Complex Continuing Care & Rehabilitation

South West LHIN Complex Continuing Care & Rehabilitation Final Report Executive Summary March 29 th, 2012

South West LHIN 0. Preliminaries Table of Contents 1. Executive Summary 1.1 Project Overview 1.2 Current State Findings 1.3 Future State 1.4 Expanded Role of the CCAC & Processes 1.5 Recommendations 1.6 Next Steps 2. Detailed Recommendations 3. Data Analysis & Hospital Profiles 4. CCAC Role & Processes 5. Secondary Research & Sources

Sources 0. Preliminaries 3

Acknowledgements Thank You! The effort of the following individuals was invaluable to the creation of this report Working Group Members Donna Ladouceur, Co-Sponsor South West CCAC Elaine Gibson, Co-Sponsor St. Joseph s Health Care London Parkwood Hospital Susan Warner, Project Lead South West LHIN Sue McCutcheon, Lead Access to Care Mary-Lynn Priestap, Co-Lead SW CCAC Sherry Frizzell, Co-Lead St. Joseph s Health Care London Arminda Dumpierrez, OPTIMUS SBR Nas Farzan, OPTIMUS SBR Steering Committee Members Dr. Keith Sequeira, St. Joseph s Health Care London Parkwood Elaine Burns, Grey Bruce Health Services Mary Cardinal, Huron Perth Health Alliance Brenda Lambert, St. Thomas Elgin General Hospital Wendy Abbas, Woodstock General Hospital Lana Dunlop, SW CCAC Dr. Peter Hodes, Physician Terri Guzyk, McCormick Home Brian Ashby, SW LHIN Andria Appeldoorn, Access to Care 4

Acknowledgements Thank You! This report could not have been completed without the valuable contribution of representatives from the following Hospitals: St. Thomas Elgin General Hospital Woodstock General Hospital Stratford General Hospital (HPHA) St. Marys General Hospital (HPHA) Seaforth Community Hospital (HPHA) Clinton Public Hospital (HPHA) Listowel Memorial Hospital London Health Sciences Centre St. Joseph s Health Care, London Parkwood Strathroy General Hospital Alexandra Hospital South Huron Hospital Owen Sound General Hospital (GBHS) Chesley & District Memorial Hospital (SBGHC) Tillsonburg Memorial Hospital Wingham & District Hospital Woodstock Private Hospital Four Counties Health Services Alexandra Marine Hospital 5 5

1. Executive Summary 6

South West LHIN Executive Summary Table of Contents 1. Project Overview 2. Current State Findings 3. Future State 4. Expanded Role of the CCAC & Processes 5. Recommendations 6. Next Steps

Project Overview 8

Project Overview Project Rationale ALC Alternative Level of Care (ALC) pressures have been long recognized as a symptom or consequence of health systems inadequately aligned with the needs of an aging and complex population. ATC Access to Care can reduce the demand for Long Term Care (LTC) and facilitate clients receiving the right care in the right place at the right time. CCC/ Rehab The Complex Continuing Care and Rehabilitation initiative is one of three initiatives from Access to Care in the South West LHIN: Home First will promote a cultural shift towards proactive discharge planning with home as the primary discharge destination Realign Assisted Living/Supportive Housing/Adult Day Programs (AL/SH/ADP) community capacity and implement the CCAC expanded role to facilitate single point access to these services Realign Complex Continuing Care and Rehabilitation bed capacity in hospitals and implement the CCAC expanded role to facilitate single point access to these services 9

Project Overview Project Mission Mission & Success Improve Access to Care by ensuring health care delivery in the right place at the right time Recommend new processes for the expanded role of the CCAC in coordinating access to CCC and Rehabilitation beds Timely access, high and consistent utilization of CCC and Rehabilitation beds, and increased discharges to the community Project Success (Outcomes) Greater understanding of current CCC and Rehabilitation bed distribution and utilization across the South West LHIN Recommendations that support bed realignment and the CCAC as a single point of access including common eligibility criteria Clearer perspective on the current processes on the admission of CCC and Rehabilitation patients to hospitals Stakeholder engagement and change management strategy recommendations to drive success in the implementation phase 10

Project Overview Methodology The following mix of inputs were used to derive the Current and Future State Qualitative Inputs Quantitative Inputs Fifteen (15) Interviews Completed at hospitals in South West LHIN that have permanently funded CCC and/or Rehab Beds. Secondary Research examining current state at other LHINs and Provinces. Input Types: Physician involvement in admissions process Perceptions concerning how patients can be discharged sooner Staff understanding of major differences between CCC/Rehab and LTC eligible patients Presence of repatriation process & eligibility criteria Data Analysis & Validation Current & Future State Assessment ALC Usage of CCC and Rehab Bed Data from Cancer Care Ontario. One-day Snapshot Data from thirteen (13) hospitals for proxy and weighting purposes where ALC data unavailable. Input Types: # of CCC and Rehab Beds Total CCC/Rehab Patient Days % ALC Utilization of CCC & Rehab Average Length of Stay Patient Type Referral Source Discharge Venue 11

Current State Findings 12

Current State Findings Interview Themes There is a high degree of inconsistency in the approaches and processes across the LHIN What s Working Well Employee awareness of primary challenges Acknowledgement that collaboration is needed Current Challenges Lack of formalized definitions Barriers to discharge Expertise Gaps Misplaced Expectations Concerns implementation Loss of staff Loss of autonomy Potential duplication of effort Key Success Factors implementation Goal uniformity Greater creativity in discharge planning Seamless integration 13

Current State Findings Role of the CCAC The CCAC currently plays a limited role in CCC & Rehab Key Findings CCAC s Current Role Significant variability in the role of the CCAC across the LHIN Limited involvement in CCC and Rehab admissions processes Some involvement in CCC and Rehab discharge processes 14

Current State Findings CCC & Rehab Beds by Region Rehabilitation beds, of which there are 184, are significantly better utilized than CCC beds (266) Region CCC Beds Weighted CCC Utilization Rehab Beds Weighted Rehab Utilization North (Grey & Bruce) Central (Huron & Perth) South East (Norfolk & Oxford) South West (Middlesex & Elgin) 0-16 84% 76 68% 23 90% 63 43% 22 63% 45 47% 10 100% London 82 81% 113 98% Total 266 62.32% 184 91.89% Note: 25 CCC beds were close in the North in 2004 / 2005 15

Current State Findings CCC & Rehab Beds by Hospital Region Hospital CCC Beds CCC Utilization Rehab Beds Rehab Utilization North Owen Sound 0-16 84% Central Listowel 25 68% 0 - Wingham 12 58% 5 80% St. Marys (HPHA) 5 70% 0 - Stratford (HPHA) 20 74% 14 95% South Huron 4 75% 4 75% Seaforth (HPHA) 10 71% 0 - South East Woodstock 33 67% 22 63% Alexandra 14 24% 0 - Tillsonburg 16 8% 0 - South West St. Thomas Elgin 45 47% 10 100% London Parkwood 82 81% 113 98% Total 266 62.32% 184 91.89% 16

Bed Numbers Utilization Current State Findings CCC - Utilization & Beds by Region There appears to be over capacity in the South that could potentially be redistributed to the North, which has no beds CCC Bed Weighted Utilization Rate by Region 2011 100 100% 80 80% 60 60% 40 40% 20 20% 0 London Central SE SW Actual Needed Utilization Utilized 0% 17

Bed Numbers Utilization Current State Findings Rehab - Utilization & Beds by Region The current utilization rate of Rehab beds in the South West LHIN is on par with expectations Rehab Bed Utilization Rates by Region 2011 120 120% 100 100% 80 80% 60 60% 40 40% 20 20% 0 London Central SE SW North Actual Needed Utilized Utilization 0% 18

Current State Findings Key Takeaways In the case of CCC, people are in the wrong beds 37%* of the time 1 Compromised access to care High ALC-LTC use of CCC beds 2 Decision making hampered Limited visibility into/knowledge of number of beds and ongoing bed utilization 3 Inconsistent standards & procedures Absence of formalized admissions and discharge criteria and processes resulting in high inconsistencies across the LHIN *Based on weighted utilization of CCC beds across the LHIN 19

Future State 20

Future State Introduction Two critical components of the CCC/Rehab Initiative of the Future State Bed Realignment How many CCC & Rehab beds are needed in the South West LHIN Where to realign current beds based on optimal number CCAC Expanded Role & Related Processes Expanded role of the CCAC as single point of access and enhanced system navigator New admission and discharge processes Referral Tools & IT enablers 21

Future State Guiding Principles The foundations of our approach were the following: 1 2 3 4 5 6 7 Data as the main driver, perspectives as input Appropriate utilization of resources Accounting for a projected significant increase in demand Geographic consolidation to leverage economies of scale and caregiver expertise Improving geographical distribution of resources Aligning with the South West LHIN s Blueprint Vision 2022 Considering regional priorities concerning minimizing additional capital requirements or human resource needs 22

Future State Realignment Calculation Model The following model provided the basis for calculating the future number of beds 1 Specific Factoring in Utilization of Demographic CCC & Rehab Shifts & Risk beds in South Factors West LHIN 2 3 Adjusting for Continued ALC Use of CCC & Rehab Beds 4 Unmet Need 5 6 System Overall Change Utilization Reduction Target (CCC Only) Removal of ALC Patient days from Total Patient Days. One-day Snapshot on February 21 st to fill in data gaps. Adjusting for population growth and health risk factors. Adjusting for continued use of beds by ALC Patients. Accounts for patients that are newly eligible, and/or now have improved access to resources. Utilization Target accounts for variability in bed occupancy. Anticipated Reduction in demand for CCC beds on basis of improvements. Rational for not utilizing Baseline Approach (Population/Bed Ratios) 1. Cannot deduce appropriate utilization of resources 2. Absence of comparables renders benchmarking problematic 3. Baselining assumes homogeneity of populations 23

Future State The following were the inputs into the Logic Model Logic Model Inputs CCC INPUTS 2013 2016 2021 Pop. Growth 5% 13% 30% Risk Factors 3% 5% 10% ALC Use* 25% 20% 15% System Change* 5% 7% 9% Unmet Need* 3% 1% 1% Utilization* 93% 93% 93% REHAB INPUTS 2013 2016 2021 Pop. Growth 5% 13% 30% Risk Factors 3% 5% 10% ALC Use* 5% 4% 3% Unmet Need* 3% 1% 1% Utilization* 87% 87% 87% Inputs: Population Growth: Ministry of Finance population projection figures, 2006-2021 Risk Factors: From South West LHIN Environment Scan. These encompass lifestyle factors that may increase the susceptibility of residents of this LHIN to future healthcare system usage. *Targets set by CCC/Rehab Steering Committee & Working Group members based on Provincial targets and LHIN research and comparators 24

CCC Bed Realignment Recommendations The net impact of the realignment is a 7 bed increase to 457 total beds By Region Region North (Grey & Bruce) Central (Huron & Perth) South East (Norfolk & Oxford) South West (Elgin & Middlesex) London (City of London) CCC Beds Current CCC Beds Future Rehab Beds Current Rehab Beds Future 0 10* 16 18 76 73 23 28 63 38 22 19 45 30 10 12 82 85 113 144 Total 266 236 184 221 *Please see next page for detailed rationale 25

CCC Bed Realignment Recommendations By Region Bed recommendations in the North are based on forecasted population / bed ratios CCC Bed Range* 2013 2016 2021 North - Minimum 37 38 41 North - Maximum 102 104 122 The data shows that we could need 41 beds in the North by 2021. In the absence of utilization data the number of CCC beds in the North was benchmarked against the range of population / bed ratios forecasted in the other 4 regions of the LHIN Based on available space and the impact on utilization at other hospitals we recommend: 25% of the goal by 2013 = 10 beds 50% of the goal by 2016 = 20 beds 100% of the goal by 2021 = 41 beds *The numbers above are driven by the higher proportion of ageing population in the North compared to the rest of the LHIN 26

Future State Sensitivity Analysis The impact of the projections are significant and cannot be overstated CCC BEDS SENSITIVITY ANALYSIS % ALC, SYSTEM CHANGE & UTILIZATION PROJECTIONS REGION CURRENT 2013 (0%) 2013 (100%) London 82 71 85 Central 76 56 73 South East 63 28 38 South West 45 23 30 North 0 10 10 TOTALS 266 188 236 REHAB BEDS SENSITIVITY ANALYSIS % ALC & UTILIZATION PROJECTIONS REGION CURRENT 2013 (0%) 2013 (100%) London 113 120 144 Central 23 22 28 South East 22 15 19 South West 10 11 12 North 16 15 18 TOTALS 184 183 221 Implication If bed numbers are calculated only on the basis of verifiable data (population growth & lifestyle factors), the number of beds required is significantly less Logic Model Inputs CCC INPUTS 2013 2016 2021 Pop. Growth 5% 13% 30% Risk Factors 3% 5% 10% ALC Use* 25% 20% 15% System Change* 5% 7% 9% Unmet Need* 3% 1% 1% Utilization* 93% 93% 93% 27

CCC Bed Geographic Distribution CURRENT STATE FUTURE STATE 28

Rehab Bed Geographical Distribution CURRENT & FUTURE STATE 29

Expanded Role of the CCAC & Processes 30

Expanded Role of the CCAC Guiding Principles The Future State process must consider the following: Future state cannot slow patient access to care Evaluation outcomes related to implementation of process are clear CCC and Rehab are active points of care, not final discharge destinations Eligibility criteria will adequately reflect CCC and Rehab populations at each site and is consistent across the LHIN Beds are system resources that are to be utilized effectively and efficiently across the LHIN 31

Expanded Role of the CCAC What We Did Collaborated in the development and testing of current & future state processes and tools Based on the information gathered during the interview process and the newly expanded role of CCAC, a future state process map was developed (Appendix CCAC Role & Processes ) This future state aligned with the work of Resource Matching and Referral (RM&R) and was shared with a various stakeholders from across the South West LHIN and CCAC for feedback during a two-day Kaizen event and one-day consensus session Feedback obtained indicated that the interim and final electronic processes and tools that will be implemented will not exclude the need for clinicians to communicate from time to time 32

Expanded Role of the CCAC Early Adopter Early Adopter - Woodstock General Hospital (WGH) is testing new processes and tools In the new Rehabilitation Unit that opened on March 1, 2012 testing of the expanded role of the CCAC and related processes is underway New eligibility criteria and referral for admission documents have been created and are presently being tested Referrals for WGH Complex Continuing Care and Rehabilitation services will be facilitated by the South West CCAC Determining which patients will be admitted to these beds will be a collaborative decision between physicians, the clinical team and the CCAC Case Manager 33

Expanded Role of the CCAC Future State The CCAC as a single point of access will have increased responsibilities for CCC & Rehab determining eligibility for admission Focus of CCAC s Future State Expanded Role Providing applicants with information Assess and determine eligibility for admission Recommending appropriate admissions to CCC & Rehab beds Monitoring and managing waiting lists 34

Recommendations *Proposed recommendations align with the strategic priorities reflected in South West LHIN Health System Design Blueprint Vision 2022 35

Recommendations Recommendations are organized into 4 categories Overview 1 CCC & Rehab Bed Realignment Bed transition & removals for increased utilization and geographic consolidation 2 CCAC Role & Processes New roles, processes & tools for improved Access to Care 3 Governance & Redistribution Governance & accountability mechanisms for implementation 4 Stakeholder Engagement & Change Management A customized approach to drive transformational change 36

Recommendations Stakeholder Engagement & Change Management Recommendation 1. Proactively promote stakeholder awareness through communication explaining CCC and Rehab as different specialized programs and what the changes mean for each stakeholder. 2. Develop a detailed change management strategy that drives transformational change through a compelling vision, change team, tools, training and feedback loops. 3. Develop a comprehensive stakeholder engagement strategy that includes a communications and change management strategy and is overseen by the implementation Management Office (IMO). 4. Customize stakeholder engagement channels for different stakeholders including physicians, clinicians, CCAC, LHIN, hospitals, the community and other health care system providers. 5. Leverage technology as a stakeholder engagement tool through podcasts, websites, intranets, webinars, video and social media depending on the objective. Urgency Immediate Short term Short term Short term Short term 6. Update Funding and Accountability agreements including physician incentives. Short term 37

Recommendations Governance & Redistribution Recommendation Urgency 1. Develop an Implementation Management Office (IMO) that includes governance, policy, methodology, tools, audits, hospital implementation champions and an ATC implementation Council. 2. Develop a detailed systems level implementation plan that includes all three Access to Care initiatives to ensure the most efficient approach in addressing system stakeholders and capacity. 3. Implement a meaningful accountability mechanism that holds stakeholders accountable in implementing the agreed upon future state recommendations. 4. Develop a patient transition plan for each affected hospital site. Other service providers across the care continuum will feel the effect, which renders a coordinated strategy crucial. 5. Develop detailed resource re-distribution plan for hospitals whose CCC/Rehab programs are being affected. The implementation or dissolution of infrastructure and staffing resources must be coordinated and receive the same priority. 6. Implement ongoing data reporting and checkpoints so that key decision makers are able to continue to make process, program and bed evaluations and adjustments on an informed and timely basis, based on metrics. Immediate Immediate Short term Short term Short term Short term 38

Recommendations CCAC Expanded role and Future State Processes CCAC Role & Process Recommendation 1. Implement standardized definitions, criteria and processes governing the provision of CCC and Rehab services across the LHIN. Ensure stakeholder buy-in through training and education. 2. Leverage the key role of the CCAC as a system navigator for clinical teams through early involvement in plan of care, family meetings, through adoption of Bullet Rounds, and waitlist management. 3. Address the lack of community resources that support discharge, including supportive housing, mental health programs and services for other high-needs groups, through collaborative partnerships to understand system capacity and processes. 4. Implement the interim IT integrated infrastructure necessary to roll out CCAC as a single point of access (while waiting for RM&R solution) including e- notifications, eligibility and referral forms and other tools. 5. Address ALC/LTC issues through potential alternatives in care such as restorative care units, convalescent units and/or long term care beds and review the process for accessing LTC beds regularly. Urgency Immediate Immediate Immediate Immediate Short term Note: Capital and Human Resources impacts must be thoroughly assessed 39

Recommendations (for SW LHIN Consideration) CCC Bed Realignment CCC realignment improves use of resources and geographic distribution Recommendation Resource Impact* Capacity 1. North - Add 10 beds to Owen Sound in a phased approach. Reevaluate every six months for a two year period. 2. Central Add 1 bed to Wingham; remove 1 bed from Listowel; remove 2 beds at South Huron and convert 2 to Rehab; and add 1 bed to HPHA. Wingham & Listowel changes due to capacity, South Huron due to lack of critical mass. 3. South East Remove 14 from Alexandra; 16 from Tillsonburg; and add 5 to Woodstock - a new facility equipped with scale, expertise and experience acquired through CCAC Pilot Program. 4. South West Remove 15 beds from St. Thomas Elgin due to low utilization and proximity to Parkwood. 5. London Increase Parkwood by 3 beds due to expected increase in demand. Low Minimal - Moderate Minimal Minimal Low Required space exists N/A N/A N/A Required space exists *Resources include all capital & human resource expenses 40

Recommendations (for SW LHIN consideration) Rehab Bed Realignment Rehab realignment increases resources on the basis of demand Recommendation Resource Impact* Capacity 1. North - Add 2 beds to Owen Sound due to utilization pressures. Low Required space exists 2. Central Add 1 bed to Wingham; convert 2 CCC to Rehab beds at South Huron; add 2 bed to HPHA to alleviate capacity issues. Minimal-Low Required space exists 3. South East Remove 3 beds from Woodstock due to perceived under utilization. Minimal N/A 4. South West Add 2 beds to St. Thomas Elgin due to utilization pressures. 5. London Add 31 total rehab beds (mix to be determined) to address capacity issues and leverage economies of scale in resourcing and clinical expertise. Medium High Unknown Required space exists *Resources include all capital & human resource expenses 41

Recommendations Other Considerations 1 System Impact Some of the other critical considerations include: 1. Collateral impact on healthcare system of shifting ALC patients out of CCC 2 Hospital Impact 2. Bed realignment may raise strategic questions concerning sustainability and specialization of specific hospital sites 3 Financial Impact 3. The net financial impact of implementing all Access to Care initiatives 4 Resource Strategy 4. Addressing long term resource gaps through proactive engagement and collaborative partnerships 5 Unmet Need 5. With increased geographical proximity to underserved communities achieved, consider cultural engagement strategies 42

Recommendations Summary Key Takeaways The net result is a minimum 5% boost in demand between 2011 and 2013 against a minimal increase in bed requirements 1 Bed Realignment Initiative A net increase of 7 (1.6%) to 457 total CCC & Rehab beds CCC beds decreased from 266 to 236 Rehab beds increased from 184 to 221 2 3 CCAC Expanded Role & Process Improvement Implementation Consideration Requirements CCAC as system navigator and single point of access Introduction of standardized processes, methodologies & tools Strong governance & accountability mechanisms Use Stakeholder Engagement & Change Management to drive transformational change 43

Next Steps 44

Implementation Approach (for SW LHIN Consideration) 1. Bed Realignment 1. Establish an Implementation Management Office & Governance Structures 2. Develop a detailed ATC system implementation plan that includes all 3 ATC initiatives 3. Develop a detailed Implementation plan including bed transition plan High Level Action Plan 2. CCAC Role & Processes 1. Implement CCAC Expanded Role on a phased approach after pilot feedback 2. Implement future state processes, tools and technology including interim IT solutions 3. Plan and implement stakeholder education and training for new processes and tools 3. Stakeholder Engagement & Change Management 1. Develop a robust Communication Strategy 2. Develop a detailed Stakeholder Engagement & Change Management Strategy 3. Update Funding and Accountability Agreements 45

Stakeholder Engagement CCAC Role & Process Realignment & Governance Implementation Roadmap - for LHIN Consideration Timetable Establish Implementation Management Office (IMO) Approvals Bed Realignment Implementation Developed Detailed Implementation Plan Phased Rollout of Expanded CCAC Role Plan Implement Future State Processes, Tools & Technology Stakeholder Engagement Strategy Change Management Strategy Implement Stakeholder Engagement & Change Management Plan Project Plan Project Management, Monitoring, and Control Project Close 46

Discussion The approach should be to design a system that fits the people, not to fit the people into a system. - Anonymous South West LHIN Hospital CEO 47

2. Detailed Recommendations 48

South West LHIN Detailed Recommendations Table of Contents 1. CCC Beds by Region Current & Future 2. Rehab Beds by Region Current & Future 3. Considerations 4. Change Management 5. Stakeholder Engagement 6. Bed Transition Plan 7. Expanded Role of the CCAC 8. Future State Processes 9. IT Enablers 10. Communication 11. Processes 12. Community Resources 13. LHIN Vision Alignment 14. Implications

CCC Beds by Region Current & Future The following are the suggested future state CCC bed numbers on the basis of the analysis Recommendations Region Current 2013 2016 2021 North (Grey & Bruce) Central (Huron & Perth) South East (Norfolk & Oxford) South West (Middlesex & Elgin) London (City of London) 0 10 20 41 76 73 74 84 63 38 39 44 45 30 31 35 82 85 87 98 TOTAL 26 236 245 280 50

Rehab Beds by Region Current & Future Recommendations The following are the suggested future state Rehabilitation bed numbers on the basis of the analysis Region Current 2013 2016 2021 North (Grey & Bruce) Central (Huron & Perth) South East (Norfolk & Oxford) South West (Middlesex & Elgin) London (City of London) 16 18 19 23 23 28 30 35 22 19 20 24 10 12 14 17 113 144 155 188 TOTAL 184 221 239 288 51

Considerations Recommendations Develop a detailed for plan LHIN consideration to execute transformation change in Complex Continuing Care and Rehabilitation across the South West LHIN in a timely and resource efficient manner The desired future state for Complex Continuing Care and Rehabilitation will only become a reality through a strong implementation plan and process that encompasses all key milestones of the transformation and is driven by a strong project management framework such as a Project Management Office (PMO). Apart from the best practices in implementation planning and project management in terms of scope, budget, time-line, project charter, detailed work plan etc. we recommend the following: System Level Implementation should be at an overall Access to Care level, not based on individual initiatives due to the overlap between stakeholders and outcomes and the importance of implementation at a systems perspective. The roll up of the three Access to Care initiatives will ensure that there are not duplicate or multiple requests / communications for key stakeholders. Implementation success of the Complex Continuing Care and Rehabilitation is directly tied to the success of the Home First and Assisted Living / Supportive Housing / Adult Day Program to provide additional capacity to address ALC patients who will need to be removed from CCC / Rehab beds in the future state. Recognizing that these recommendations will result in integration and that the LHIN integration process will need to be executed which may impact timelines, time should be built into the plan 52

Considerations Recommendations Data Reporting & Check Points A key component of the implementation should include formal checkpoints to review progress, outcomes and adjust the plan as needed. This includes adjustments to data reporting so that the changes made to the current state can be measured and understood on a timely basis. Include all the related project metrics from the project charter Implementation Governance Model The implementation governance structure should be different from the planning phase due to the different requirements and outcomes including: Develop a Implementation Management Office (IMO) Framework Introduce IMO (similar to a PMO structure) needed tools and methodology Develop IMO governance and policy development The IMO becomes the owner of an integrated implementation plan that includes the change management and stakeholder engagement components Institute implementation health checks and audits Internal implementation Champions at each hospital site level to drive change and communicate with the IMO Access to Care implementation Committee to review key decisions made up of senior players from the LHIN, CCAC and Hospital Promoting Adherence Include processes to measure and address adherence issues accountability 53

Change Management Recommendations Develop a detailed Change Management Strategy and Plan to drive transformation change in Complex Continuing Care and Rehabilitation across the South West LHIN Realigning the Complex Continuing Care and Rehabilitation beds requires transformative change due to the large degree of changes related to approach, processes and locations. Change management is about more than just helping people manage the change, a strong change management strategy should include the following key components: Develop a compelling vision for change This vision should inspire stakeholders to change their behavior of how they approach Complex Continuing Care and Rehabilitation and tied back to the Access to Care outcomes and aligned with the LHIN Blueprint Vision 2022 Develop key change messages for different stakeholders The key messages should clearly outline the reasons for change and specific benefits for each stakeholder group and the risks of not adopting the change Change Management Key Success Factors Rigorous process that outlines the specific steps needed to take the organizations from current state to future state Driven internally by a skilled lead, working with a small group of change agents to ensure implementation of the change management process Recognition that change is a process and not an event Awareness of where different individuals are on the change journey and flexibility in the process to account for differences Understanding the impact of the individual response to change on the success of the change event 54

Change Management Recommendations Why Change Management Fails Narrow focus on results change is a process and a journey Optional change it must be clear that that change is not an option to drive transformational change Outsourced key components of change management must be driven internally for sustainability Lack of focus change management success depends upon it being a sustained priority and focus Key Components of a Change Management Plan Identify Change Management Lead and Change Advisory Committee or Board to drive process Introduce change management concepts and identify risks & barriers to change Develop change management toolkits and provide change management training Facilitate change management workshops to help stakeholders address change Tie change into accountabilities and outcomes Implement feedback and issue resolution channels for ongoing engagement Use surveys to gauge stakeholders positions pre and post change to also measure the success of the change management program Provide one on one coaching sessions as needed for key stakeholders Check with key stakeholders to ensure they understand new processes and roles Provide opportunities for stakeholders to debrief about the transformational change Plan to manage and address different issues that surface throughout the journey Facilitate process implementation sessions for new teams to establish the new way forward Identify other stakeholders affected by the change--strategic partners, advisors, etc. Incorporate change management needs into the communication plan 55

Stakeholder Engagement Recommendations Develop an inclusive, flexible and proactive Stakeholder Engagement Strategy across the South West LHIN at a systems level that includes the three Access to Care Initiatives System Approach Integrate the Change Management and Communications strategy as key components of the Stakeholder engagement strategy to ensure the consistency, timing and delivery methods of key messages. The change management lead, communications lead and stakeholder engagement lead (could be the same person as the communications or change management lead) should work closely together under and be managed by the IMO Customization & Delivery Channels Each key stakeholder group should have their own customized engagement strategy including defining the appropriate delivery channels for engagement such as: Physicians engagement channels need to be flexible to minimize time requirements for physicians but maximize engagement for implementation - this could include multiple channels such as podcasts/videos to communicate key engagement components and join existing physician events to drive further engagement Clinicians engagement needs to be at a tactical level related to changes in process and tools at a hospital site level as well as overall as a group to ensure consistency and address common questions and concerns that could be funneled into an online forum for example CCAC engagement delivery channel can be more formal due to roll out of the new CCAC role such as role clarity sessions including problem solving for expected barriers and how to manage these situations 56

Stakeholder Engagement Recommendations Customization & Delivery Channels Continued Technology Community multiple channels to engage key stakeholders in the community could be used to address different local community needs / requirements such as face to face town halls versus online communication Assisted Living / Supportive Housing / Adult Day Programs a critical part of stakeholder engagement for the implementation of the CCC/Rehab future state which overlaps with the work being done in the AL / SH / ADP initiative Use technology as a tool to engage stakeholders across geographies and to address busy schedules such as: Podcasts that stakeholders can access when they have an opportunity to hear important messages in a more dynamic manner than written communications A dedicated website for stakeholder questions, communication channels and interactive blog posts, forums, etc. Webinars that can provide a more dynamic environment to communicate key messages Online video campaigns that involve key stakeholders and can easily be forwarded, commented on etc. by other stakeholders Social Media 57

Bed Transition Plan Recommendations Develop a detail Bed Transition Plan to encompass the strategic, financial and tactical requirements and manage all potential risks once bed realignment numbers have been determined Patient Transition Some patients who do not fit the future state definitions of CCC and Rehab, and especially at hospital sites where beds will be transitioned out, will need to be assessed to determine the best care environment for them. The best options need to be weighed against where there is system capacity in their community such as supportive housing. The Home First and AL/SH/ADP initiatives also underway under the Access to Care project charter will support patient transitions. For example. A patient transition plan for each affected hospital site should be developed by the hospital with support from the CCAC and the LHIN to ensure an appropriate regional / systems perspective Resource Adjustments Changes to some programs will be needed as part of the bed realignment, this will have a direct impact on staffing. Depending on the increase / decrease of beds the specific changes will need to be detailed along with financial implications at the hospital level. These adjustments although necessary at a hospital site level will need to be reviewed from a systems perspective to ensure minimal financial impact and the appropriate movement of some resources possible between hospital sites. Community Resources In order to successfully implement bed realignment and transition additional community resources will be needed. The specific community resources will need to be consulted to confirm capacity, transition process etc. Updated Accountability Agreements Funding and Physician Incentives to align with the future state. 58

Expanded Role of the CCAC Recommendations The capabilities of the CCAC Case Manager must be actively leveraged in order to maximize impact Clinical teams must use the expertise of the CCAC Case Manager as a system navigator to provide individualized assessments and match people with the appropriate services Involve CCAC early in care planning The role of the CCAC Case Manager as a skilled communicator must be leveraged during family meetings in which discharge plans are discussed and resources and supports are assessed. They ought to facilitate families and patients in identifying realistic goals related to discharge Bullet Rounds/Inter-professional Rounds should be adopted by all organizations across the South West LHIN 59

Future State Processes Recommendations Ensure consistency with definition, terminology, eligibility, priority of access to beds and process: Physicians, hospital and CCAC staff need to embrace a collaborative approach with this process Education must be developed that focuses on the new process, the use of the eligibility and referral documents as well as the clinical specialties of CCC and Rehab Right tools and right process need to be understood by everyone involved in the process to ensure the right people are in the right beds Regular reviews need to occur to ensure definitions, terminology, eligibility, priority of access to beds and process are current and workarounds are not being created 60

Interim IT Enablers Recommendations There is presently no electronic referral and matching system that meets the needs of this project We are aware that the RM&R initiative being developed will meet the needs of the CCC/Rehab initiative with the co leads and sponsors having had the opportunity to assist with the shaping of this work. A 2 day Kaizen event was held in Feb. with CCAC, hospitals and HealthTech, the RM&R consultant firm that is coordinating this work and in March consensus day event was held that included LHINs 1, 2, 3, 4. However the RM&R system is at least 2 years away. Because there is no system available, it has been identified that there are IT enablers that will be required to make the single point of access a success and to ensure we meet our guiding principles To further complicate the decisions that need to be made, there is a partial solution for the CCC part of the project from the CCAC perspective, there will be module available within the CCAC data base which will be available after April 25. This module will meet some of the needs for the CCC part of the initiative but there is nothing in the foreseeable future for Rehab. CCAC has investigated and will start to use the CHRIS CCC module when it becomes available but as there is both training and business process work that will need to be done, it is not possible to implement the CHRIS CCC immediately. 61

IT Enablers Recommendations There is a need for an interim solution for IT enablers for both CCC and Rehab. KPMG is working on a solution. The recommendations below will be necessary for the single point of access to roll out across the South West LHIN. Recommendations for IT enablers: E-notification of referral, eligibility and referral form that will be housed in the system Bed board management (matching) tracking tool that identifies services offered by facilities, ability to access patient information online electronically, and send agreements Electronic wait list that has the ability to access and update patient information from Community/ CCAC/Rehab, receive notification, prepare information and discharge client transfer client to rehab, and send agreements Electronic offer and acceptance notification 62

Communications Recommendations Communication/Stakeholder awareness: CCC and Rehab are different specialized programs communication must highlight these differences Communication must identify that CCC and Rehab are specialized programs that allow patients/clients to receive appropriate level of care provided by an inter-professional team who are knowledgeable and skilled regarding the care needs of this population. It is a client-centred, goal driven program that enables clients to optimize their health potential before moving to their final discharge destination Specific communication needs to be targeted at physicians, clinicians and CCAC. There must be a clear understanding of what these changes mean to the practice of each individual team member Specific communication needs to be created for the general public to enhance their understanding that CCC and Rehab are specialized programs which are not offered in every hospital. The public needs to know where these programs can be accessed. For example, what organizations are able to provide these specialized programs? Communication must identify role clarity and accountability between hospitals, CCAC and other community health agencies Who does what, by when in the processeveryone needs to be aware How will the public access this information? 63

Processes Recommendations Cont d Determine the services required to operate CCC and Rehab programs: Determine best practices in CCC and Rehab programs Ensure clinical practices align with best practices Identify standard metrics related to patient/client outcomes Identify a consistent standard of care for CCC and Rehab programs Identify clinical competencies related to CCC and Rehab specialties Ensure the programs take into account the cultural diversity of the community Scope of Rehab Care varies - the following groups/levels were identified in the interviews: Slow progress / low capacity for functional improvement Slow to moderate progress / low to moderate capacity for functional improvement Moderate to rapid progress / moderate to high capacity for functional improvement Rapid progress / high capacity for functional improvement Lifelong condition / periodic need for rehabilitative interventions 64

Community Resources Recommendations Cont d Address the lack of community resources that support discharge: It has been identified that the inconsistency of community resources across the South West LHIN has posed a challenge to discharge planning All 3 initiatives need to align during the implementation phases, there must be thoughtful consideration about the way these initiatives impact each other Awareness that ALC LTC is impacting the availability of CCC and Rehab beds: Many patients/clients who are presently occupying CCC and Rehab beds are awaiting LTC placement. As the Home First and Assisted Living/ Supportive Housing/ Adult Day Programs (AL/SH/ADP) initiatives are implemented there will be a reduction in the number of people who are eligible for LTC. There will also be a population deemed ALC who would have been admitted to CCC or Rehab but now do not fit the new criteria for CCC & Rehab In keeping with creating hospital environments that accommodate the physical and mental health needs of seniors, new alternatives in care must be considered. As beds are realigned the opportunity exists for hospitals to consider adopting other types of care: restorative care units and/or convalescent units or long term care beds Processes for accessing LTC beds need to be reviewed on a regular basis 65

LHIN Vision Alignment The recommendations align with the LHIN s Vision for an Integrated Health System of Care: CCC/Rehab realignment recommendations align with the multi-community integrated health system of care approach Service delivery by geographic clustering of moderate volume / complexity services focused on targeted populations CCAC expanded role aligns with: Seamless referral relationships with local and LHIN providers 66

Implications of Recommendations The recommendations proposed will impact the community, CCAC, hospitals, physicians, clinicians and several different community support service agencies. The realignment of beds poses a concern, particularly for those organizations and communities that are losing CCC beds, as hospitals contribute to the viability of the community. Perceptions that the loss of beds will result in loss of staff, people will not have access to CCC/Rehab services close to home Community support agencies may need to consider an increase in patient numbers and complexity. 67

Implications of Recommendations Long Term Care Homes could see an increase in acuity and complexity of patients. The expanded role of CCAC may be perceived as limiting access to CCC/Rehab beds, duplicating work and prolonging the time it takes to access the beds. With standardized eligibility criteria the potential exists that there will be patients who may not fit either CCC/Rehab/LTC. This could result in extended stays or ALC in acute care. There may be a requirement for advanced clinical knowledge and skills be required for CCC/Rehab and Long Term Care. Hospitals may be required to provide community outreach programs 68

Implications of Recommendations Hospitals may be required to care for patients in a way that reduces functional decline Processes that support pro-active discharge planning between CCAC and hospitals must take place CCAC to work with hospitals to assess adults and seniors with complex needs within 48 hours of admission and prior to ALC designation CCAC must understand the discharge options available to effectively assist patients and their families Engagement of mental health in-patient and out-patient programs must be encouraged to support CCC/Rehab patients with mental health care needs 69

Evaluation Considerations In collaboration, hospitals and CCAC are responsible to: Continually monitor changes in processes and outcomes and take corrective actions where necessary o Monitor accessibility to CCC/Rehab beds (CCC/Rehab appropriate patients being able to access beds in a timely manner) o Monitor patient population accessing CCC/Rehab beds (right people in the beds) 70

Detailed Next Steps ATC CCC/Rehab and AL/SH/ADP Recommendations Activity Purpose Decision Making Group 1. Review draft recommendations Ensure alignment with Project Sponsors Kelly Gillis, Sandra Coleman Ensure support from Steering Committee CCC/Rehab Steering Committee CCC/Rehab Steering Committee Ensure alignment with South West CEO South West CEO Vision Receive input from Core Operations Group ATC Core Operations Group 2. Update South West Health System Input to the process, implementation plan, South West HSLC Leadership Council stakeholder engagement 3. Update South West LHIN Board of Directors Input from Board regarding alignment to priorities South West LHIN Board of Directors 4. Update South West CCAC Board of Directors Input from Board on the change from SW CCAC South West CCAC Board of Directors 5. Finalize recommendations Receive endorsement of Steering Committee CCC/Rehab Steering Committee 6. Engage stakeholders in implementation discussion 7. Finalize recommendations and high level implementation plan (including synergy between ATC initiatives) 8. Approval of Recommendations and high level implementation plan Receive input on recommendations and implementation Endorsement of recommendations/high level implementation plan Endorsement of recommendations/high level implementation plan Decision required to move system change forward Hospital/CCAC CEO Group including CNE Group ATC Core Operations Group South West LHIN Health System Leadership Council South West LHIN Board of Directors 71

3. Data Analysis & Hospital Profiles 72

South West LHIN Data Analysis & Hospital Profiles 1. Methodology 2. 1 Day Snapshot Table of Contents 3. Collected Data Overview 4. CCC Admits by Hospital, 2008-2010 5. Rehab Admits by Hospital, 2008-2010 6. CCC Utilization & Beds by Hospital 7. Rehab Utilization & Beds by Hospital 8. CCC Bed Realignment Numbers 9. Rehab Bed Realignment Numbers 10. Hospital Profiles 11. Rehabilitation Services 12. System Change

Methodology The following mix of inputs were used to derive the Current and Future State Qualitative Inputs Quantitative Inputs Seventeen (17) Interviews Completed at all hospitals in South West LHIN that have permanently funded CCC and/or Rehab Beds. Secondary Research examining current state at other LHINs and Provinces. Input Types: Physician involvement in admissions process Perceptions concerning how patients can be discharged sooner Staff understanding of major differences between CCC/Rehab and LTC eligible patients Presence of repatriation process & eligibility criteria Data Analysis & Validation Current & Future State Assessment ALC Usage of CCC & Rehab Bed Data from Cancer Care Ontario. One-day Snapshot Data from thirteen (13) hospitals for proxy and weighting purposes where ALC data unavailable. Input Types: # of CCC & Rehab Beds Total CCC/Rehab Patient Days % ALC Utilization of CCC & Rehab Average Length of Stay Patient Type Referral Source Discharge Venue 74

Methodology Realignment Calculation Model The following model provided the basis for calculating the future number of beds 1 Specific Factoring in Utilization of Demographic CCC & Rehab Shifts & Risk beds in South Factors West LHIN 2 3 Adjusting for Continued ALC Use of CCC & Rehab Beds 4 Unmet Need 5 6 System Overall Change Utilization Reduction Target (CCC Only) Removal of ALC Patient days from Total Patient Days. One-day Snapshot on February 21 st to fill in data gaps. Adjusting for population growth and health risk factors. Adjusting for continued use of beds by ALC Patients. Accounts for patients that are newly eligible, and/or now have improved access to resources. Utilization Target accounts for variability in bed occupancy. Anticipated Reduction in demand for CCC beds on basis of improvements. Rationale for not utilizing Baseline Approach (Population/Bed Ratios) 1. Cannot deduce appropriate utilization of resources 2. Absence of comparables renders benchmarking problematic 3. Baselining assumes homogeneity of populations 75

Methodology The following were the inputs into the Logic Model Logic Model Inputs CCC INPUTS 2013 2016 2021 Pop. Growth 5% 13% 30% Risk Factors 3% 5% 10% ALC Use* 25% 20% 15% System Change* 5% 7% 9% Unmet Need* 3% 1% 1% Utilization* 93% 93% 93% REHAB INPUTS 2013 2016 2021 Pop. Growth 5% 13% 30% Risk Factors 3% 5% 10% ALC Use* 5% 4% 3% Unmet Need* 3% 1% 1% Utilization* 87% 87% 87% Inputs: Population Growth: Ministry of Finance population projection figures, 2006-2021 Risk Factors: From South West LHIN Environment Scan. These encompass lifestyle factors that may increase the susceptibility of residents of this LHIN to future healthcare system usage. *Targets set by CCC/Rehab Steering Committee & Working Group members based on Provincial targets and LHIN research and comparators 76

Methodology Sensitivity Analysis The impact of the projections are significant and cannot be overstated CCC BEDS SENSITIVITY ANALYSIS % ALC, SYSTEM CHANGE & UTILIZATION PROJECTIONS REGION CURRENT 2013 (0%) 2013 (100%) London 82 71 85 Central 76 56 73 South East 63 28 38 South West 45 23 30 North 0 10 10 TOTALS 266 188 236 REHAB BEDS SENSITIVITY ANALYSIS % ALC & UTILIZATION PROJECTIONS REGION CURRENT 2013 (0%) 2013 (100%) London 113 120 144 Central 23 22 28 South East 22 15 19 South West 10 11 12 North 16 15 18 TOTALS 184 183 221 Implication If bed numbers are calculated only on the basis of verifiable data (population growth & lifestyle factors), the number of beds required is significantly less Logic Model Inputs CCC INPUTS 2013 2016 2021 Pop. Growth 5% 13% 30% Risk Factors 3% 5% 10% ALC Use* 25% 20% 15% System Change* 5% 7% 9% Unmet Need* 3% 1% 1% Utilization* 93% 93% 93% 77

1 Day Snapshot The Hospitals in the LHIN were asked to conduct a 1-day snapshot on Tuesday, February 21 st, to provide bed utilization metrics as inputs into the bed realignment Logic Model. The data served as a proxy for hospitals for which there was no data in the CCO report 78

Collected Data Overview The following is an overview of the ALC and Snapshot Data used in the analysis Hospital CCC Rehab St. Joseph s Parkwood St. Thomas Elgin Listowel Memorial ALC Data Snapshot Data ALC Data Snapshot Data -- -- Alexandra (Ingersoll) -- -- Owen Sound (GBHS) -- -- St. Marys Memorial (HPHA) -- -- Seaforth Community (HPHA) -- -- Stratford General (HPHA) Woodstock General -- Tillsonburg District -- -- South Huron -- -- Wingham & District -- -- 79

CCC Admits by Hospital, 2008-2010 After Parkwood, Stratford (Central), St. Thomas Elgin (SW) and Woodstock (SE) took in the most CCC patients between 2008-2010 CCC Admins by Hospital - 2008-2010 32% 13% 2% 4% 5% 1% 13% 3% 6% 16% 5% South Huron Listowel Tillsonburg Wingham Stratford Alexandra Seaforth St. Marys Woodstock St. Thomas-Elgin Parkwood 80

Rehab Admits By Hospital, 2008-2010 In addition to accounting for 60% of all General Rehab intakes, Parkwood has the only Specialized Rehab Beds in the entire LHIN General Rehab Admits by Hospital - 2008-2010 2% 2% 11% 60% 12% 14% South Huron Wingham Stratford Grey Bruce St. Thomas-Elgin Parkwood 81

Bed Numbers Utilization CCC Utilization & Beds by Hospital The weighted utilization rate of CCC beds for the South West LHIN is 62.32%*. For comparative purposes, the HNHB LHIN rate is 64.2% 100 CCC Bed Utilization Rate by Hospital 2011 100% 80 80% 60 60% 40 40% 20 20% 0 0% CCC Utilization *Excludes ALC-CCC component 82

Bed Numbers Utilization Rehab Utilization & Beds by Hospital Rehab Utilization & Beds by Hospital The weighted utilization rate of Rehabilitation beds for the South West LHIN is 91.89%* Rehab Bed Utilization Rates by Hospital 2011 120 120% 100 100% 80 80% 60 60% 40 40% 20 20% 0 Parkwood Wingham Stratford South Huron Woodstock St. Elgin-Thomas Owen Sound 0% Rehab Utilization *Excludes ALC-CCC component 83

CCC Bed Realignment Numbers By Hospital/Organization Realignment facilitates a more equitable access to services Region Hospital Current Beds Future Beds +/- North Owen Sound 0 10 +10 Central Listowel 25 24-1 Wingham 12 13 +1 HPHA 35 36 +1 South Huron 4 0-4 South East Woodstock 33 38 +5 Alexandra 14 0-14 Tillsonburg 16 0-16 South West St. Thomas Elgin 45 30-15 London Parkwood 82 85 +3 Total 266 236-30 The Huron Perth Healthcare Alliance (HPHA) may distribute its beds according to its Vision 2013 plan 84

Rehab Bed Realignment Numbers Region Hospital Current Rehab Beds By Hospital/Organization Virtually all of the increase (37) in Rehab beds is accounted for by a decrease (30) in CCC beds Future Rehab Beds North Owen Sound 16 18 +2 Central Wingham 5 6 +1 HPHA 14 16 +2 South Huron 4 6 +2 South East Woodstock 22 19-3 South West St. Thomas Elgin 10 12 +2 London Parkwood 113 144 +31 Total 184 221 +37 +/- 85

Hospital Profiles St. Joseph s Health Care, London Parkwood Hospital 86

St. Joseph s Health Care, London Parkwood Hospital Parkwood will gain 3 beds; remains destination for most complex of patients STATISTICS & INFORMATION Current CCC Beds 82 Future (2013) CCC Beds 85 Average Length of Stay (Days) 67.7 Change +3 Utilization Rate (ALC Data) 81% Existing Eligibility Criteria Types of Patients Functional Loss Complex Awaiting Rehab Behavioural Post-Surgical Strokes Sources of Referral CCAC ER/ACU Discharge Locations Home LTC/Retirement Y 87

St. Joseph s Health Care, London Parkwood Hospital Parkwood s Rehab program will grow by 27%. Scale can be beneficial STATISTICS & INFORMATION Current Gen Rehab Beds 63 Future (2013) Rehab Beds 94 Average Length of Stay (Days) 34.6 Change +31 Utilization Rate (ALC Data) 98%* Existing Eligibility Criteria Types of Patients Post-Surgical Strokes Orthopedic Sources of Referral CCAC Hospitals ER/ACU Discharge Locations Home LTC/Retirement Acute Care Y *Includes General & Specialized Rehab Beds 88

St. Joseph s Health Care, London Parkwood Hospital The Specialized beds remain untouched as no reliable measure of their use could be made STATISTICS & INFORMATION Current Spec. Rehab Beds 50 Future (2013) Rehab Beds 50 Average Length of Stay (Days) 34.6 Change 0 Utilization Rate (ALC Data) 98%* Existing Eligibility Criteria Types of Patients Musculoskeletal Multiple Sclerosis Peripheral Neuropathy MVC Sources of Referral ER/ACU Family Members GPs Discharge Locations Home LTC/Retirement Acute Care Death *Includes General & Specialized Rehab Beds Y 89

Hospital Profiles St. Thomas Elgin General Hospital 90

St. Thomas Elgin General Hospital High CCC-ALC utilization renders loss impact low from Patient care perspective STATISTICS & INFORMATION Current CCC Beds 45 Future (2013) CCC Beds 30 Average Length of Stay (Days) 51 Change -15 Utilization Rate (ALC Data) 47% Existing Eligibility Criteria Types of Patients Functional Loss Complex Post-Surgical Strokes Palliative Sources of Referral ER/ACU Community Discharge Locations Home LTC/Retirement Death Y 91

St. Thomas Elgin General Hospital It s clear that St. Thomas is in need of additional resources STATISTICS & INFORMATION Current Gen Rehab Beds 10 Future (2013) Rehab Beds 12 Average Length of Stay (Days) 15 Change +2 Utilization Rate (ALC Data) Snapshot Existing Eligibility Criteria Types of Patients Behavioural Strokes Orthopedic MVC Sources of Referral ER/ACU Community 100% 100% Discharge Locations Home LTC/Retirement Y 92

Hospital Profiles Woodstock General Hospital 93

Woodstock General Hospital Woodstock will be the hub of the Southeast; it has a weighted utilization rate of 67% STATISTICS & INFORMATION Current CCC Beds 33 Future (2013) CCC Beds 38 Average Length of Stay (Days) 30 Change +5 Utilization Rate (ALC Data) Snapshot Existing Eligibility Criteria 59% 100% Types of Patients Functional Loss Complex Awaiting Rehab Behavioural Post-Surgical Strokes Palliative Sources of Referral CCAC ER/ACU Hospitals Discharge Locations Home LTC/Retirement Acute Care Death Y 94

Woodstock General Hospital Woodstock s usage is unclear; high probability it can lose a handful with minimal impact STATISTICS & INFORMATION Current Gen Rehab Beds 22 Future (2013) Rehab Beds 19 Average Length of Stay (Days) N/A Change -3 Weighted Utilization 63% Existing Eligibility Criteria Types of Patients Post-Surgical Orthopedic MVC Sources of Referral ER/ACU Hospitals Discharge Locations Home ER/ACU Y 95

Woodstock General Hospital Woodstock General Hospital Evaluation Findings Based on 13 patients to Rehab: All patients were assessed within 24 hours of referral (Monday to Friday) Time from assessment to eligibility was within 24 hours Time from acceptance to transfer: o 6 were within 24 hours o 1 was 48 hours o 1 was 72 hours (Transfer from London) o 5 were not eligible for admission No referrals to date for CCC. 96

Woodstock General Hospital Woodstock General Hospital Evaluation Findings Continued Eligibility and Referral Forms: o Takes approximately 1 hour to complete referral and eligibility CCAC Expanded Role: o o o o o o Feels part of team on Rehab, acute care not part of team yet, role clear on Rehab but not yet on Acute ( seen as roadblock) CCAC team also needs role clarity around this expanded role Clarity with hospital team regarding role still needs work If a patient is not willing to participle in program, it is a hospital responsibility to discuss the possibly of discharge (enforcement role) Bullet rounds are not consistent at this hospital Increased work load for CCAC support staff with new role at WGH 97

Hospital Profiles Stratford General Hospital (HPHA) 98

Stratford General Hospital (HPHA) The HPHA will receive 1 new CCC bed and 2 Rehab beds. Their allocation to be determined STATISTICS & INFORMATION Current CCC Beds 20 Future (2013) CCC Beds 21 Average Length of Stay (Days) 19.4 Change +1 Utilization Rate (ALC Data) 74% Existing Eligibility Criteria Types of Patients Functional Loss Complex Post-Surgical Strokes Sources of Referral ER/ACU Community Discharge Locations Home LTC/Retirement Y 99

Stratford General Hospital (HPHA) An efficient hospital, Stratford General could benefit from additional beds STATISTICS & INFORMATION Current Gen Rehab Beds 14 Future (2013) Rehab Beds 16 Average Length of Stay (Days) 28.5 Change +2 Utilization Rate (ALC Data) 95% Existing Eligibility Criteria Types of Patients Complex Strokes Orthopedic Sources of Referral ER/ACU Community Discharge Locations Home LTC/Retirement Y 100

Hospital Profiles St. Marys General Hospital (HPHA) 101

St. Marys Memorial Hospital (HPHA) St. Marys proximity to other hubs renders an increase as per 2013 vision unnecessary STATISTICS & INFORMATION Current CCC Beds 5 Future (2013) CCC Beds 5 Average Length of Stay (Days) 15.7 Change 0 Utilization Rate (ALC Data) 70% Existing Eligibility Criteria Types of Patients Functional Loss Complex Post-Surgical Strokes Sources of Referral ER/ACU Community Discharge Locations Home LTC/Retirement Y 102

Hospital Profiles Seaforth Community Hospital (HPHA) 103

Seaforth Community Hospital (HPHA) These bed numbers are consistent with HPHA s 2013 Vision STATISTICS & INFORMATION Current CCC Beds 10 Future (2013) CCC Beds 10 Average Length of Stay (Days) 38.1 Change 0 Utilization Rate (ALC Data) 71% Existing Eligibility Criteria Types of Patients Functional Loss Complex Post-Surgical Strokes Sources of Referral ER/ACU Community Discharge Locations Home LTC/Retirement Y 104

Hospital Profiles Wingham & District Hospital 105

Wingham & District Hospital Wingham plays an important role due to its location STATISTICS & INFORMATION Current CCC Beds 12 Future (2013) CCC Beds 13 Average Length of Stay (Days) 60 Change +1 Utilization Rate (Snapshot) 58% Existing Eligibility Criteria Types of Patients Functional Loss Complex Behavioural Sources of Referral ER/ACU Community Discharge Locations Home LTC/Retirement Y 106

Wingham & District Hospital It is recommended that an additional bed will be added to Wingham & District STATISTICS & INFORMATION Current Gen Rehab Beds 5 Future (2013) Rehab Beds 6 Average Length of Stay (Days) 28 Change +1 Utilization Rate (Assumption) 80% Existing Eligibility Criteria? Types of Patients Strokes Orthopedic Sources of Referral CCAC Hospitals ER/ACU GPs Community Discharge Locations Home LTC/Retirement CCC 107

Hospital Profiles South Huron Hospital 108

South Huron Hospital South Huron s patients can be served at Seaforth Community STATISTICS & INFORMATION Current CCC Beds 4 Future (2013) CCC Beds 0 Average Length of Stay (Days) N/A Change -4 Utilization Rate (Snapshot) 75% Existing Eligibility Criteria Types of Patients Functional Loss Complex Post-Surgical Strokes Orthopedic Palliative Sources of Referral ER/ACU Discharge Locations Home LTC/Retirement N 109

South Huron Hospital It is recommended that 2 of the 4 CCC beds be converted into Rehab beds STATISTICS & INFORMATION Current Gen Rehab Beds 4 Future (2013) Rehab Beds 6 Average Length of Stay (Days) N/A Change +2 Utilization Rate (Snapshot) 75% Existing Eligibility Criteria Types of Patients Post-Surgical Strokes Orthopedic Sources of Referral ER/ACU Family Discharge Locations Home LTC/Retirement N 110

Hospital Profiles Owen Sound General Hospital (GBHS) 111

Owen Sound General Hospital (GBHS) Access to care will be improved for thousands with the placement of beds at Owen Sound STATISTICS & INFORMATION Current CCC Beds 0 Future (2013) CCC Beds 10 Average Length of Stay (Days) 0 Change +10 Utilization Rate (ALC Data) N/A Existing Eligibility Criteria N/A Types of Patients N/A Sources of Referral N/A Discharge Locations N/A 112

Owen Sound Hospital (GBHS) Owen Sound can use additional beds, but there s no rush to integrate STATISTICS & INFORMATION Current Gen Rehab Beds 16 Future (2013) Rehab Beds 18 Average Length of Stay (Days) 33 Change +2 Utilization Rate (ALC Data) 84% Existing Eligibility Criteria Types of Patients Post-Surgical Strokes Orthopedic Sources of Referral ER/ACU Community Discharge Locations Home LTC/Retirement Y 113

Hospital Profiles Listowel Memorial Hospital 114

Listowel Memorial Hospital Listowel appears to have a bit of overcapacity and is in relative proximity to Stratford STATISTICS & INFORMATION Current CCC Beds 25 Future (2013) CCC Beds 24 Average Length of Stay (Days) 104 Change -1 Utilization Rate (Snapshot) 68% Existing Eligibility Criteria Types of Patients Functional Loss Complex Behavioural Sources of Referral ER/ACU Community Discharge Locations Home LTC/Retirement Y 115

Hospital Profiles Alexandra Hospital 116

Alexandra Hospital Alexandra is poised to lose all of its beds; Woodstock as primary CCC resource for County STATISTICS & INFORMATION Current CCC Beds 14 Future (2013) CCC Beds 0 Average Length of Stay (Days) 61 Change -14 Utilization Rate (ALC Data) 24% Existing Eligibility Criteria Types of Patients Complex Behavioural Post-Surgical Strokes Palliative Sources of Referral CCAC ER/ACU Discharge Locations LTC/Retirement Death Y 117

Hospital Profiles Tillsonburg Memorial Hospital 118

Tillsonburg District Memorial Hospital Regional proximity to Woodstock and low utilization mitigate CCC impact STATISTICS & INFORMATION Current CCC Beds 16 Future (2013) CCC Beds 0 Average Length of Stay (Days) 72 Change -16 Utilization Rate (ALC Data) 8% Existing Eligibility Criteria Types of Patients Complex Behavioural Sources of Referral ER/ACU Discharge Locations Home LTC/Retirement Death N 119

Rehabilitation Services By Hospital/Organization Hospital/Organization CCC Rehabilitation St. Joseph s Health Care, London - Parkwood Hospital St. Thomas Elgin General Hospital Woodstock General Hospital Wingham & District Hospital Alexandra (Ingersoll) Hospital Occupational therapist Physiotherapy Therapeutic Recreation Speech Therapy Registered Dietitians Occupational Therapy Physiotherapy Recreational Therapy Occupational Therapy (Part Time) Physiotherapy (Part Time) Leisure Recreation Occupational Therapy Physiotherapy Speech Therapy Recreational Therapy Occupational Therapy Physiotherapy Occupational Therapy Physiotherapy Therapeutic Recreation Speech Therapy Dieticians Social Worker Audiology Occupational Therapy Physiotherapy Recreational Therapy Occupational Therapy (Part Time) Physiotherapy (Part Time) Occupational Therapy Physiotherapy Speech Therapy Recreational Therapy N/A 120

Rehabilitation Services By Hospital/Organization Cont d Hospital/Organization CCC Rehabilitation Huron Perth Healthcare Alliance (HPHA) South Huron Hospital Tillsonburg District Memorial Hospital Listowel Memorial Hospital Owen Sound Hospital (Grey Bruce Health Services) Occupational Therapy Physiotherapy Social Worker Dietitian Activation Pastoral Care No formal program Physiotherapy Social Worker Speech Therapy Occupational Therapy Physiotherapy Occupational Therapy Physiotherapy Social Worker Dietitian Activation Pastoral Care No formal program Physiotherapy Social Worker Speech Therapy N/A Not Provided N/A N/A Occupational Therapy Physiotherapy Speech Therapy Social Worker Recreational Therapy 121

System Change Efficiencies from System Change stem from a range of initiatives Change Assumption Potential Impact Timing Community Stroke Rehabilitation Teams The number of individuals with a stroke that require in hospital rehabilitation will decrease and for those who do require hospitalization, it is expected that their length of stay will decrease. At Parkwood Hospital, 32% decrease in ALC days on Inpatient Stroke Rehabilitation. 18% decrease in average LOS on inpatient stroke rehabilitation 44.9% decrease in days waiting for admission to rehab. Teams implemented across the South West LHIN in 2010/11 Behavioural Support Teams are being formed The proportion of the total in-patient separations by acute and alternate level of care lengths of stay (LOS) for the target population should decrease. The proportion of the total ALC days that are for the target population. The proportion of the target population that returned to their original living situation following an acute care admissions. 6.3% of all discharges among seniors involved someone living with a dementia. Of acute inpatient discharges with dementia or Alzheimer s Disease in any diagnosis field, 41.7% came from the community, and of those who came from the community, 58.2% were discharged home. Hiring of teams began in December 2011 across the South West LHIN Home First Initiative 12/13 target is to have 50% reduction of ALC LTC cases in hospitals where Home First is implemented. After 5 months at LHSC UH, we are seeing a decrease in number of ALC cases by 9 active cases per week. This translates to a 17% improvement in this population (from 48.5 to 39.5 average active cases per week). For this population, a 10% improvement in the next year might be reasonable. London & St. Thomas Q4 2011/12, Tillsonburg and Owen Sound Q3 2012/13, Woodstock Q4 2012/13, rest of the communities in 13/14 Eligibility Criteria Criteria are being implemented for adults with complex needs requiring assisted living, supportive housing and adult day programs. 20-30% of assisted living and supportive housing will transition to service better aligned to their needs by applying consistent eligibility criteria. Limited change expected in the 2012/13 year due to phased implementation. The need for extensive transition plans will mean that change in metrics will be slow for this group. Implementation under LHIN consideration occurring over the 12/13 fiscal year 122

4. CCAC Role & Processes 123

South West LHIN CCAC Role & Processes Table of Contents 1. Current State Process Findings 2. Future State: Expanded Role of the CCAC 3. Future State Process Summary 4. Process Maps

Current State Process Findings Admission Process Assessments Significant procedural inconsistencies are noted across the LHIN CCC Current State Process Map Key Process Findings: High variability in access to care Larger version in Appendix Rehab Current State Process Map Larger version in Appendix Volatility of Average Length of Stay times Lack of standard tools eligibility, referral protocol, waitlist management Learning on the job due to absence of sufficient pre-requisite expertise contributing to slower patient transition across the continuum of care 125

Future State: Expanded Role of the CCAC The legislated expanded Role of the CCAC will be implemented for CCC & Rehab CCACs are optimizing their capacity as system navigators and care coordinators CCACs are working toward facilitating smooth transitions to complex continuing care beds and rehabilitation beds In partnership with health service providers, CCACs will support clients in receiving integrated, coordinated and client-centered care, focusing on the complex needs of an aging population i.e. CCAC was legislated to authorize admissions for to Long Term Care Homes using standardized eligibility criteria and assessment information resulting in consistency of admissions to LTCHs Context 126

Future State: Expanded Role of the CCAC What Does the Expanded CCAC Role mean for patients? Early intervention to prevent crisis and hospitalization Assessment for most appropriate care destination Coordinated access to the right care at the right place with quality outcomes CREMS - Linkages with EMS/hospital diversion Single point of access RM & R Collaborative discharge planning Standardized criteria Home to ED Acute In-patient admission Discharge to rehab/ccc/ convalescent care Admission to LTCH, assisted living or other longterm care destinations Discharge Home Linkage with Primary Care Identification of high risk clients/ frequent users of ER/hospital services Intense case management Enhanced home care services Linkages with primary care ED notification/identification of clients who could be diverted home with support/follow-up CCAC clients Additional risk markers Case managers in EDs GEM nurses in EDs Escort home with support (Home at Last) Collaborative discharge planning Joint rounds Early identification of ALC/Early referral to CCAC Role clarity Protocols for communication with patients Enhanced home care services Intense case management for at risk clients Standardized assessment in the home (minimize hospital assessments) Linkages with primary care Protocols using RAI indicators to support consistent care planning Outreach teams/ professional services Protocols to using RAI indicators to support consistent care planning, eligibility and priority decisions Shared commitment to Home First philosophy Source: CCAC Expanded Role, April 2011 Authors Margaret 2012 Mottershead All rights reserved (CEO, OACCAC), Bernie Blais, LHIN Co-Chair (CEO, NSM LHIN), Sandra Coleman, CCAC Co-Chair ( CEO, SW CCAC) 127

Future State Process Summary Redesigned Process Flow Future State Performance Metrics: % of patients placed in CCC and Rehab bed within distance of home address In Progress/Completed Initiatives: CCAC Case Manager implemented as Single Point of Access to CCC & Rehab services in early adopter site Standardized eligibility criteria in place Referral for admission documents being tested % of patients meeting criteria % of CCC and Rehab patients admitted within x days of referral Time from referral to CCAC assessment Time from CCAC referral to CCC and Rehab acceptance Time from acceptance to admission 128

Process Maps Current State CCC 129

Process Maps Current State Rehab 130

Process Maps Future State - Acute to CCC (Part 1) 131

Process Maps Future State - Acute to CCC (Part 2) 132

Process Maps Future State - Community to CCC & Rehab (Part 1) 133

Process Maps Future State - Community to CCC & Rehab (Part 2) 134

5. Secondary Research & Sources 135

South West LHIN Secondary Research & Sources Table of Contents 1. Case Study: North Simcoe Muskoka (NSM) 2. Case Study: Hamilton Niagara Haldimand Brant (HNHB) 3. Canadian & International 4. RM&R in Ontario 5. Sources

Case Study: North Simcoe Muskoka (NSM) NSM s successes may not be transferable given the differences in scale, minimal bed realignment, and hospitals (4) involved What Happened NSM LHIN engaged in a CCC bed realignment initiative in Q4 2009 Successes implementation: Standardized eligibility criteria Standardized admissions & discharge processes Centralized Waitlist Management Barriers Physicians initially pushed back viewed newly ineligible patients as an ALC dump onto their hospitals ONA and other unions not pleased Result Bed realignments complete Implemented CCAC role as single point of access 137

Case Study: Hamilton Niagara Haldimand Brant (HNHB) HNHB s experience highlights the importance of a well-articulated enforcement and funding strategy What Happened HNHB LHIN engaged in a CCC bed realignment initiative in Q2 2010 Successes Stakeholder agreement concerning future bed numbers Early adopters on board Established CCC Implementation Steering Committee for oversight LHIN funded Project Coordinator to lead efforts Barriers Poor funding strategy provided little incentive to hospitals losing beds Overlap of other ongoing and new initiatives Lack of meaningful leadership to enforce realignment plan Result Realignment initiative currently on hold and unlikely to occur 138

Canadian & International International No formal international conventions concerning CCC. Ontario CCC Bed realignment initiatives were underway in NSM and HNHB as of Q4 2009 and Q1 2010, respectively. Saskatchewan Saskatoon Health Region developed a Complex Continuing Care strategy around ensuring THE RIGHT CARE, at the RIGHT TIME in the RIGHT SETTING in 2010. No designated CCC beds as of March 2012; 28 beds in Transitional Care Unit awaiting transfer to LTC. Most medically complex. 139

Canadian & International British Columbia CCC patients are accounted for under the Residential Care Local Home and Community Care Programs (HCC) in each designated Health Region control access to services Manitoba Manitoba has a single entry system for each of its 12 Regional Health Authorities. They govern access to both CCC and Rehabilitation services No formal conventions concerning the identification of CCCeligible patients Nova Scotia CCC eligible patients fall under the Community Care Services umbrella in Nova Scotia. Access to care decisions for both Rehabilitation and CCC services are made at the District Health Authority level of which there are 9 in the province. 140

RM&R in Ontario Resource Matching & Referral initiatives were underway in all 14 LHINs as of Q2 2010 The MOHLTC clustered the 14 LHINs into 3 groups to develop standardized referral pathways across and to ensure economies of scale and knowledge sharing are achieved. Cluster 1 South West Erie St. Clair Hamilton Niagara Haldimand Brant Waterloo Wellington Cluster 2 Toronto Central Central Central East Central West Mississauga Halton North Simcoe Muskoka Cluster 3 North East North West Champlain South East 141

5. Co-Lead Supporting Information 142

CCC / Rehab Initiative Objectives Objectives for CCC / Rehab CCAC Role & Processes Ensure accessible CCC/Rehab inpatient beds across the South West LHIN Have a clear definition of a CCC/Rehab patient Identify CCC/Rehab eligibility criteria Establish a process for CCAC to coordinate all admissions to CCC/Rehab beds Implement processes to ensure appropriate and timely access and utilization of CCC/Rehab beds Reduce ALC waiting time for CCC/Rehab beds in acute care Facilitate early discharge planning 143

CCC / Rehab Initiative Objectives Deliverables for CCC / Rehab CCAC Role & Processes Project work plan completed Interviews with hospital stakeholders to identify current state and solicit engagement in the project (Appendix Interview tool and current state flow) Data collected on bed capacity and admission processes (Appendix one day snapshot) Test coordinated access and criteria for admission Identify definition of CCC/Rehab based on existing expert definitions Develop standardized eligibility criteria for CCC/ Rehab based on the literature and existing tools (Appendix) Develop a standardized referral form based on existing referral forms. Validation of this information was confirmed during the RM&R Kaizen sessions (Appendix) Develop wait list management tool Develop a referral process Evaluate new processes - Findings will inform the future implementation planning implementation(early Adopter/ Woodstock General Hospital) PDSA - CCAC expanded role (Appendix) PDSA Patient flow process(appendix) PDSA - Eligibility criteria and referral form (Appendix) 144

CCC / Rehab Initiative Objectives Project Planning Process In October of 2011, the CCAC and Hospital sponsors Donna Ladoucuer and Elaine Gibson, SW LHIN Representatives Susan Warner and Access to Care Interim Project Lead Marg McAlister met to review the project charter which was written June 2011. A steering committee was formed and began meeting December 2011. Membership included a wide variety of clinical expertise and representation from across the SW LHIN: Project Sponsors Access to Care Project Lead Project Co-Leaders SW LHIN Representation Representation from hospitals from the surrounding geographic area Physician (specialist) champions e-health representation Quality and Process Improvement representation Long Term Care representation 145

CCC / Rehab Initiative Objectives Project Steering Committee The CCC/Rehab Steering Committee would: Provide guidance and oversight to the successful realignment of CCC/Rehab bed capacity in hospitals and to the implementation of the CCAC expanded role to facilitate a single point of access to these services Guide LHIN wide direction setting, implementation planning, and stakeholder engagement. Be accountable to The Health System Leadership Council (HSLC) that is providing strategic oversight for Access to Care initiative. Report to the HSLC as required, in addition to the Access to Care Sponsors (LHIN Senior Director and CCAC CEO). 146

Sources Representatives from the following hospitals were interviewed as part of the primary research component of this Report: Primary St. Joseph s Health Care, London Parkwood Hospital St. Thomas Elgin General Hospital Woodstock General Hospital Stratford General Hospital (HPHA) St. Marys General Hospital (HPHA) Seaforth Community Hospital (HPHA) Clinton Public Hospital (HPHA) Listowel Memorial Hospital Alexandra Hospital South Huron Hospital Owen Sound General Hospital (GBHS) Chesley & District Memorial Hospital (SBGHC) Tillsonburg Memorial Hospital Wingham & District Hospital Woodstock Private Hospital 147 147

Sources In addition to primary research the following source documents were consulted: Secondary South West LHIN Health System Design Blueprint Vision 2022 HEALTH epathways RM&R Project Current State Assessment South West LHIN report on CCC/Rehabilitation beds CCAC Follow Up Report Cancer Care Ontario (CCO) CCAC Expanded Role Steering Committee work CCC/Rehab Expert Panel Update Barry Monahan Report Caring for our Aging Population and Addressing ALC, Dr. David Walker HMHB LHIN Final Report from the Task Group on Coordinated Strategy for Complex Care NSM LHIN Complex Continuing Care Program Policies and Procedures 148