Assess and Restore Funding Opportunity

Transcription

1 Assess and Restore Funding Opportunity Central East LHIN Board Meeting, January 2014 James Meloche, Senior Director, SDI 1

2 Objective Inform the LHIN Board on the Ministry of Health and Long-Term Care Assess and Restore Policy Situate the Assess and Restore Policy within the Central East LHIN s Integrated Health Service Plan (IHSP) and Seniors Strategic Aim Obtain approval from the LHIN Board on one-time Assess and Restore Funding Opportunity 2

3 Assess and Restore Context In Ontario, there are 1.9M seniors who account for 14% of the population but utilize 45-50% of health care resources. Even when preventative programs are in place (e.g. community exercise and falls prevention classes, Senior Friendly Hospitals initiatives), frail seniors are vulnerable to stressors that can lead to hospitalization and rapid functional decline. Unaddressed, this functional decline can lead to permanent loss of selfcare abilities in Activities of Daily Living (ADLs) (especially toileting, bathing, and ambulation) and this can result in the need for long-stay Long-Term Care Home (LTCH) placement. 3

4 Assess and Restore Context Ontario is therefore implementing an Assess & Restore (A&R) approach to care which: complements other initiatives (e.g. Senior Friendly Hospitals, Rapid Response Nursing Programs, Nurse-Led Outreach Teams, Home First, Health Links) that are also focussed on preserving the ability of seniors to live independently in their community; targets community-dwelling, high-risk frail seniors with restorative potential who have experienced reversible functional loss and for whom home- and/or ambulatory-based rehabilitative care alone is not a safe and effective option; and involves the use of standardized processes for assessment and system navigation for frail seniors to sub-acute beds in hospitals and LTCHs to restore their strength and mobility and enable them to return home. 4

5 A&R Policy Direction Five Elements The Policy will clarify Ministry direction on five identified elements of A&R: Early Risk Identification of at-risk seniors in community, primary care, and hospital settings Standardized Assessments to determine whether a person is at high risk for loss of independence, has restorative potential, and requires facility-based (in-hospital or in-ltch) care (vs. in-home- and/or ambulatory-based care). Timely Navigation to the appropriate home and/or ambulatory care or level of facility-based A&R care ( sub-acute complex, convalescent, and geriatric rehab care see Appendix F at slide 21). Standardized Care based on best-practice assessments and care planning Coordinated Transition Home to ensure gains are maintained. 5

6 A&R Implications for LHINs and Health Service Providers The final Assess and Restore Policy will have implementation and oversight responsibility for LHINs and HSPs in all five elements: Early Risk Identification Standardized Assessments Timely Navigation Standardized Care Coordinated Transition Home On December 16 th, 2013, the Ministry allocated $8M one-time targeted funding to Ontario s LHINs to expand A&R capacity and access. $ 947,100 Central East LHIN Allocation 6

7 Assess and Restore Funding Opportunity ASSESS AND RESTORE IN THE CENTRAL EAST LHIN 7

8 Assess and Restore Aligned to Seniors Aim The Central East LHIN welcomes the Ministry policy direction and funding opportunity. The Assess & Restore Policy complements the strategic and program initiatives the Central East LHIN has undertaken since Aging at Home Strategy. 8

9 Assess and Restore Compliments Central East LHIN Initiatives A&R Elements Examples of Central East Initiatives Early Risk Identification Exercise and Falls Prevention Programs Hospital Geriatric Activation Standardized Assessments Sector-wide implementation of RAI-Community Homecare (CSS), RAI- HomeCare (CCAC), RAI-Long Term Care assessments Enhanced CCAC role GAIN Clinics Timely Navigation Home First Implementation Resource Matching and Referral (RMR) Community Enhancements Standardized Care Central East Regional Specialized Geriatrics Senior Friendly Hospital Initiatives (LHIN-wide) Geriatric Activation and Hospital Transitional Care programs Enhancement to LTC Convalescent Care Programs GAIN Community Clinics Coordinated Transition Home Home First Rapid Response Nursing Virtual Ward 9

10 Assess and Restore Funding Opportunity FUNDING RECOMMENDATIONS 10

11 Context December 16 th, 2013: $ 947,100 was allocated as one-time 2013/14 Funding to the Central East LHIN The following conditions are attached: Projects must: Expand capacity (incl. education, planning, home adoption, increase ambulatory or home services) Expand access (incl. care coordination, information sharing) Develop provincial standards Not for capital projects Caution to create operating pressures in future fiscal year. We were prepared: Central East pre-engaged Hospital Chief Nursing Executives to submit proposals in advance. Proposals were reviewed and validated with hospitals and their potential partners. Plan was to be submitted to the Ministry by December 20 th,

12 Recommendations - A&R Capacity Expansion (1 of 2) Hospital Project Type Description Funding RVHS CMH PRHC Ambulatory Rehab Ambulatory Rehab Ambulatory Rehab Enhance physiotherapy services on the weekend to provide 7 day a week therapy for high risk populations during seasonal surge Jan - March $32,000 $18,500 $18,825 TSH Ambulatory Rehab To improve care transitions for Acute Care for the Elderly patients to discharge home. These care transitions include the coordination of care at the point of discharge, navigating support to enable patients to successfully follow-up and manage their care in the community, and the opportunity to build capacity in collaboration with primary care to support continuity of care. The model will also see an expansion of OP physio and occupational therapy services for the targeted population. $190,000 RMH Ambulatory Rehab Extend Rehabilitation Assistant coverage on weekend for the coverage of the walking program $14,805 12

13 Recommendations - A&R Capacity Expansion (2 of 2) Hospital Project Type Description Funding RMH Education Explore, develop and implement program format and $47,810 HHHS Education interprofessional care path for "3 Moments of Mobility" $15,000 NHH Education Education workshops for point of care staff of the norms of gerontology best practices. $41,000 13

14 Recommendations - Increase A&R Access (1) Hospital Project Type Description Funding NHH Care Coordination Comprehensive gerontological assessment and interventions will be provided by a Nurse Practitioner (NP) led Inter-professional team who possess the required clinical competencies in gerontology. The Assess and Restore model will be an extension of the Restorative foundation which focuses on restoring, and is crucial to NHH s ALC strategy. $203,800 LH Care Coordination Assess and Restore Team responsible for early identification of frail seniors at risk for loss of independence through early assessment and focused restorative interventions to reduce the risk of deterioration $308,360 LH Care Coordination Patient navigator will focus on acute, complex medicine patients that have had a least 2 previous visit within the last 6 months and are greater than 65. The navigator role at LH will focus on the continuum of the patient s journey from arrival in the ED to supporting connections within 72 hour post discharge. $57,000 14

15 Comments Given our knowledge of the local context and our ability to quickly engage our regional health system, the Central East LHIN was well prepared to take advantage of this funding opportunity. We had strong support and commitment from all Central East LHIN hospitals to implement and evaluate outcomes. The Central East LHIN submitted its Assess and Restore plan to the Ministry. All projects were endorsed without revision. A written report on results is to be submitted to the Ministry by June 13, This will be shared with the Board upon completion. 15

16 Questions and Discussion 16