducing duplication. Dr. Baker also refers to the recently passed (June 2010) Excellent Care for All Act ECFAA) 5, highlighting the promotion and dissemination of evidence based recommendations, supporting health care providers in quality improvement and adoption of best practices. One of the key populations of interest is the frail elderly and those with co-morbidities. Dr report and recommendations support both the work of the Rehab and CCC Expert Panel and the recommendations of the Caring for Our Aging Population and Addressing Alternate Levels of Care 6 report. C C A C Expanded Role In 2011, under new legislation, the Community Care Access Centres (CCACs) across the province will assume an expanded role as the core navigators through the health system. This includes rehab and CCC. Implementation strategies and timelines on this new role are being established at the LHIN level. The plan for the NE LHIN is for rehab and CCC to be ready for implementation in November Currently, the NE CCAC plays an enhanced role in some of the referrals to CCC/slow paced rehab/convalescent care in both Sault Ste. Marie and Sudbury. In light of this new expanded role, CCAC staff are members of the NE LHIN Core Stakeholder Group for the rehab and CCC systems. Alternate Level of Care Resource Matching and Referral (A L C R M & R) Project The ALC RM&R project is a provincial initiative. The LHINs have been divided into several clusters, of which the NE LHIN forms a cluster that includes the North West, South East and Champlain LHINs. The purpose of the Provincial ALC RM&R Business Transformation Initiative (BTI) is to standardize referral processes, forms and terminology across the province for in-scope referral pathways. The goal is to improve communication and patient flow, ensure acute care. The referral pathways include referrals to rehab and CCC and as such have relevance to the rehab and CCC project in terms of referral processes and pathways. 5 Ministry of Health and Long Term Care. Excellent Care for All Act (ECFAA), Enhancing the Continuum of care: Report of the Avoidable Hospitalization Advisory Panel Submitted to the Ministry of Health and Long-Term Care. November,

21 Geriatric Services The Northeast Specialized Geriatric Services (NE SGS) was established in 2009, which allowed for the recruitment of a Geriatrician and the hiring of an inter-professional team located in Sudbury. Since that time and through additional funding, some of which included the MOHLTC Aging at Home funding distributed via the LHINs, the service has been able to evolve further throughout the NE LHIN with the development of teams (including Care for the Elderly physicians and nurse practitioners) in a number of communities across the NE LHIN, development of standardized assessment, a Falls program, case management and Telemedicine clinics. In 2010, a Geriatric Rehab Unit (GRU) was established, as well as a Geriatric Day Hospital (GDH). As there is only one Geriatrician in the NE LHIN, the program uses a consultation model to provide services to those in northeastern Ontario. The program is focused on identification of frail and at-risk elderly, preventing disability and decline and restoring their overall function. The team is working on capacity building and planning for sustainability. Another initiative related to the geriatric population includes the Geriatric Emergency Management (GEM) nurses who assist ED staff in developing geriatric knowledge and skills and assist them in interfacing with the community. Many hub hospitals (the Sault Area Hospital (SAH), Health Sciences North (HSN) and West Parry Sound Health Centre (WPSHC)) now have a GEM program in place. In January 2010, a report entitled Developing Specialized Geriatric Services and Programs in Sudbury Hospitals was submitted to the Sudbury ALC Steering Group. The report was commissioned by Health Sciences North (HSN) (formerly the Hôpital régional de Sudbury Regional Hospital (HRSRH) and completed by an external consultants. The report identified opportunities for the development of a model of specialized geriatric units and teams in Sudbury hospitals. Some of the recommendations and next steps identified in the report have been implemented (GRU, GDH) while some of the suggested integrations of services remain works in progress. 7 7 Developing Specialized Geriatric Units and Programs in Sudbury Hospitals. Prepared by Maureen Vickers, January,

22 Methodology In October 2011 a Core Stakeholder Group was formed to work with the NE LHIN to review and advise on each step of the review process in terms of content, methodology and timelines, including the final report. The group met for the first time on November 1, Once the project charter was finalized, surveys and data collection tools were developed to gather information regarding: current capacity; utilization of beds (inpatient rehab and CCC); service volumes (outpatient rehab and CCC) over the past 3 years; patient criteria (Functional Independences Measures (FIM) scores); LOS; referral processes and sources and waitlists; and resources (staffing). Surveys were distributed to all hospitals within the NE LHIN that provide rehab and CCC, as well as to the NE CCAC. Twenty-five (25) surveys were distributed to the hospitals within the NE LHIN and one (1) to the NE CCAC. Surveys were distributed on November 9, 2011 with data returned by November 18, One hundred (100) percent of facilities and agencies returned the surveys. Findings The N E L H IN Characteristics The area covered by the NE LHIN is approximately 400,000 square kilometres, with a population of 582,159 (Census 2011). Some of the following characteristics describe the population, with a comparison to provincial averages. These characteristics are noticeably different from the provincial averages and are relevant to creating a comprehensive rehab and CCC system. 22

23 Table 1: Characteristics of the N E L H IN Population N E L H IN Province Population density 1.4 persons per square kilometre 13.4 persons per square kilometre Older population 17% 14% Age Dependency Ratio 24.5% 19.9 % Aboriginal population 10% 2% F rancophone one population 24% 4% The NE LHIN also shows a higher prevalence of chronic diseases including: Table 2: Prevalence of Chronic Disease in the N E L H IN N E L H IN Province A rthritis/rheumatism Asthma High Blood Pressure Diabetes Heart Disease Source: North East LHIN Demographic, Socioeconomic, and Population Health Profile, November 2008 The population density, ratio of older population and prevalence of chronic diseases have implications for building a comprehensive system of rehabilitative care. Clearly, the distribution across large rural areas means clients may not be served directly in their own communities. Access may need to be created in other ways, such as through Telemedicine. Alternatively, services may need to be provided in settings that may not be seen as appropriate in more urban areas. For example, patients may require a longer inpatient stay to achieve optimal outcomes if outpatient or in-home rehab services are not available in the home community. The prevalence of an older population also speaks to the need for the rehabilitative system to be supported and complemented by well-developed geriatric services across the region. Rehabilitation and Complex Continuing Care System There are 186 health service providers in the NE LHIN, including 25 hospitals. Each of those 25 hospitals provides some type of rehabilitative services through designated rehab and/or CCC beds that include a variety of programs and services, including outpatient rehabilitative services and consultative services through Telemedicine (see Appendix D). Designated rehab beds are situated in five (5) hospitals (HSN, TADH, NBRHC, SAH, and West Parry Sound Health Centre (WPSHC)), with one (1) hospital providing regional, specialized services (HSN). 23

24 Eighteen (18) hospitals, including four (4) hub hospitals and 14 community hospitals, have designated CCC beds; all attached to acute care facilities. The system also includes one (1) free standing facility providing CCC. Within CCC there are a variety of rehabilitative services. Rehabilitative services/consultations through Telemedicine are also available at selected sites. Two (2) hospitals, HSN and SAH, are providing transitional services which have been temporarily added to the system to address ALC pressures. Those beds are expected to be closed by March In the community, the CCAC, through their five (5) area offices, provide rehabilitative services in clients homes. Three (3) LTCHs in the NE LHIN (Sudbury, North Bay and Sault St Marie) provide convalescent services in a total of 30 beds designated as Convalescent Care under the Transition to Home program. The following two maps display ratios of rehab, CCC and LTC beds per 1,000, first for the total population and then for the population over the age of 75. Figure 1: Map # of Rehab, C C C and L T C Beds per 1,000 Population 24

25 Figure 2: Map of # of Rehab, C C C and L T C Beds per 1,000 Aged 75+ Population There are no current provincial benchmarks for the sizing or siting of rehab and CCC services. One other LHIN (Hamilton Niagara Haldimand Brant) developed a logic model for determining the sizing of their CCC beds across their LHIN. After redefining and consolidating their definitions and their streams of care, the Expert Panel Task Group used CCC bed utilization, excluding ALC, adjusting for population growth for those over the age of 75, adding 5% for unmet needs, a 12% ALC rate and a 92 % occupancy rate to determine the sizing and siting of the CCC system. The final number of beds per population was not published. The model proposed did not take into account the rehab services in designated rehab beds or CCAC rehab services within the system. While there may be also be differences in the geography (i.e. rural versus urban and overall population density), their logic model has potential for assisting the NE LHIN in estimating sizing of CCC within the NE LHIN borders. 25

26 Designated Inpatient Rehabilitation Beds Capacity and Utilization Since 2008/09, 22 beds have been added to the system in the NE LHIN (three (3) beds at HSN and 19 at the NBRHC in February 2011). HSN provides specialized and regional rehab services for the NE LHIN, with 10 beds designated for ABI. Their Intensive Rehabilitation Unit (IRU) also admits other patients for specialized services from outside their hub area. Following is data from 2010/11. Detailed data can be found in Appendix E. Table 3: Inpatient Rehabilitation Data HSN T A D H NBR H C SA H WPSH C # of Beds 30 (10 ABI) (as of Feb 2011) # of Admissions Occupancy* 98.3% 86.58% 83.20% 98.09% 25% Internal 82.8% 72% 80.5% 97% 86% Admissions Admissions Outside Hub A rea 31% N/A N/A 0% 0% Hours per Patient Day (HPPD) guidelines suggest 94% occupancy for rehab beds. *N/A information not available The number of admissions and occupancy has increased significantly in HSN since the hospital relocated its rehab department to the same campus that housed its acute care. Having easy access for determining admission has speeded up the process for internal referrals/admissions and enabled admissions for more complex patients who require on-site medical support. Occupancy in rehab units is further influenced by the availability of rehab staff (Physiotherapists (PTs), Occupational Therapists (OTs) and Speech-Language Pathologists (SLPs)) and changes in practice. For example, the low occupancy at WPSHC is partially accounted for by a change in practice. There has been significantly less utilization for MSK patients since the hiring of a new orthopaedic surgeon and the subsequent change in practice, with MSK patients in WPSHC being discharged directly home from acute care. 26

27 Table 4: Percentage Rehab Episodes Market Share by Facility for 2010/2011 HSN T D H NBR H C SA H WPSH C Primary Within Hub Other Hub Other LHIN Out of province The market share or actual number of patient rehab episodes by location of residence shows some variability across the LHIN. Hospitals for the most part provide service to patients in their immediate catchment area and within their hub, making up 85% to 97% of rehab episodes. Ratios of primary to within the hub vary considerable from: 2 to 1 (North Bay Regional Health Centre) to 6:1 for Timmins and District Hospital and Health Sciences North. Theses variable ratios could be partially due to the population and geographical distribution and proximity to the hub centre. Health Sciences North, as the regional centre, predictably has the highest share of patients from other hubs. North Bay and Timmins also serve significant numbers of patients with outside their hub, 10 and 14 % respectively. This may be due to long standing referral patterns and again geographical population distribution and proximity. West Parry Sound stands out in their distribution. Two factors may be influencing this pattern, as they are geographically on the edge of the NE LHIN and they also serve a large summer population who reside elsewhere in the province the remainder of the year. Further details about actual referral patterns will become available as the NE Rehab Network continues its audits around external refills (see Table 17). Referrals to rehab programs outside the NE LHIN are infrequent. There are however, a few situations where this does occur. WPSHC continues to refer patients south to Toronto if specialized services are required. This has been a referral pattern established over many years and suits patients in their catchment area. Likewise, James Bay has developed a referral relationship with Kingston for patients requiring rehab. Description of programs and admission criteria will be addressed in the program section, together with program descriptions in CCC. 27

28 Alternative Level of Care (A L C) In 2011 in the hub hospitals (HSN, TADH, NBRHC, SAH and including WPSHC), between 14% (March) and 26% (January) of patients receiving service in the rehab beds were classified as ALC. These are assumed to be patients who have completed their rehab and are awaiting services or placement in another sector, often a LTCH. There has been recent clarification about reporting ALC in acute care and designation of patients as rehab or CCC when they become ALC in acute care and are transferred. However, classification of patients as ALC in rehab is inconsistent and requires further clarification. Figure 3: A L C Utilization in Rehab in Hub Hospitals, 2011 Types of Patients Served As indicated in Table 4, in 2010/11, programs admitted most frequently patients with the following diagnoses by Rehabilitation Client Groups (RCGs). 28

29 Table 5: Admission to Inpatient Rehab by R C G HSN T A D H NBR H C SA H WPSH C Stroke (50%) Stroke (51%) Stroke (64%) Orthopaedic Conditions (42%) Orthopaedic Conditions (60%) Brain Dysfunction (14.2%) Orthopaedic Conditions (25%) Orthopaedic Conditions (16%) Stroke (32%) Stroke (32%) Amputation of Limb (14.2%) Medically Complex (11%) Neurological Conditions/Med ically Complex (6%) Medically Complex (15%) As noted in Table 5, stroke patients are clearly the largest population utilizing inpatient rehab. All five (5) rehab centres in the NE LHIN provide stroke rehab. In northeastern Ontario, few patients who experience a stroke are referred outside their own region, which is a change from past practices. Only in very complex situations would patients be referred to another facility, either within the LHIN or outside the LHIN and/or attending hospital. Variations in inpatient MSK utilization are indicative of differing practices, with patients undergoing hip and knee replacements using inpatient rehab in some areas and not in others, raising questions about pathways that integrate current best practices. Table 6: L OS by R C G G rouping HSN T A D H NBR H C SA H WPSH C Stroke Brain N/A Dysfunction Neurological Conditions Spinal Cord N/A N/A Dysfunction Amputation N/A of Limb O rthopaedic Conditions Medically Complex Details are available in Appendix F. 29

30 Since 2008/09, there has been a reduction in LOS across all client groupings. Table 6 demonstrates the variations of LOS across client groupings and across facilities. Length of Stay is often driven by the system, rather than by patient need. This is true across the province and an issue the Rehab Expert Panel is seeking to address. Some rehab programs have specific target LOS and patients may not be admitted if the goals appear not to meet the designated time frame. The complexity of the patient s care, such as the severity of the stroke, complications related to hip fracture or hip and knee replacements will also impact LOS. Another factor is the availability of alternative services, such as outpatient rehab services, community rehab of the right frequency and intensity, or availability of the right service in the patie services in a community hospital. Patients may remain in rehab for additional time, rather than being repatriated to their home hospital, if the clinical determination is that a longer stay and further rehab will result in a better outcome for the patient. From interviews and consultations with the NE LHIN CCC and Rehab Core Stakeholder Group, it was also clarified that patients from HSN are sometimes repatriated to their home communities to complete their rehab. This may account for some short lengths of stay for patients with specialized needs in the hub hospitals. The same is true for other hub hospitals that may repatriate patients to community hospitals for some ongoing rehab. Admission Functional Independence Measure (F I M) Scores The FIM scale assesses physical and cognitive disability. This scale focuses on the burden of care; that is, the level of disability indicating the burden of caring for them. Data about FIM scores reported includes only the mean FIM score. It is not known whether there are outliers that have influenced the mean, especially when it is either very high or very low. The FIM score should reflect the complexity of patients and the severity, for example, of their stroke. This would in turn influence LOS, assuming patients with more severe, complex challenges would have a longer LOS. This has not proven to be the case in comparisons across hospitals. This could be a function of comparing only mean FIM scores. From interviews with stakeholders, it was also clarified that a number of patients, especially from specialized programs at HSN (ABI, spinal cord and amputation), are repatriated to their home communities to complete their rehab. The data in the community rehab facility would show a much higher admitting FIM score, as the patient is already well into his/her recovery trajectory, requiring perhaps only another week or two of rehab. This also has implications for reported LOS. The resulting overall mean FIM scores would not reflect the functional level of the usual patients admitted to the unit. 30

31 The reported FIM scores also depend on how patients are classified when admitted to rehab. If they are classified as ALC or acute care while in a rehab bed and are officially admitted at later point, it is expected they would have a higher FIM score. Details are available in Appendix G. Table 7: Admission F I M Scores HSN T A D H NBR H C SA H WPSH C Stroke Brain N/A Dysfunction Neurological Conditions Spinal Cord N/A N/A Dysfunction Amputation N/A of Limb O rthopaedic Conditions Medically Complex Challenges and Recommendations Challenges Recommendations Action Responsibility Differences in practice, specifically around MSK and utilization of inpatient beds 1. Determine congruence with Best Practices in rehab for MSK and stroke as endorsed by the Expert Panel. Develop and implement a template for measuring congruence and complete by March 31, Core Stakeholders and Rehab and CCC Officer Limited Availability of PT, OT, SLP 2. Expand the concept of the rehab team to include a more enhanced role for nursing and provide training opportunities (i.e. Rehab certification through Canadian Nurses Association (CNA)) and training for the team to include a more enhanced role for nursing. This will enable a more around the clock/7 day a week approach to rehab. Disseminate information about CNA certification. North East Rehab Network to facilitate with hub hospitals and core stakeholder group. Follow up re: uptake January North East Rehab Network Core Stakeholders in rehab and CCC 31

32 Challenges Recommendations Action Responsibility Identification of ALC within rehab 3. Wherever possible clarify and create standard approach to classifying patients as ALC in rehab and CCC so data can be interpreted consistently and compared. Expand the mandate of group currently addressing classification of ALC in acute care to include rehab and CCC. LHIN and Core stakeholders in rehab and CCC Limited data describing the population 4. Collaboration between NE LHIN, North East Rehab Network and the hub hospitals to develop and apply a template for system monitoring and comparisons across the rehab facilities and reduce duplication of effort to monitor the data. The template should include at least: o FIM Median and range as well as means o FIM Efficiency scores o ALC across rehab sites o Wait times o Key questions s re: shifts in outpatient changes in volumes and shifts in staffing between inpatient and outpatients Develop and apply a template, building on the North East Rehab Network template and this report, enabling system monitoring and ensuring congruence with the Expert Panel Data recommendations. Utilize existing systems (NRS). Determine a reporting schedule. Template to be completed by June 30, First report ready June NE LHIN and North East Rehab Network Outpatient Rehabilitation Hospital based outpatient services are provided at all five (5) hub hospitals. Utilization The services include: Outpatient rehab services (PT, OT, SLP, Physiotherapist Assistant (PTA) and Occupational Therapist Assistant (OTA)); Geriatric and Adult Day Hospital programs; Seating and Mobility Clinic; Assistive Communication Clinic 32

33 Outpatient ABI Rehab; and Orthotics and Prosthetics. Outpatient data: The data for outpatient services is challenging, as not everything is tracked or reported in a consistent manner. The data presented in Table 8 reflects volumes reported for 2010/11 for four (4) hospitals (TADH, NBRHC, SAH and WPSHC). For HSN, only data for 2010/11 is available. The data represents PT, OT, SLP visits and some data may also represent visits to congregate programs, such as educational programs around back care and healthy aging. Details are available in Appendix H. Table 8: Outpatient Visits Total Total # of Patients *2819 Total # of Visits 29,156 Average # of Visits 10.3 visits per patient *Actual # of patients is discrete only by discipline, not in the total. Some outpatient rehab services are provided in community hospitals. Information about services is available on the North East Rehab Network website with contact information. Many providers are unaware of this information which could impact referrals made back to community hospitals (see Appendix I). Four (4) community hospitals use Telemedicine as a way to access rehab, whether it be assessment for admission to inpatient rehab, follow up or virtual rehab. This is an area not well explored and could have a significant impact in increasing access. Telemedicine is also used in geriatric assessments. Challenges and Recommendations Challenges Recommendations Action Responsibility Outcomes in outpatient programs, especially for MSK patients, are better than in home services as services can be more frequent and intense. 5. Review congruence with best practices for MSK, especially hip and knee replacements (together with recommendation #1) Develop and implement template for measuring congruence and complete by March 31, Core Stakeholders and Rehab and CCC Officer 33

34 Challenges Recommendations Action Responsibility Lack of outpatient services impacts inpatient stay Include questions in the rehab data template. Shifting of staff from outpatient to inpatient services, resulting in decreasing the amount of outpatient service available 6. Add some key questions to the rehab template (R#4) to monitor: o longer inpatient stays related to lack of outpatient services o overall shifts in outpatient services o when outpatient services/volumes decrease because staff is reassigned to inpatient services. North East Rehab Network and LHIN Lack of knowledge about availability of rehab services in community hospitals 7. Disseminate information to providers about services available and about the NE Rehab Network web site. Develop communication about information available. North East Rehab Network with LHIN communications Accessing rehab in rural and remote communities 8. Explore the possibilities for integrating Telemedicine in providing/accessing care as part of developing a comprehensive rehabilitative model. Engage with Telemedicine and NE LHIN staff responsible for Telemedicine in preparation for model development to determine their capacity. Build on the experience of stroke and ABI. Initiate by March 31, Core stakeholder Group and NE LHIN Telemedicine lead 34

35 Community Rehabilitative Care C C A C The CCAC provides PT, OT and SLP services in the client s home, across five (5) branches across the NE LHIN. Data is available for 2009/10 and 2010/11. The data is broken down by discipline, by branch office and by diagnosis (i.e. stroke, hip/knee replacement, hip fracture and all other diagnoses) (see details in Appendix J). Utilization In 2010/11, the total number of visits by Allied Health professional staff was as follows in table 9. The Number of clients seen could not be estimated at this time by branch office. Table 9: Total C C A C Visits by Allied Health Professional Staff Total # of Patients Total # of Visits Estimated Average # of Visits Timmins North Bay Parry Sound Sudbury Sault Ste. Marie K irkland Total 5,493 4,795 8,034 2,430 11,975 10, , The percentages of visits in 2010/11, for the diagnostic groupings where best practices are available are as follows: Table 10: Percentage of C C A C Visits by Allied Professional Staff by Diagnostic G rouping Timmins North Parry Sudbury Sault Ste. K irkland Total Bay Sound Marie All visits 4,795 8,034 2,430 11,975 10, ,354 Hip/K nee 7.4 % 2.9% 11.4 % 10.3 % 6.1 % 3.7 % 7.1 % Replacement Hip 3.4 % 4 % 2.1 % 2.8 %.17 % % F racture Stroke 0.3 % 1.4 % 1.6 % 3.7 % % All Other 88.9 % 92.8 % 85.1 % 85.3 % 90 % 96.3 % 88.9 % Visits for hip and knee replacements vary from 2.9% in North Bay to 10.3 % in Sudbury. Stroke represents a very small percentage, compared to the % of the population in inpatient rehab. 35

36 Challenges and Recommendations Challenges Recommendations Action Responsibility Variations in visits for specific diagnostic groups across branches 9. Review and apply best practices for MSK and stroke, together with recommendation #1. Develop and implement template for measuring congruence and complete by March 31, Core Stakeholders and Rehab and CCC Officer Reduce duplication of effort between CCAC and outpatient services. 10. Work collaboratively with outpatient services in the various communities to leverage access to services. Partners within the North East Rehab Network to explore current collaborations across communities and identify opportunities such as sharing staff. In progress and ongoing. CCAC and outpatient providers Community Services (Outpatient and C C A C) A total of 68,510 visits/encounters occurred outside the hospitals beds for patients requiring rehab services from PT, OT, and SLP. Patients in outpatient services receive more visits that those through the CCAC (10.3 versus 7.2). Current data does not enable calculation of the total number of patients/clients who were involved in the visits, other than by discipline within each of the outpatient and CCAC datasets. From current data, the total number of patients reported is 8,312 although many of those will have been double counted if they saw more than one (1) discipline. While this seems to be a large number of visits and patients, providers report access to outpatient as an issue for their patients. T ransitional Care Beds In 2010, to support the objectives of the ED/ALC strategy, the MOHLTC applied Aging at Home and Urgent Priorities Funding to increase capacity and flow of patients across the health system by developing temporary and transitional beds. Two such units currently exist in the NE LHIN, both of which have targets prior to their closure. 36

37 HSN currently has a 60 bed Functional Assessment and Outcome Unit. Thirty (30) beds are scheduled to close by end of fiscal 2012, with the last 30 scheduled to close by March 31, At last reporting, of the 60 beds, 55 patients were ALC waiting for transition to a LTCH. SAH has 68 transitional beds (48 transitional and 20 restorative beds). Eighteen (18) of these beds are scheduled to close on or by April 1, 2012; the remaining 50 on or by April 1, For the purpose of this report, the transitional care beds, which are time limited, are separated out from the rehab and CCC beds inventory. However the planned closure of the aforementioned 128 beds over the course of the next 15 months will have implications for the Rehab and CCC system. Complex Continuing Care Three hundred and one (301) CCC beds in the NE LHIN are located across 18 sites. Thirteen of those sites are located in community hospitals, while the majority of beds are located in hub hospitals and a free standing facility in Sudbury. How those beds operate in community hospitals is different than the latter grouping, and the data will be presented separately. Since 2008/09, there has been an overall increase in CCC beds. Sixty four new beds were added (32 at St. Continuing Care Centre (SJCCC)), with 32 beds being transferred from HSN and additional 32 beds at NBRHC) at the same time there were some shifts in the # of beds designated/allocated/staffed at the rural community hospitals. Hub Hospitals and St. Continuing Care Centre (SJC C C) Following is data from the 4 area hub hospitals and SJCCC for 2010/2011 (see detailed data in Appendix K). Utilization Length of stay and occupancy varies by program as detailed in Appendix K. 37

38 Table 11: C C C Beds in Hub Hospitals and SJC C C T A D H NBR H C* SA H WPSH C SJC C C # of Beds * 25 15** 64 # of Admissions * 45 N/A 126 Occupancy 95.85% 87.3 %* 98.8% N/A 97.66% Average L OS *NBRHC was in transition in 2011 with an increase in CCC beds from 10 to 42 beds and also in terms of classifying patients as CCC. ** WPSHC data is currently being reviewed by the hospital. Access to CCC beds is managed internally in acute care hospitals, while access to the SJCCC beds is managed through the CCAC. A L C Occupancy in CCC is generally high in the hub hospitals. Classification of patients as CCC varies across facilities where the hospital also has acute care, rehab and CCC beds. Patients may be transferred to a CCC bed, but not yet be formally discharged from their acute care or rehab bed. A patient may also be ALC and may be classified as acute care ALC or ALC/CCC. In 2011, the number of ALC patients occupying CCC beds fluctuated. At the beginning of the year, weekly averages were between 29 and 32%. Since September, weekly data shows 35 to 36% of patients in CCC are ALC. This increase represents approximately an additional 8 beds across the system being utilized for ALC patients. The increase could represent a change in reporting or actual increased utilization. Figure 4: A L C in C C C in Hub Hospitals and SJC C C 38

39 Occupancy at SJCCC has been fluctuating as programs are developed and changed. In the current year (2011/12) to date, occupancy in the medically complex beds was 30.48, while occupancy in the Assess and Restore beds was 137.5, indicative of a program shift. Furthermore, the process for admission is a new process for both the CCAC and SJCCC, as the CCAC enters into a new phase of its expanded role. All CCC beds seek to be flexible in their programming and classifying of beds to address the needs of patients. This will be addressed in the section on programs, access and flow, beginning on page 32 of this report. Community/Rural Hospitals with C C C Beds Thirteen (13) community hospitals in the NE LHIN provide some CCC. The number of designated beds ranges from one (1) to 21. Utilization, on the other hand, as demonstrated through number of admissions in Table 13 and in the detailed report in the Appendix L, varies considerably, mostly based on need within the community. In most cases, the beds are integrated with acute care beds, both operationally and in terms of staffing. While beds are designated within the system as CCC, they may be used for other purposes, often for ALC patients awaiting placement. In other cases, patients remain in a CCC bed, as there are no other resources available in the community to meet their needs. L OS The average LOS for 2010/11 ranged from 52.5 to 409 days. As LOS is estimated at time of discharge, in past years LOS has been as high as 4,567 days, which likely included one outlier, perhaps an unusually long stay for one patient. Table 12: Data for Designated C C C Beds in Community Hospitals Total Ranges # of Hospitals 13 # of Beds Designated/Allocated # of Admissions # of Discharges L OS days Occupancy % 39

40 Utilization and A L C ALC patients make up for the majority of patients occupying CCC beds in rural community hospitals reporting to the NE LHIN reveals that for the most part 96% of patients in CCC beds are actually ALC patients. Again, lack of other appropriate discharge destinations may account for the high percentages. Figure 5: A L C in Community Hospitals In addition to ALC, patients in CCC beds in community hospital beds may require complex and intense nursing care that cannot be addressed in any other facility accessible for those patients. In that way, the community hospitals play an important role in providing services closer to home. Clearly, the configuration and utilization of CCC beds in the rural communities is considerably different from the more urban hospitals. Additional data from the Health Analytics Branch, LHIN Support Unit was obtained regarding admissions and discharges from all CCC units in the NE LHIN. The Admissions and Discharges from Complex Continuing Care Units, NE LHIN, Fiscal Years 2008 to 2010 provide an overall Average Length of Stay (ALOS) compared to the provincial average. The high ALOS in 2009 is likely accounted for by the transfer of 32 beds from HSN to SJCCC. In 2010/11, the NE LHIN ALOS was 10.6 days higher than the provincial average. Availability of alternative accommodation may be partially responsible, as most of the facilities reporting above the average were rural hospitals in small communities. 40

41 Table 13: Provincial Data: Admission and Discharged for C C C in N E L H IN and Province A L OS N E L H IN/Province 186.1/ / /90.1 C M I Scores: N E 1.16/ / /1.29 L H IN/Province Admitted from : Acute care Rehab Home Home Care Other 86.2% 5.6 % 3.0 % 2.0 % 3.2 % Case Mixed Index (C M I) The report 8 also measured the average Case Mixed Index (CMI) compared to the provincial average, indicating in general that patients in CCC units in the NE LHIN scored lower on the CMI measure than the provincial average. In the period reported, only one (1) hospital in the NE LHIN noted a higher admission and discharge CMI than the provincial average (HRSRH in 2008). Table 14: C M I Scores for C C C in N E L H IN and Province N E Hub Hospitals Range C M I Scores N E Community Hospitals Range C M I *This does not include SJHC Provincial Average C M I Score The CMI is a measure of relative resource allocation. The CMI value represents the relative cost of caring for an average continuing care patient within a Resource Utilization Grouping (RUG) class compared to the average patient in the population. A CMI value of 1.0 indicates that the cost of caring for a patient or group of patients is equal to the average cost in the continuing care population. 8 Hospital CCC- Rehab Funding, from HBAM

42 The data indicates that resource requirements of patients in the hub area hospitals are greater than those in community hospitals. Ideally, this data could be validated through comparison of Minimum Dataset (MDS) RAI scores. However, the MDS RAI is not utilized throughout the NE LHIN and therefore complete data is not available. Challenges and Recommendations Challenges Recommendations Action Responsibility Program definitions and streaming across settings To be addressed in program section (R #11 ) See action in program section. Classification of CCC patients as ALC See Recommendation # 3 Convalescent Care Thirty (30) beds in the NE LHIN across three (3) sites have been designated as convalescent care. The sites are located in Sault Ste. Marie (12 beds), North Bay (5-6 beds) and Sudbury (12 beds). These particular settings are part of the MOHLTC Transitional Program and are defined beds provided to an individual who requires a period of time in which to recover strength, endurance or functioning, who are likely to benefit from a short stay (up to 90days) in a long-term care home 9 9 Ministry of Health and Long-Term Care. Transitional Care Program Framework. August, P

43 Utilization Following is a summary of utilization in 2010/11. Table 15: Utilization in Convalescent Care Extendicare Van Daele (Sault Ste. Marie) Leisure World (North Bay) Extendicare York (Sudbury) # of Beds # of Admissions A L OS 57 days 49 days days Occupancy % 87 % Primary Source of Referral: Acute Care Other* * Other is mostly community/home 53 % 47% 94% 6% 87% 13% Access to convalescent care beds is through the CCAC. Since the Sault Ste. Marie beds have become operational, there has been a substantial shift in the referral pattern, with almost half the admissions coming from the community. This could be an indication of awareness of availability of convalescent beds and appropriate access to these beds. Convalescent care services could provide much needed support to families caring for elderly family members and also admission to hospital. Program Definitions across the Rehab and C C C System Across the rehab and CCC system, a variety of definitions and program descriptions are being used. Lack of specificity within the definitions and admission criteria is challenging the system as clinicians, system navigators and families sort out where an individual needs to be. This is not unique to the NE LHIN. N E L H IN facilities provide the following types of beds/services/programs: Intensive Rehab Slow Stream Rehab Functional Assessment and Outcome Assess and Restore Services Medically Complex Services Transitional Beds 43

44 General CCC Geriatric Rehab Restorative Care Dementia Care Convalescent Care These services and programs are provided in designated rehab beds, CCC beds in acute care hospitals and in CCC beds in one free standing facility and in LTCHs. A summary of programs/services can be found in Appendix M. From the program descriptions, it is clear that there is considerable overlap. Definitions are mostly driven by provincial definitions from the MOHLTC or the rehab community. Those definitions are then further defined and operationalized by regional groups (i.e. North East Rehab Network, NEO Stroke Network, ABI Network, etc.) and local hospitals/facilities through their admission and discharge criteria. Definitions applied/used by designated rehab programs are more standardized as a result of the work being conducted by the North East Rehab Network and the NEO Stroke Network, with all providers engaging at the same table in sorting out the rehab care for right place, for the right patient. At the same time, best practices have been defined and adopted in several facilities in the North East for stroke, hip and knee replacements and hip fractures. The protocols and clinical pathways for these populations assist in defining the flow of patients in their recovery trajectory. For many years it has been recognized that rehabilitative care happens in many CCC beds and the role of CCC in rehabilitative care is evolving. differentiating it from other levels of care. The Walker Report introduced the concept of Assess and Restore, both as a philosophy and a program and a number of programs in the NE LHIN now provide Assess and Restore. Challenges and Recommendations Challenges Recommendations Action: Responsibility Overlap in program descriptions, criteria for admission 11. Streamline programs, definitions and criteria across the system from rehab to CCC to convalescent care, utilizing the Expert Panel framework to inform the process. With core stakeholder group, using the Expert Panel Template, clarify and streamline definitions, where programs fit. Core stakeholder Group and Rehab and CCC Officer 44

45 12 by clinical data, including the Alpha FIM (for acute care) FIM (for rehab), and the RAI (for CCC and Convalescent Care), Expert assessment of the level intensity of care required. Utilizing the work of the Expert Panel, develop a clearer process across the NE LHIN for determining overall need and the data elements required to identify needs of individual patients. March to September, NE LHIN and Transitional Care Units and Core Stakeholder Group Access and Referral Access and flow of patients across the system is a critical element of a comprehensive rehabilitative system in addition to the actual sizing and siting of services and programs. Services and programs in the NE LHIN are accessed in a number of ways: Table 16: Referral Processes and Access Rehab Beds/Services Internal: from within the same acute care facility Rehab Beds/Services External: from another hospital/facility Referral Process and Decisions Referrals and decisions about eligibility and admission are made by the clinical teams within the hospital. Several hospitals have a method for categorizing/prioritizing patients. Patients are triaged, e.g. accepted, pending further info or waitlisted and/or progress to be followed. Common referral form developed through the partnerships at the North East Rehab Network is used throughout the NE LHIN. The admitting team reviews the information, requests additional information as needed and makes decisions about admission. Same process as above. Access and Agreements Patients are transferred as soon as the patient is ready, has been deemed eligible and a bed is available. Wait times are reportedly short, usually a few days. External patients have equal access to rehab beds. North East Rehab Network audit provides data from two (2) facilities over the past year. Average days from referral to admission 7.0 days in Sudbury and 3.2 days in Timmins (see Table 19). 45

46 Transitional Beds/Services CCC Programs/Services Convalescent Beds in LTCH CCAC Referral Process and Decisions Same process as above. All transitional beds have only internal admissions. Internal process, access CCC beds from acute care and rehab. Access to CCC beds at SJHC through the CCAC Case Manager (CM) system. On referral, CM completes MDS RAI Home Care (HC) and directs referral. Goal: Referral to assessment 48 to 72 hours Application submitted post assessment; a decision is requested within 24 hours. Admissions when a bed is available. Same process as CCC beds above. Very specific and detailed policies and procedures are in place around referrals, assessments and decision making. Access and Agreements Patients may return to home or hospital once rehab is completed or as a part of their reintegration into their own community. Patients may be admitted to acute care or rehab bed in their own community for completion of rehab. This is true especially of patients admitted to regional centres for specialized rehab: ABI, spinal cord injury, amputation, etc. Wait times are not tracked, but tend to be not long. Process is new and somewhat cumbersome resulting delays in access and admission. Wait times for specific rehab services vary from 24 to 91 days (see Table 19). 46

47 There is very little specific data about how well current processes are working, other than anecdotal reporting with some exceptions. Overall wait times for rehab beds and CCC beds are reported long although there is no consistent method or process for measuring wait times. Many of the processes for transitioning patients to rehab and CCC happen internally and are well managed. For internal admissions, there is a strong incentive to move patients through the system in as timely a manner as possible to help manage overall beds effectively. Specific wait times are not tracked. For external admissions and transitions, there are different challenges in the timing of making a referral, communicating the appropriate information, completing assessments, making decisions and arranging transfers. The North East Rehab Network has developed with its partners a common referral/admissions form, which is helpful in facilitating external referrals and transitions to rehab. All facilities in the NE LHIN utilize the same form. The facilities with rehab beds seek to review and respond to external referrals in a timely manner, equivalent to their internal referrals. The North East Rehab Network has in the past year developed a tracking system for monitoring activity around patient flow as it applies to external rehab referrals through their External Referral Audit. Data from the External Referral Audit (from October 2010 to November 2011) examined data from two (2) hospitals: HSN and TADH. Table 17: External Referrals and to HSN and T A D H Utilization HSN T A D H # of Patients Referred # Accepted into Program 41 (76%) 14 (79%) # Accepted, but patient declined admission 5 (10%) 0 Total % Admitted 66.7% 82.4 % # Patients (50%) 9 (52.9%) Flow Average # of Days from Referral to Accept/Decline Average # of Days from Acceptance to the Program to Admission Average # of Days from Referral to Admission Source: North East Rehab Network 47

48 two (2) hospitals who were in a position to provide the data. In the coming year, the two (2) other larger centres (NBRHC and SAH) plan to provide data as well. From the data available, it is evident half the patients are over the age of 65 and over 60% of the patients referred had suffered a stroke. Of all referrals to the program for two (2) of the hospitals, 76% (HSN) and 79% (TADH) were accepted. Those not accepted fell into two categories: not appropriate for the program or they did not meet eligibility criteria. For HSN, there were also five (5) patients (10%) who were accepted, but declined admission. The decision to decline the admission to HSN was sometimes related to location of the program. Actual flow and timing of the process varied between the two hospitals, with a faster turnaround in Timmins. The timing of the process could be related to the complexit and the information provided or needing follow-up. This data is of value in monitoring actual flow and estimating wait times for rehab. For referrals to SJCCC, the wait list is managed by the NE CCAC this is a new process. There are specific targets for referrals to assessment to decision to admission. However, there are reported issues with and delays in the process, as the details of how patients are triaged, assessed and referred are evolving. Responsiveness to referrals is currently less than ideal, which is recognized by the participants. No specific data is available. The ALC RM&R project, which is developing common processes for matching referral to resources, may be of help in streamlining the processes. There is data available for referrals to CCAC rehab services: Table 18: Wait Times for C C A C Rehab Services Wait time: Mean length of time in days from referral to first service 2008/ / /11 (rehab) PT OT SLP OTA N/A N/A PTA N/A N/A Social Worker (SW) Personal Support Worker (PSW) 48

49 There has been a reduction in wait times form 2009/10 to 2010/11, except for Speech. The long wait times for CCAC rehab services may be directly related to availability of rehab staff in the various regions. Wait times are also different for some diagnostic groups, such as MSK, where service may be put into place immediately on discharge from acute care. Again, specific data for those situations was not available. Challenges and Recommendations Challenges Recommendations Action Responsibility Development of a process for transition to rehab and CCC that meets the needs of patients and referring and admitting facilities 13. Evaluate the current process in place for CCC admissions to SJCCC and SAH as a pilot/test for future process. Process currently being undertaken to address the challenge. Report expected by February 29, CCAC and SJHC and HSN Improve wait time tracking Matching actual practice to targets for referral to assessment to decision to admission. Reduce wait times 14. Develop more specific tracking methods to measure: a) actual to targets for processes for all external referral transition points: to inpatient rehab; to CCC; and to the CCAC. b) Actual wait times. 100 % participation by hub hospitals with designated rehab beds in the North East Rehab Network External Referral Audit. Include data in the regular reporting template (See R # 4). North East Rehab Network and hub hospitals Initiate specific tracking of referrals through the CCAC to CCC and convalescent care of actual to targets by September 30, Monitor actual wait times. CCAC All core stakeholders Collaboration already in progress with ALC RM&R processes. 49

50 C C A C Enhanced Role Currently, the CCAC is already managing transitions to the Convalescent Care Program (CCP) and CCC at SJCCC and external referrals to SAH CCC. The target date of implementation for the CCAC enhanced role for rehab and CCC is March From the perspective of the CCAC, there are currently a number of challenges that impact the processes for referral and transitions that would increase significantly, as the volume will increase significantly once they assume the enhanced role in accessing/referring for rehab and CCC. Current case managers need to have enhanced expertise and knowledge to manage the more complex and uncertain referrals. Training is in process. Patient population is typically very elderly, with an uncertain future and there may be lack of clarity about the best discharge destination. Patients are often referred, then put on medical hold without a clear mechanism to reactivate the referral. Lack of clarity of admission criteria across CCC and the CCP makes the referral process difficult, recognizing the challenge to build in flexibility, consistency and clarity. Timing of the referrals is challenging. Referrals are often made as soon as patients are classified as ALC, although they may not yet be ready for rehab. A high volume of referrals is made on Fridays, creating a backlog for case managers to meet the standard of completing the assessment within 48 to 72 hours. Information required to make the right decision/information required by the admitting facility is not always made available. There may be some of referrals to minimize ALC days in CCC and the CCP Decisions about whether to use the RAI HC or the short RAI Contact Assessment (CA) When is the application of either assessment appropriate and adequate to move the patient along to the right service? RAI CA is used when the patient is seen in the ED and is eligible to make direct referral without admission to acute care. Challenges and Recommendations Challenges Recommendations Action Responsibility Transition to enhanced CCAC role for CCC and rehab CCAC and Stakeholders 15. Support the CCAC initiative to develop case managers with particular expertise in rehabilitative care to manage transitions to rehab and CCC. Include rehab and CCC stakeholders as processes are being developed and tested. 50

51 16. Create mechanism for CCAC collaboration with acute care, rehab and CCC as new processes are developed. Ongoing. Resources and Costing Resource Intensity and type and mix of clinical staffing serve as an important component of the programs and services. The actual resources, as well as the expertise and experience of staffing resources, impact the level of service provided. In comparing staffing across the three (3) levels of service provided in facilities with beds, there is differentiation of Allied Health staffing in rehab compared to CCC and convalescent care between rehab. Hospitals staff their units, mostly using guidelines set out by the MOHLTC, and using the Healthcare Indicator Tool (HIT) to assess their staffing in relation to their comparators in the province. Comparators are often not within the same LHIN. Many factors influence staffing levels and play a role in the services programs are able to provide. Some of the factors include: Availability of staff Expertise and experience of staff Access to continuing education Access to support for integration of best practices that are available, especially stroke, hip and knee replacement, and hip fractures Medical support and expertise Physiatrist (only in the NE LHIN), Geriatric Support (one (1) Geriatrician in NE LHIN) Other clinical support (Nurse Practitioners, Nurse Clinicians, consultative services) Management and administrative (IT, Quality Management Support) Educational supports (i.e. educators) System supports (District Stroke Coordinators, Regional Stroke System) Variations in staffing are complex and difficult to interpret in light of the many factors that come into play, together with variations in how patients are classified, and understanding the needs of patients in the beds. However, comparisons have value in adding information to the bigger picture of the rehab system and ultimately also costing. In order to create a comprehensive system, sized, sited and funded appropriately, resource comparisons will inform the bigger picture. 51

52 Following is the range of staffing across rehab, CCC and Convalescent care: Table 19: Staffing Ranges Nursing Hours Worked per Primary Service Recipient Allied Health Staffing Designated Rehab Beds C C C beds Convalescent Beds 2.5 to to to to to to.77 Further details are available within the data for each sector in the Appendices N, O and P. Rehab beds provide more Allied Health (PT, OT, SLP, Rehabilitation Therapist (RT) and assistants) than do CCC and convalescent care, while nursing hours are higher further out into the continuum. However, ratios of professional staff to nonprofessional staff providing care change as one goes along the continuum of care with higher proportions of nonprofessional staff providing services in CCC and convalescent care. In convalescent care, much of the care is provided by personal support workers. In CCC, depending on the varies. SJCCC employs only Registered Nurse (RN) and Registered Practical Nurse (RPN) staff with a higher ratio of RPNs (ratios vary from 1RN per 2.35 RPNs, to 1 RN per 4.4 RPNs) in their CCC programs. Medical staffing also varies across the system. There is only one (1) physiatrist in the NE LHIN. Other rehab and CCC units are staffed by family physicians, hospitalists or other physicians with a special interest in rehabilitative services. Some programs are also supported by family physicians, designated as Care for the Elderly physicians, who are supported through the NE SGS program. Several facilities also have Nurse Practitioners (NPs) who provide another level of clinical expertise. Costing of Rehab and CCC were extracted from reports from the Health System Information Management Division, of the MOHLTC, obtained through the NE LHIN. 52

53 Table 20: Actual and Health Based Allocation Model (H B A M) Expected Unit Cost Rehab 2009/10 Actual Unit Cost* Expected Unit Cost** Variance HSN 13,425 18, (-28.3%) TADH 12,243 12, (+1.5%) NBRHC*** 18,589 12, ,528 (+54%) SAH 11,531 12, (-4.39%) WPSHC 12,636 12, (+4.8 %) Source: HBAM *Actual Unit Cost: Actual Expenses/Weighted Cases **Expected Unit Cost: Base Value + Chronic/Rehab Facility Type Value + Teaching Facility Type Value *** NBRHC was opening up new programs during this period, which may account for higher actual unit cost. Table 21: Actual and H B A M Expected Unit Cost C C C 2009/10 Actual Unit Expected Unit Variance Cost* Cost** TADH (+14.3%) NBRHC (-18%) SAH (-4.6 %) WPSHC (+ 39.8%) ***SJHC (+15.8%) Source: Health HBAM *Actual Unit Cost: Actual Expenses/Weighted Cases **Expected Unit Cost: Base Value + Chronic/Rehab Facility Type Value + Teaching Facility Type Value ***SJHC: beds were transferred from another centre during fiscal 09/10 53

54 Facility Comparison Results On facility comparison costs, key items identified with NE LHIN IT staff were selected to highlight as possible indicators for meaningful comparison: Table 23: Facility Comparison Rehab Rehab 2009/10 HSN T A D H NBR H C SA H WPSH C* Functional Centre.90%.50% 70%.80% 1.9% (F/C) Operating Expense to Total Operating Expenses of Facility/NE LHIN Compensation Expense 86.3% >100% 85.4 % 91.3% 94.9% to Operating F/C Expense Average Expense per $ $ $ $ $1, Primary Service Recipient Activity % of UPP Hours of 90.5% 90.2% 95% 94.4% 87.0 % Total Hours UPP Worked and Purchased Hours per Primary Service Recipient Average # of Beds Staffed and in Operation Source: Health System Information Management Division *Data from WPSHC is not accurate and possibly related to classification of patients in rehab beds. 54

55 Table 22: Facility Comparison C C C C C C 2009/10 T A D H NBR H C SA H WPSH C SJC C C Functional Centre 4.40%.90 % 1.60 %.20 % 59.4 % (F/C) Operating Expense to Total Operating Expenses of Facility/NE LHIN Compensation Expense 92.1% 87 % 79.6 % FOI 75 % to Operating F/C Expense Average Expense per $ $ $ $ $ Primary Service Recipient Activity % of UPP Hours of 96.9 % 94.2 % 90.1 % FOI 91.5 % Total Hours UPP Worked and Purchased Hours per Primary Service Recipient Average Beds Staffed and in Operation Source: Health System Information Management Division This is a first time cost comparison across facilities. There may be issues and challenges around reporting and classification of patients, which account for some of the variability. At this point, the information is presented for information purposes only in an attempt to align costs with service, assuming rehab is more costly than CCC and CCC is more costly than convalescent care. As a comprehensive model is further developed, the relative costs of specific programs and levels of care is important in creating a sustainable model, where patients receive the right service, in the right place, at the right time and at the most reasonable cost. Enablers and Barriers North East Rehab Network A key enabler in the system is the North East Rehab Network (N E RN). The North East Rehab Network has been in existence since It secured some funding from the NE LHIN to assist in the development of the Network, including the development of a Strategic Plan. The Network membership includes all of the five (5) hospitals that have designated rehab beds, the NE CCAC, the NEO Stroke Network, the NE ABI Network and as a representative from the NE LHIN. Since a planning event with a subsequent report, published in November 2009, the Network has: 55

56 Developed a common rehab referral form, now in use for all external referrals within the NE LHIN; Gathered current data about the rehab system in the NE LHIN for 2008/09 and 2009/10; and Developed a website that includes a listing of all services available across the NE LHIN. The establishment of the Network has enabled collaboration, sharing of information and practices and problem solving to address issues of common concern. As such, the Network is a critical and well informed partner for the NE LHIN in developing a comprehensive model for rehabilitative care. Table 24: Other Enablers and Barriers Enablers Background reports to support the directions for developing a comprehensive model for rehabilitative care Leadership and work of the Rehab and CCC Expert Panel Commitment of the NE LHIN to develop a comprehensive rehabilitative system Barriers Timing of the Expert Panel work on filling in the details on the framework, identifying the data points to support the framework and developing the tool for sizing and siting Inconsistent and incomplete data about transitions from acute to rehab to CCC *Multiple initiatives happening concurrently (CCAC enhanced role, ALC RM&R initiative) North East Rehab Network work and partnerships Economic constraints *These could be seen as enablers as well as barriers. Project Accomplishments to Date and Activities Outstanding To date, this project has accomplished the following activities, as outlined in the Project Charter (see Appendix A): Inventory of current rehab and CCC inpatient capacity, updating the inventory completed by the North East Rehab Network Inventory of hospital-based outpatient and CCAC rehab services Inventory of current access and flow through identification of associated admission/discharge criteria, interdependencies and linkages across the continuum of care 56

57 Review of the actual utilization of beds (inpatient) and services (outpatient and CCAC) over the past three (3) years Identification of definitions of terms currently in use in northeastern Ontario describing general and specialized rehab and CCC beds (including CCC in small hospitals) Comparison of the definitions, admission and discharge criteria and linkages to other provincial jurisdictions and the terms and directions of the Expert Panel when available (further work to be conducted in the next steps in aligning the programs and services with the Expert Panel framework/matrix) Review of the current activity and recommendations for the coordination of inpatient rehab and CCC waitlist management, admission, referral and placement process across the NE LHIN, including the interdependencies and key linkages across the continuum of care. This review will be conducted in relation to the new mandate and enhanced role of the CCAC. Review of current funding from the NE LHIN to rehab and CCC across the NE LHIN (as per the recommendation of the Expert Panel pg 8) Review data currently being gathered and where data is stored, analyzed Identification of the key enablers and barriers to implementation, and the mechanisms and monitoring activities required to sustain the future state (partially completed) Identification and description of next steps Remaining Work to be conducted: Evaluation and review of current congruence with best practices identified in the Phase I Expert Panel Report pg 6 (to be conducted in immediate next steps) Evaluation of the potential capacity freed from within existing health care system through the introduction of best practices, using a provincial methodology if and when available (Phase I report pg 6). Description of a potential service delivery model (i.e., acute, convalescent care, designated rehab beds, Assess and Restore, restorative care/low tolerance-long duration rehab, complex care, and NE LHIN-funded ambulatory rehab services) to include linkages and interdependencies across the continuum of care and in keeping with the work of the Rehab and CCC Expert Panel (to be partially conducted in the immediate next steps) Recommendations and steps for transitioning from current to future state with timelines Methodologies for the sizing and siting of specialized/general rehab and CCC beds across the region in keeping with the activity and work of the Expert Panel (Expert Panel due to report in the fall of 2012) 57

58 Projection of future demand and inpatient capacity requirements (sizing and siting of general and specialized inpatient rehab beds) Possibilities for future sizing and siting of NE LHIN-funded ambulatory rehab services, (i.e. hospital-based outpatient services and CCAC therapy services) Next Steps and Infrastructure Next Steps This phase of the NE LHIN Rehab and CCC Systems Review Project addressed collecting baseline data about how the system is being used and how it is functioning and identifying challenges. The next phase will address and follow-up on a number of recommendations that can be accomplished in the next few months, before March 31, Following are recommended next steps: 1. Completion, review and finalization of Interim Report 2. Review of Expert Panel Matrix model and its application to the NE LHIN and streamlining of programs and services in CCC 3. Evaluation and Review of Best Practices in Rehab and the community for Stroke, Joint replacement and Hip Fracture 4. Expansion of mandate and membership of current core stakeholder group 5. Appointment of Rehab Lead within the LHIN(1 day week) Infrastructure In order to move the LHIN to the next steps of developing a comprehensive rehabilitative system, the following infrastructure changes are recommended. Challenges Recommendations Action Responsibility Collaboration from all the sectors involved in rehabilitative care LHIN and Core Stakeholder Group 17. Create a group that includes representation of all stakeholders involved in rehabilitative care across the NE LHIN, including all hospitals, NE CCAC, geriatric services and convalescent care, that will follow-up on this review and drive the development of a comprehensive service delivery model for rehabilitative care. April Create a strong stakeholder group under the NE LHIN umbrella with enhanced membership and mandate. Create NE LHIN lead for rehabilitative care. 58

59 Summary of Challenges and Recommendations Inpatient Rehab Challenges Recommendations Action Responsibility Differences in practice, specifically around MSK and utilization of inpatient beds 1. Determine congruence with Best Practices in rehab for MSK and stroke as endorsed by the Expert Panel. Develop and implement a template for measuring congruence and complete by March 31, Core Stakeholders and Rehab and CCC Officer Limited Availability of PT, OT, SLP 2. Expand the concept of the rehab team to include a more enhanced role for nursing and provide training opportunities (i.e. Rehab certification through Canadian Nurses Association (CNA)) and training for the team to include a more enhanced role for nursing. This will enable a more around the clock/7 day a week approach to rehab. Disseminate information about CNA certification North East Rehab Network to facilitate with hub hospitals and core stakeholder group. March to November Follow up re: uptake January North East Rehab Network Core Stakeholders in rehab and CCC Identification of ALC within rehab 3. Wherever possible clarify and create standard approach to classifying patients as ALC in rehab and CCC so data can be interpreted consistently and compared. Expand the mandate of LHIN group currently addressing classification of ALC in acute care to include rehab and CCC. March to May, 2012 LHIN and Core stakeholders in rehab and CCC Limited data describing the population 4. Collaboration between NE LHIN, North East Rehab Network and the hub hospitals to develop and apply a template for system monitoring and comparisons across the rehab facilities and reduce duplication of effort to monitor the data. Develop and apply a template, building on the North East Rehab Network template and this report, enabling system monitoring and ensuring congruence with the Expert Panel Data recommendations. NE LHIN and North East Rehab Network 59

60 Challenges Recommendations Action Responsibility The template should include at least: Utilize existing systems (NRS). o FIM Median and range as Determine a reporting well as means schedule. o FIM Efficiency scores o ALC across rehab sites Template to be o Wait times completed by June 30, o Key questions s re: shifts in outpatient changes in volumes and shifts in First report ready June staffing between inpatient and outpatients Outpatient Rehab Challenges Recommendations Action Responsibility Outcomes in outpatient programs, especially for MSK patients, are 5. Review congruence with best practices for MSK, especially hip Develop and implement template for Core Stakeholders and Rehab and CCC Officer better than in home and knee replacements measuring services as services (together with congruence and can be more frequent recommendation #1) complete by March and intense. 31, Lack of outpatient services impacts inpatient stay Shifting of staff from outpatient to inpatient services, resulting in decreasing the amount of outpatient service available 6. Add some key questions to the rehab template (R#4) to monitor : o longer inpatient stays related to lack of outpatient services o overall shifts in outpatient services o when outpatient services/volumes decrease because staff is reassigned to inpatient services. Include questions in the rehab data template June North East Rehab Network and LHIN 60

61 Challenges Recommendations Action Responsibility Lack of knowledge about availability of rehab services in 7. Disseminate information to providers about services available Develop communication about information North East Rehab Network with LHIN communications community hospitals and about the NE Rehab available March Network web site. 31, Accessing rehab in rural and remote communities 8. Explore the possibilities for integrating Telemedicine in providing/accessing care as part of developing a comprehensive rehabilitative model. Engage with NE LHIN Telemedicine lead in preparation for model development to determine their capacity. Build on the experience of stroke and ABI. Initiate by March 31, Core stakeholder Group and NE LHIN Telemedicine lead Community Rehabilitative Care (C C A C) Challenges Recommendations Action Responsibility Variations in visits for specific diagnostic groups across branches 9. Review and apply best practices for MSK and stroke, together with recommendation #1. Develop and implement template for measuring congruence and complete by March 31, Core Stakeholders and Rehab and CCC Officer Reduce duplication of effort between CCAC and outpatient services. 10. Work collaboratively with outpatient services in the various communities to leverage access to services. Partners within the North East Rehab Network to explore current collaborations across communities and identify opportunities such as sharing staff. In progress and ongoing. CCAC and outpatient providers 61

62 C C C Challenges Recommendations Action Responsibility Program definitions and streaming across settings To be addressed in program section (Recommendation #11). See action in program section. Classification of CCC patients as ALC See Recommendation #3. Program Definitions across the Rehab and C C C System Challenges Recommendations Action: Responsibility Overlap in program descriptions, criteria for admission 11. Streamline programs, definitions and criteria across the system from rehab to CCC to convalescent care, utilizing the Expert Panel framework to inform the process. With core stakeholder group, using the Expert Panel Template, clarify and streamline definitions, where programs fit. Core stakeholder Group and Rehab and CCC Officer Establi by clinical data, including the Alpha FIM (for acute care) FIM (for rehab), and the RAI (for CCC and Convalescent Care), Expert assessment of the level intensity of care required. Utilizing the work of the Expert Panel, develop a clearer process across the NE LHIN for determining overall need and the data elements required to identify needs of individual patients. March to September NE LHIN and Transitional Care Units and Core Stakeholder Group Access and Referral Challenges Recommendations Action Responsibility Development of a process for transition to rehab and CCC that meets the needs of patients and referring and admitting facilities 13. Evaluate the current process in place for CCC admissions to SJCCC and SAH as a pilot/test for future process. Process currently being undertaken to address the challenge. Report expected by February 29, CCAC and SJHC and HSN 62

63 Challenges Recommendations Action Responsibility Improve wait time tracking 14. Develop more specific tracking methods to measure: 100 % participation by hub hospitals with designated rehab beds in the North East Rehab Network External Referral Audit. North East Rehab Network and hub hospitals Matching actual practice to targets for referral to assessment to decision to admission. a) actual to targets for processes for all external referral transition points: to inpatient rehab; to CCC; and to the CCAC. Include data in the regular reporting template (See Recommendation # 4). CCAC Reduce wait times b) Actual wait times. Initiate specific tracking of referrals through the CCAC to CCC and convalescent care of actual to targets. All core stakeholders September 30, Monitor actual wait times. Collaboration already in progress with ALC RM&R processes. C C A C Enhanced Role Challenges Recommendations Action Responsibility Transition to enhanced CCAC role for CCC and rehab CCAC and Stakeholders 15. Support the CCAC initiative to develop case managers with particular expertise in rehabilitative care to manage transitions to rehab and CCC. Include rehab and CCC stakeholders as processes are being developed and tested. To November Create mechanism for CCAC collaboration with acute care, rehab and CCC as new processes are developed. Ongoing. 63

64 Next Steps and Infrastructure Challenges Recommendations Action Responsibility Collaboration from all the sectors involved in rehabilitative care LHIN and Core Stakeholder Group Future Work 17. Create a group that includes representation of all stakeholders involved in rehabilitative care across the NE LHIN, including all hospitals, NE CCAC, geriatric services and convalescent care, that will follow-up on this review and drive the development of a comprehensive service delivery model for rehabilitative care. April Create a strong stakeholder group under the NE LHIN umbrella with enhanced membership and mandate. Create NE LHIN rehabilitative care. Several issues were identified in the report, which have relevance for building a comprehensive rehabilitative service delivery model but are referred for future work some due to the availability of current resources to pursue the work, priorities and importance of the work at this time and others because it lies beyond the scope of this particular project. Explore further the unique role of rural community hospitals as it relates to rehabilitative care. Lack of consistent data about hospital based outpatient rehabilitative services Development of a better understanding of comparators, differences in rehabilitative care as it relates to staffing and costs. 64

65 Appendices 65

66 APPE NDI X A N E O L H IN Rehabilitation (Rehab) and Complex Continuing Care (C C C) Systems Review Project Charter November 8, 2011 Scope Conduct a review of the current status, in terms of access and flow, of Rehab and CCC programs and services in the NEO LHIN, including inpatient, hospital-based outpatient and publicly funded community based rehab services (i.e. CCAC and tele-rehab). This will be the first part of a longer process to develop a comprehensive service delivery model. The project goal is to develop recommendations and an implementation plan to enhance access and patient flow to Rehab and CCC occurring in the NEO LHIN. This initiative will support ED and ALC priorities and is in keeping with the recommendations of the Rehabilitation and Complex Continuing Care Expert Panel. The project will include the following activities: o o o o o o o o o o Inventory of current rehab and CCC inpatient capacity, updating the inventory completed by the North East Rehab Network. Inventory of hospital based outpatient and CCAC rehab services Inventory of current access and flow through identification of associated admission/discharge criteria, interdependencies and linkages across the continuum of care. Review of the actual utilization of beds (inpatient)and services (outpatient and CCAC) the past 3 years Identification of definitions of terms currently in use in NEO describing general and specialized rehab and CCC beds (including CCC in small hospitals). Comparison of the definitions, admission and discharge criteria and linkages to other provincial jurisdictions and the terms and directions of the Expert Panel when available. Review of the current activity and recommendations for the coordination of inpatient rehab and CCC waitlist management, admission, referral and placement process across the LHIN, including the interdependencies and key linkages across the continuum of care. This review will be conducted in relation to the new mandate and enhanced role of the CCAC. Evaluation and review of current congruence with best practices identified in the Phase I Expert Panel Report (pg 6). Evaluation of the potential capacity freed from within existing health care system through the introduction of best practices, using a provincial methodology if and when available (Phase I report pg 6). Review of current funding from the LHIN to rehab and CCC across NEO LHIN (as per the recommendation of the Expert Panel pg 8). o Review data currently being gathered and where data is stored, analyzed. 66

67 Description of a potential service delivery model, (i.e., acute, convalescent care, designated rehab beds, assess/restore, restorative care/low tolerance-long duration rehab, complex care, and LHIN-funded ambulatory rehab services) to include linkages and interdependencies across the continuum of care and in keeping with the work of the Rehab and CCC Expert Panel. o o o Identification of the key enablers and barriers to implementation, and the mechanisms and monitoring activities required to sustain the future state. Recommendations and steps for transitioning from current to future state with timelines. Identification and description of next steps, including, but not limited to: Methodologies for the sizing and siting of specialized/general rehab and CCC beds across the region in keeping with the activity and work of the Expert Panel. Projection of future demand and inpatient capacity requirements (sizing and siting of general and specialized inpatient rehab beds). Possibilities for future sizing and siting of LHIN-funded ambulatory rehab services, (i.e., hospital based outpatient services and CCAC therapy services). O rganization/membership/ Structure A core stakeholder group will be formed to include the Senior Director ED/ALC, NE LHIN, NE LHIN staff consultant responsible for rehab and CCC, the chair of the North East Rehab Network, a representative of the NEO Stroke Network, a representative of the NEO Brain Injury Network, a representative from NBRHC, representatives of small hospitals providing rehab and CCC (WPSHC and TADH, SAH), representatives from 2 other small hospitals, a representative from the CCC sector (St NE CCAC and the Rehabilitation and Complex Continuing Care Officer. The core stakeholder group will review and advise on each step of the review process, in terms of content, methodology and time lines, including the final report. K ey Stakeholder Involvement and Linkages: The project will link closely with relevant organizations and agencies at local, regional and provincial levels. Key partners will include the North East Rehab Network, the NEO Stroke Network and the Provincial Rehab and CCC Expert Panel, NE Specialized Geriatric Program. The project will engage stakeholders, including key medical staff, from within those bodies as well as other organizations and agencies within the 4 hub areas of the NE LHIN who provide Rehab and CCC programs and services. Consultation will include information gathering, validation and feedback. Accountabilities The Rehab and CCC Officer will lead the project and report to the Senior Director AED/ALC project. The Core stakeholder group will review and advise. 67

68 Timeline The project will begin October 11, 2011 and be completed with a final report by December 23, The sequencing and timing of various activities and future steps are somewhat dependent on the activity of the Rehab and CCC Expert Panel. This includes their work on definitions and endorsement of a service delivery model. Communications The project will draw on the expertise and work with the Senior Corporate Adviser, Communication and Community Engagement to develop a communication strategy for the project. N E L H IN Rehab and C C C Systems Review Time Line Week 1. Oct. 11 Oct. 14 Week 2. Oct. 17 Week 3. Oct. 24 Oct. 27 Week 4. Oct. 31 Activity Develop project charter including activity and timelines Gather and review all key documents relevant to the project (local, regional and provincial) Initiate review of current inventory and develop methodology to update information related to: capacity: # and type of beds, services, volume of services, past 3 years (08/09; 09/10; 10/11 and 011/12 available) admission and discharge criteria, agreements, linkages, referral information, processes definitions Finalize project charter Recruit core stakeholder group Formulate a communications plan Review data and inventory material already available, data currently being gathered, reported and analyzed, including frequency and where submitted. Continue Review data and inventory material already available Complete draft methodology for inventory Meet with core stakeholder group to review project and process, stakeholder engagement and inventory methodology. Deliverable Draft project charter Time lines Inventory of documents Project charter Methodology for inventory Core stakeholder meeting 68

69 Activity Inform broader stakeholder group of the project objectives, activity, time lines and upcoming requests for information Deliverable Week 5 Nov. 7 Nov. 10 Week 6 Nov. 14 Week 7 Nov. 21 Week 8. Nov. 28 Week 9. Dec. 5 Send out request for updated inventory information to be returned by November 16 Development of methodology for reviewing congruence with provincial BP standards for stroke, hip fracture and hip and knee replacement, in consultation with the Rehab and CCC Expert Panel Review methodology for evaluating congruence with provincial BP standards for stroke, hip fracture and hip and knee replacement with core stakeholders Revise and fine tune methodology for evaluating congruence. Review current funding to rehab in NEO Send out request for evaluation of congruence with BP to be returned November 25 (10 working days). (or conduct interviews depending on methodology developed Gather and analyze information returned re: inventory (due Nov 10 th ) Review of the current activity and recommendations for the coordination of inpatient rehab waitlist management, admission, referral and placement process across the LHIN, including the interdependencies and key linkages across the continuum of care. Analyze and review inventory updates, activity related to flow, definitions, admission criteria etc. Continue analysis and review of inventory, coordination, processes, data and linkages Analyze information returned re: congruence with Best Practices (due Nov. 25) Develop a potential service delivery model based on findings of NEO review and recommendations from the Expert Panel. Identify enablers and barriers Draft final report Core stakeholder discussion about key ideas and recommendation for the report, including the next steps re: Type, sizing and siting of rehab and CCC services and programs Methodology for review of congruence with BP Summary of current status coordination, wait list management, data availability, linkages Summary of congruence related to Best Practices for stroke, MSK 69

70 Week 10 Dec. 12 Week 11 Dec. 19 Activity Review of Final Report Completion of Final Report Deliverable Final Report 70

71 APPE NDI X B Conceptual F ramework Matrix Local Regional Provincial Group 1: slow progress/low capacity for functional improvement Group 2: slow to moderate progress/low to moderate capacity for functional improvement Group 3: moderate to rapid progress/moderate to high capacity for functional improvement Group 4: rapid progress/high capacity for functional improvement G roup 1 G roup 2 G roup 3 G roup 4 Potential for Functional Recovery LOW HIGH HIGH HIGH Risk of Deterioration HIGH HIGH HIGH LOW Complexity related to comorbidities HIGH LOW HIGH LOW Complexity related to psychosocial factors LOW HIGH HIGH LOW 71

72 APPE NDI X C 72

73 APPE NDI X D N E O L H IN Rehabilitation (Rehab) and Complex Continuing Care (C C C) Systems Review Summary of Services December 2, 2011 Current Rehabilitation Specialized Intense Rehabilitation: ABI, SCI, complex stroke, General Intense Rehab Outpatient rehab Day Hospitals Geriatric and Adult Outpatient ABI Rehab Seating and Mobility Clinic Assistive Communications Clinic (ACC) Complex Continuing Care General CCC Medically Complex Palliative Assess and Restore/Restorative Where provided Health Science North Health Science North Timmins North Bay Sault St Marie West Parry Sound Health Science North Timmins North Bay Sault St Marie West Parry Sound Health Science North North Bay Health Science North Health Science North Health Science North Timmins Sault Ste Marie West Parry Sound North Bay Sault Ste Marie St. Joseph Continuing Care Centre (Sudbury) Timmins North Bay Sault Ste Marie 73

74 Current Care Slow Stream Transition Dementia Care Geriatric Rehab Functional Assessment and Outcome Unit Convalescent Care Community Care rehab CCAC Where provided St. Joseph Continuing Care Centre (Sudbury) Timmins North Bay Sault Ste Marie North Bay St Joseph Continuing Care Centre (Sudbury) Health Science North to downsize in April 2012 and close by April 2013 Leisureworld, North Bay Extendicare York, Sudbury Extendicare Van Daele, Sault Ste Marie Timmins North Bay Parry Sound Sudbury Sault Ste Marie Kirkland Community Hospitals Complex Continuing care Notre Dame Hospital Hearst 21 West Nipissing General Hospital Sturgeon Falls 19 Sensenbrenner Hospital Kapuskasing 18 Anson General Hospital Iroquois Falls 15 Kirkland and District Hospital Kirkland Lake 15 Englehart and District Hospital Englehart 14 Temiskaming Hospital New Liskeard 11 Blind River District Health Blind River 10 Centre Lady Minto Hospital Cochrane 8 Bingham Memorial Hospital Matheson 6 Mattawa General Hospital Mattawa 3 Espanola General Hospital Espanola 2 74

75 St. Joseph's General Hospital Elliot Lake 1 Other outpatient rehab services Hornepayne Community Hospital Chapleau General Hospital Weeneebayko General Hospital Manitoulin Health Centre (Little Current & Mindemoya James Bay General Hospital Hôpital de Smooth Rock Falls Hospital Lady Dunn Health Centre Hornepayne Chapleau Moose Factory Manitoulin Island Moosonee Smooth Rock Falls Wawa 75

76 Rehab Inpatient Health Sciences North North Bay Regional Health Centre Timmins and District Hospital Sault Area Hospital West Parry Sound Health Centre 30 beds 10 beds 29 beds 15 beds 5 beds staff shared with other beds Nursing (hours per week) RN RPN PSW Total Nursing hours per week RN/RPN/PSW ratios 1 to to 1 1 to 1.36 to.55 1 to 1 to3 1 to 5.4 Nurse Practitioner Nurse Clinician 0.3 Nursing hours per patient per day (staff shared) Allied Health Staff(FTEs) PT PTA OT OTA SLP RT RTA Rehab asst Psychology 1 Other Hours per week PT PTA OT OTA SLP Psychologist 37.5 RT RTA Rehab Assistants CDA 37.5 Other Total allied health professionals hours per week Total Allied health asst's hours per week Allied Health Staff Prof to assistant ratio 2.36/1 3.5/1 2 to to to 1 PT/OT/SLP/Other hours per patient per day PTA/OTA/RTA/Other hours per patient day Total Allied Health hours per patient per day (staff shared)

77 Health Sciences North Timmins and District Hospital North bay Health Science Centre Sault Area Hospital West Parry Sound Health Centre in days in days in days in days in days (% of admissions) (% of admissions) (% of admissions) (% of admissions) (% of admissions) Length of stay Stroke 2008/ / / Brain Dysfunction 2008/ / / Neurological Condition 2008/ / / Spinal Cord Dysfunction 2008/ / / Amputation of Limb 2008/ / / Orthopedic Condition 2008/ / / Medically Complex 2008/ / /

78 Health Sciences North Timmins and District Hospital North Bay Regional Health Sault Area Hospital West Parry Sound Health Admit FIM score Admit FIM score Admit FIM score Admit FIM score Admit FIM score D/C FIM score D/C FIM score D/C FIM score D/C FIM score D/C FIM score Stroke 2008/ / / Brain Dysfunction 2008/ / / Neurological Condition 2008/ / / Spinal Cord Dysfunction 2008/ / / Amputation of Limb 2008/ / / Orthopedic Condition 2008/ / / Medically Complex 2008/ / /

79 Outpatient Services Health Sciences North Timmins and District Hospital North Bay Regional Health Centre Sault Area Hospital West Parry Sound Health Centre Services offered Outpatient Rehab (OPR) Outpatient PT, OT, SLP, OTA, PTA Outpatient Rehab Program (OPR) Outpatient PT, OT, SLP, OTA, PTA Geriatric and Adult Day Hospital (DH) Outpatient Day Hospital Program Seating and Mobility Clinic ((SMC) Assistive Communication Clinic (ACC) Outpatient ABI Rehab OPR Volume of Service # of patients/# of visits Physio 2008/ / / / / / / / / / / /5727 Current 400/9500(ortho) 445/ / / /550(neuro) OT 2008/ / / / / / / / / / / /5420 Current info N/A 114/ / /2814 SLP 2008/ /132 74/98 50/ / / /545 23/ / / /759 40/200 Current info N/A 54/152 78/326 45/161 Other Orthotics Prosthetics 200 new/900 repeat yr/ 1450 visits 100 new patients/yr 680 visits Hand/Upper limb 2008/ referrals 2009/ referrals 2010/ new referrals Current YTD 700/ 4932 visits Geriatric and Adult Day Hospital (DH) Seating and Mobility Clinic ((SMC) 93 patients since April 1, 2011 peds 95 patients/5- visits/week adults 5-6 visits /wk

80 Assistive Communication Clinic (ACC) current caseload pediatric 200 (5 visits/wk) adults 80 (4 visist/wk) Outpatient ABI Rehab 92/1866

81 Community Hospital Outpatient Services Hospital Location PT OT SLP Telemedicine Notre Dame Hospital Hearst X West Nipissing General Sturgeon Falls Hospital Sensenbrenner Hospital Kapuskasing x X Anson General Hospital Iroquois Falls Kirkland and District Kirkland Lake X Hospital Englehart and District Englehart x X Hospital Temiskaming Hospital New Liskeard x x X Blind River District Blind River X Health Centre Lady Minto Hospital Cochrane X Bingham Memorial Hospital Mattawa General Hospital Espanola General Hospital St. Joseph's General Hospital Hornepayne Community Hospital Chapleau General Hospital Weeneebayko General Hospital Manitoulin Health Centre (Little Current & Mindemoya James Bay General Hospital Hôpital de Smooth Rock Falls Hospital Lady Dunn Health Centre Matheson Mattawa Espanola x X Elliot Lake Hornepayne x Chapleau x x Moose Factory Manitoulin Island Moosonee Smooth Rock X Falls Wawa x x x x Source: NE Rehab Network web site

82 NE CCAC Data Template - "Rehabilitation" Staff 1 Staff 2 Rehab Staffing (FTE) - current only for NE CCAC employed staff only Parry Snd Kirkland North Bay Sudbury Sault Ste. Marie Timmins TOTAL PT OT SLP OTA PTA SW PSW Rehab Staffing (FTE) - current only for CONTRACTED Staff (?) - See Note 1 below Parry Snd Kirkland North Bay Sudbury Sault Ste. Marie Timmins TOTAL PT ?? 18.5 OT ?? 0?? 10 SLP OTA PTA ?? 5 SW ?? 9.5 PSW Volumes 1.1 (number of visits) NE CCAC Staff: Hip/Knee replacem ent 2008/ / /11 Hip/Knee replacem ent Hip/Knee replacem ent Hip All other Hip All other Hip All other VOLUMES (# of visits) Fracture Stroke dx TOTAL Fracture Stroke dx TOTAL Fracture Stroke dx TOTAL PT OT SLP OTA PTA SW PSW CONTRACTED SERVICE PROVIDERS 2008/ / /11 Volumes 1.2 (number of visits) Hip/Knee replacem ent Hip/Knee replacem ent Hip/Knee replacem ent Hip All other Hip All other Hip All other VOLUMES (# of visits) Fracture Stroke dx TOTAL Fracture Stroke dx TOTAL Fracture Stroke dx TOTAL PT OT SLP OTA PTA SW PSW

83 TOTAL (NECCAC staff + Contracted) / / /11 Volumes TOTAL 1.3 (number of visits) Hip/Knee replacem ent Hip/Knee replacem ent Hip/Knee replacem ent Hip All other Hip All other Hip All other VOLUMES (# of visits) Fracture Stroke dx TOTAL Fracture Stroke dx TOTAL Fracture Stroke dx TOTAL PT OT SLP OTA PTA SW PSW NE CCAC Staff: 2008/ / /11 Volumes 2.1 (visits per client) Hip/Knee replacem ent Hip/Knee replacem ent Hip/Knee replacem ent VOLUMES (mean # of visits per client) Hip Fracture Stroke All other dx TOTAL Hip Fracture Stroke All other dx TOTAL Hip Fracture Stroke All other dx TOTAL PT OT SLP OTA PTA SW PSW CONTRACTED SERVICE PROVIDERS 2008/ / /11 Volumes 2.2 (visits per client) Hip/Knee replacem ent Hip/Knee replacem ent Hip/Knee replacem ent VOLUMES (mean # of visits per client) Hip Fracture Stroke All other dx TOTAL Hip Fracture Stroke All other dx TOTAL Hip Fracture Stroke All other dx TOTAL PT OT SLP OTA PTA SW PSW TOTAL FOR NECCAC 2008/ / /11 Volumes 2.3 (visits per client) Hip/Knee replacem ent Hip/Knee replacem ent Hip/Knee replacem ent VOLUMES (mean # of visits per client) Hip Fracture Stroke All other dx TOTAL Hip Fracture Stroke All other dx TOTAL Hip Fracture Stroke All other dx TOTAL PT OT SLP

84 Volumes 2.3 (visits per client) 3.1 Referral Source (# of admission s by referral source, diagnosis and year OTA PTA SW PSW Referral Source (number of admissions by referral source) - See Hip/Knee replacem ent 2008/ / /11 Hip/Knee replacem ent Hip/Knee replacem ent Note 4 Hip Fracture Stroke All other dx TOTAL Hip Fracture Stroke All other dx TOTAL Hip Fracture Stroke All other dx TOTAL Acute Care Inpatient Rehab CCC LTC All other TOTAL Wait Lists Wait time: Mean length of time in days from referral to first service (rehabilitation) 2008/ / /11 PT OT SLP OTA N/A N/A PTA N/A N/A SW PSW NOTE 1: External providers do not necessarily assign staff to service CCAC clients 100% of the time. Many reported part time assignment, so assume.5 FTE As well, some external providers cover multiple branches Estimates were given for some providers as we are not sure on their FTE counts, a few were left as??? as we did not hear back from our larger providers NOTE 2: NOTE 3: NOTE 4: NOTE 5: Breakdown by Hip/Knee, Hip Fracture, and Stroke is based on the CCAC assigned Primary Diagnosis. This is the primary diagnosis that caused this client to be referred to the CCAC. Services are not assigned at the assistant level. For example, we assign and track a service at the PT level regardless if a PTA does the work. We do not have Inpatient Rehab nor CCC as a referral source We cannot pull the 2008/09 data in the timeframe required, as it resides in 6 distinct data systems.

85 CCC Timmins and District Hospital North Bay Regional Health Centre North Bay Regional Health Centre Sault Area Hospital Sault Area Hospital West Parry Sound Health Centre St Joseph's Continuing Care Centre assess and restore St Joseph's Continuing Care Centre Geriatric Rehab unit St Joseph's Continuing Care Centre Medically complex # of beds 2008/ / / current complex medical/palliative 21 transition dementia transitional 20 restorative Total # of admissions 2008/ / / current Total # of discharges 2008/ / / current Average LOS 2008/ / / current n/a Occupancy 2008/ % 92% 99.80% / % 97% 98.44% 78.94% % 2010/ % 87.30% 99.34% % 60.52% 64.63% 79.44% 96.40% 99.10% 80% % 85.15% 30.48% ReferralSources acute care 90% 2008/ n/a / n/a / n/a

86 current inpatient rehab 5% 2008/ / / current Other 5% 2008/ / / current 7

87 CCC Notre Dame Hearst West Nippising Sturgeon Falls Sensenbrenner Kapuskasing Anson General Iroqois Falls Kirkland & District Kirkland Lake Englehart& District Temiskaming Blind River Lady Minto Cochrane Bingham Matheson Mattawa Espanola St Joseph's General Elliot lake # of beds funded / floating 4 + float / designated 6 allocated / CC and 8 ALC staffed Total # of admissions 2008/ n/a n/a 2009/ n/a 2010/ n/a Total # of discharges 2008/ n/a n/a 2009/ n/a 2010/ n/a Average LOS (in days) 2008/2009 4, n/a n/a 2009/2010 3, n/a 2010/2011 N/A n/a current Occupancy 2008/ % n/a 100% 61.37% n/a 99% n/a 99.20% n/a 2009/ % n/a 100% 83.81% 99% n/a 99.50% n/a 2010/ % n/a 100% 96% 43.12% 99.50% 91% 81.60% n/a 100% 100% ALC 76.2% ReferralSources acute care primary 2008/ n/a 2009/ primary 2010/ primary current Other 2008/ / /2011 current secondary LTC 1 admit from regional rehab

88 NE LHIN: Admission criteria and referral Purpose/ Goal of program Rehabilitation Acute/intensive rehabilitation * Assess and Restore (3), North Bay (Dec 2011) Decline in health status but have capacity for further functional and cognitive improvements Need timely assessment and are at high risk for hospitalization Slow Stream (1) Palliative Timmins Pts. with complex medical conditions whose care cannot be met in community, LTC facility Transition (2) North Bay, Sault Dementia (NB) Waiting placement, in transition Complex Medical (2) Specialized programs for medically complex patients whose condition requires hospital stay, regular onsite MD care and assessment, active case management by specialized staff. (OHA) Requiring 24 hr care due to end stage disease/ medical complexity, requiring multidisciplinary/ interdisciplinary services General CCC (2) Sault and WPS** Many same as complex medical Geriatric Rehab (1) Specialized geriatric rehab for frail older persons who cannot tolerate intensity and frequency of intensive rehab program and require inpatient therapy and management of geriatric conditions that threaten return to home Convalescent Care (3) Improve strength, endurance and function Restorative care for clients following surgery, serious illness or injury General Criteria Interdisciplinary Interdisciplinary Interdisciplinary Interdisciplinary Interdisciplinary Interdisciplinary Interdisciplinary Interdisciplinary no on site PT OT Tolerance 2 to 3 hrs. Tolerance 1 to 2 Not eligible for Stable Pts in disequilibrium, MED workxx 65 + Medically stable rehab/day hours LTC Care goals met complex needs, Many same as medically min 30 min therapy 2x Care needs can Medical stability: clear Requiring Treatments unstable requiring complex day and participation in be met in LTC Dx and co morbidities, Sitting at 1 hour progressive completed medical management, ADL Ability to meds stable, no intervals process to each Plateaued skilled nursing, ADL scores greater than 7 participate in undetermined medical optimal level of Need for supervision behavioural mapping, Disequilibrium Rehab goals defined at daily physio and issues Medications mental/physical dementia care Requires multi time of admission other 2 or more areas of adjusted to /cognitive/social treatments Medically stable able to restorative care functional impairment therapeutic levels functioning direct own care programs *60 bed Functional Assessment and Outcome Unit at NHS **WPS (limited data as review of CCC and ALC data is being conducted)

89 Exclusion criteria Rehabilitation Ability to participate and learn Motivation and willingness to participate Goals: specific, measurable, realistic rehab goals and timely Benefit from program as per BP evidence Discharge plan in place Pre morbid dementia/behavioural issues Ventilator support * Assess and Restore (3), North Bay (Dec 2011) Goals Ability to learn/improve Needs 24 hour monitoring Commitment to return to community Unstable medical, psychiatric or addiction conditions TBI,SCI, Delirium Slow Stream (1) Palliative Timmins Requiring technology based care not available in the community Transition (2) North Bay, Sault Dementia (NB) Complex Medical (2) Unstable medical, psychiatric or addiction conditions Delirium TBI, SCI General CCC (2) Sault and WPS** Geriatric Rehab (1) Minimum 50 % weight bearing status for individuals with recent ortho procedures Unstable medical, psychiatric or addiction conditions Delirium TBI, SCI Convalescent Care (3) Pre other rehab fractures Special All diagnostics complete Controlled addiction/substance abuse problems lines, tube feedings, special procedures, insulin dependency, traech care, dialysis 02, Traech, CPAP, dialysis, complex wound care, IV, PICC, portacaths, stable total parenteral nutrition Pain is under control MD needs 3X week with NP 5X Technology based care oncology therapy, traech, ventilation, deep suctioning, chromic wound management, I unstable hemodialysis, continuous ventilation *60 bed Functional Assessment and Outcome Unit at NHS **WPS (limited data as review of CCC and ALC data is being conducted) traech, ventilation, deep suctioning, chromic wound management, I unstable hemodialysis, continuous ventilation 02, Traech, CPAP, dialysis, complex wound care, IV, PICC, porta caths, stable total parenteral nutrition No IV, tube feeding, ventilators

90 Rehabilitation * Assess and Restore (3), North Bay (Dec 2011) week Slow Stream (1) Palliative Timmins Transition (2) North Bay, Sault Dementia (NB) Complex Medical (2) General CCC (2) Sault and WPS** Geriatric Rehab (1) Convalescent Care (3) Expected LOS 21 days (SSM) only I site specifies LOS 3 to 6 weeks years Average 2 to 8 weeks 30 to 90 days Admission process Internal process. Physiatrist/ team/admission committee External referrals via Common referral form NE Rehab Network Access to applications via hospital web site MD to MD consult required for each referral Through CCAC after completion of the RAI for some, not in house transfer Through CCAC after completion of the RAI Through CCAC after completion of the RAI Staffing Ratios Nursing 2.5 to 4.14 hrs. ppd 3.22 to to to hrs. ppd 3.36 hrs./ppd to 4.8 hrs./ppd Staffing ratios Allied health Formal Links 1.45 to 3.3 hrs. ppd.12 to 1.65 hrs. ppd Informal repatriation agreements with some facilities CCAC 1.65 hrs. ppd.12 to 1.65 hrs ppd.12 to 1.65 hrs ppd.12 to 1.65 hrs ppd 1.6 hrs ppd.17 hrs/ppd to.77 hrs ppd CCAC provides PT OT CCAC services, case managers, Home First PHARA CCAC CCAC CCAC CCAC CCAC *60 bed Functional Assessment and Outcome Unit at NHS **WPS (limited data as review of CCC and ALC data is being conducted)

91 Rehab Inpatient Health Sciences North North Bay Regional Health Centre Timmins and District Hospital Sault Area Hospital West Parry Sound Health Centre 30 beds 10 beds 29 beds 15 beds 5 beds staff shared with other beds Nursing (hours per week) RN RPN PSW Total Nursing hours per week RN/RPN/PSW ratios 1 to to 1 1 to 1.36 to.55 1 to 1 to3 1 to 5.4 Nurse Practitioner Nurse Clinician 0.3 Nursing hours per patient per day (staff shared) Allied Health Staff(FTEs) PT PTA OT OTA SLP RT RTA Rehab asst Psychology 1 Other Hours per week PT PTA OT OTA SLP Psychologist 37.5 RT RTA Rehab Assistants CDA 37.5 Other Total allied health professionals hours per week Total Allied health asst's hours per week Allied Health Staff Prof to assistant ratio 2.36/1 3.5/1 2 to to to 1 PT/OT/SLP/Other hours per patient per day PTA/OTA/RTA/Other hours per patient day Total Allied Health hours per patient per day (staff shared)

92 Complex Continuing Care Staffing Timmins and District Hospital North Bay Regional Health Centre Complex Med/palliative North Bay Regional Health Centre Transition/ Dementia Sault Area Hospital CCC beds Sault Area Hospital Transitional & A&R (restorative) West Parry Sound Health Centre no staffing #s avalaible, reviewing the data for CCC with ALC data St Joseph's Continuing Care Centre Assess and restore St Joseph's Continuing Care Centre Geriatric Rehab unit St Joseph's Continuing Care Centre Medically complex FTE's RN RPN PSW PT PTA OT OTA RT RTA SLP Other 1 (NP) Hours per week RN RPN PSW PT PTA OT OTA RT RTA SLP Other 37.5 Nursing RN/RPN/PSW ratios 1 to 1.66 to.2 1 to 1 to.18 1 to 1.1 to 1 1 to 1.8 to to 4.1 to 4.1 1/2.35/0 1/2.35/00 1/4.4/0 Nurse Practitioner 0 1FTE 0

93 Nursing hours per patient per day 3.73hrs/ppd hr/s ppd 5.44 hrs/ppd 4.4 hrs/ppd Allied Health Staff PT/OT/SLP/Oth er hours per patient per day hrs/ ppd hrs/ ppd.77 hrs/pppd.435 hrs/ppd PTA/OTA/RTA/ Other hours per patient day hrs/ppd.83 hrs/ppd.275 hrs/ppd Total Allied Health ppd hrs/ ppd

94 Staffing Convalescent Care Extendicare Van Daele Sault Leisureworld North Bay Extendicare York Sudbury Hours per week RN RPN PSW PT Other Kinesiologist 22.5 Restorative Care physio 26.5 Nursing RN/RPN/PSW ratios 1/1/5.28 1/1.36/1 1/.64/2 Nurse Practitioner Nursing hours per patient per day 4.55 hrs ppd 3.36 hrs ppd 4.8 hrs ppd Allied Health Staff PT/OT/SLP/Other hours per patient per day PTA/OTA/RTA/Other hours per patient day.77 hrs ppd