Central East LHIN Musculoskeletal Rehab Plan 1
Executive Summary... 3 Introduction... 5 The Planning Process... 6 Values... 7 Current Context... 9 Health System Reform... 9 Demographics and Demand for Musculoskeletal Rehab... 13 Current State of Rehab Services in the Central East LHIN... 15 Rehab Services Recommendations... 32 Aligning Care to Patient Need... 32 Trauma and Non-Elective Patients... 34 Process Reviews and Quality Improvements... 36 Setting Standards... 38 Promoting Ongoing Quality Improvement and Innovation... 44 Improving Data Collection and Performance Monitoring... 46 Enhancing Preventative Care... 48 Implementation... 50 Conclusion... 54 Appendices... 55 Appendix A: Rehab Service Task Group Membership... 55 Appendix B: CMGs included in Orthopaedic Care... 56 Appendix C: Outpatient Volumes 2012/2013... 58 Appendix D: GTA Rehab Network Patient Flow Maps... 61 Appendix E: National Hip Fracture Toolkit Exert... 63 Appendix F: References... 64 2
Executive Summary Members of the Rehab Services Task Group (RSTG) have developed a set of recommendations that seek to improve the quality of care, patient access and experience, and value-for-money in rehabilitative services. The goal of the RSTG was to create a vision for a regionally coordinated program that adheres to the following values: Equitable access Services for priority and marginalized populations Regional, cluster or local service models to promote access, efficiency and clinical competence Standardization for quality outcomes Optimal patient flow Maximizing health human resources Innovations for continuous improvement Appropriateness of rehab modalities Focus on prevention Rehabilitation starts pre-operatively Like much of health system reform the ultimate impetus for this planning exercise is the growing and aging population in Ontario. As the population ages, demand for healthcare will increase. This will be felt particularly in sectors, such as rehab, that support complex patients. The Central East LHIN will be especially pressured by the aging population because the age of the population in the Central East LHIN is increasing at a faster rate than the provincial average and because investment in the Central East LHIN has been focused on acute care beds rather than less expensive rehabilitative beds that are often more appropriate for the needs of complex seniors with high needs. Rehabilitation services are provided across the continuum of care. Patients may receive rehab within the hospital sector, either in an inpatient rehab bed, a complex continuing care bed or an acute care bed. Hospitals also offer rehab services on an outpatient basis. Currently, other patients receive publicly funded care through OHIP funded physiotherapy clinics. Rehab is also provided by the CCAC in patients homes for those who cannot access outpatient care or clinics. Rehab professionals also work within Long-term Care Homes and these services are currently funded by OHIP. Those that can afford it may also obtain rehab privately. In the Central East LHIN rehab services are currently provided in each of these settings depending on patients clinical needs, their personal circumstances and where they live. The widespread use of innovative practices such as a co-managed medical models, quality improvement initiatives, senior s friendly programming and patient education have enhanced the efficiency and quality of rehabilitative care in these settings. Despite continued efforts to improve rehabilitative care and capacity, the system faces a number of pressures. Data collection is limited and lacks standardization, thus understanding current demand and patients care across the continuum of care is challenging. Bed utilization is not optimal within hospitals due to fiscal constraints and this impacts the availability of rehabilitative care. While the quality of care provided in the Central East LHIN is high, best practices are not always met. In particular, 7-day a week physiotherapy is an evidenced best practices that is not provided because of a variety of human resources models, recruitment challenges and competition for dollars. There is a dearth of outpatient physiotherapy in the North East Cluster which results in patients receiving care in a setting that is more expensive and less appropriate. 3
The recommendations made by the RSTG that seek to ameliorate some of the current challenges, and improve patient access, experience, quality and value-for-money are included below. Recommendation #1a: Recommendation #1b: Recommendation #1c: Recommendation #2: Recommendation #3: Recommendation #4a: Recommendation #4b: Recommendation #4c: Recommendation #4d: Recommendation #5: Recommendation #6: Recommendation #7: Align general musculoskeletal rehabilitation services to patients need and within their local community ensuring equity of access. Rehabilitation services for upper extremity and amputation patients should be delivered in cluster centres. Develop a plan that will allow post-orthopaedic patients across the LHIN to access outpatient care as close to home as possible. Continue to provide local care, where clinical expertise exists, to trauma and nonelective patients, including those with manageable cogitative comorbidities. Review processes within fracture clinics to identify opportunities for quality improvements, standardization, and health human resource utilization. Standardize pre-surgical education content for hip and knee replacement and hip fracture patients based on evidenced best-practice throughout the LHIN. Standardize rehab care for hip and knee replacement and hip fracture patients based on evidenced best-practice, expert opinion and surgical protocol throughout the LHIN through coordinated care plans. Review Hand Programs and, based on that review, standardize care for appropriate patient populations. Standardize rehab care and improve quality for other orthopaedic procedures based on evidenced best-practice, expert opinion and surgical protocol throughout the LHIN through coordinated care plans. Continue to support innovative practices and testing to improve the quality of care. Review information requirements and standardize data collection across sectors to support improvements in access and quality of care. Review services and recommend preventative programming for the Central East LHIN. The future implementations of the RSTG s recommendations will be affected by ongoing health system transformation. In particular, implementation of Health System Funding Reform, the Integrated Orthopaedic Capacity Plan, Resource Matching & Referral, and Physiotherapy reform will have a significant impact on implementation planning for musculoskeletal rehab. A number of the recommendations made are quick-wins and it was suggested by the RSTG that these be implemented first to ensure this work has the greatest impact over time. For example, Recommendation #4a, standardization of pre-surgical education, could be easily achieved and it would allow patients to access Hip and Knee schools in any hospital in the LHIN, no matter where they are receiving surgery. Recommendations that are harder to implement will be pursued after quickwins. For example, Recommendation #6, standardizing data collection across sectors, could be difficult to achieve given varying technology. However, those recommendations are believed to have a high impact. Thus, it is suggested that all twelve recommendations be pursued to enhance, the quality of care, patient experience and access and value-for-money. 4
Introduction Work is being done across the province to develop an integrated approach for orthopaedic care. Health System Funding Reform (HSFR) and the adoption of Quality Based Procedures are driving a shift towards funding that follows the patient. There are a variety of planning activities taking place across the province that focus on enhancing capacity to meet the needs of Ontario s aging population. An expert panel is currently exploring how to best deliver rehabilitation and complex continuing care. Care pathways are being established provincially for hip fractures. In addition, the successful transition of patients from one setting or provider to another has become an important focus. This is being supported, in part, by an expanded role for the CCAC and Resource Matching and Referral (RM&R), an IT solution which will match referred patients to available resources. Planning activities around musculoskeletal rehab services will allow Central East LHIN health service providers to take advantage of health system funding reform and leverage the work that is being done provincially. This work is also an integral component of a successfully designed orthopaedic surgical program as outlined by the Integrated Orthopaedic Capacity Plan (IOCP) that was submitted to the Ministry of Health and Long-term Care on March 30 th, 2013. Ensuring rehab services are available to support post-orthopaedic rehab patients in the right place and at the right time is a primary objective of the musculoskeletal rehab services initiative. On the whole, this planning exercise seeks to identify strategic objectives that will result in a regional system of musculoskeletal rehab that will meet the needs Central East LHIN residents while enhancing system capacity and maximizing value for money. This report contains recommendations, developed by representatives from Central East LHIN rehab services providers, that will create such a system. 5
The Planning Process A Rehab Service Task Group (RSTG) was established with a mandate to develop a future state vision for musculoskeletal rehab services in the Central East LHIN. This group met on a bi-weekly basis for five months to share information about the current state of rehab services, identify gaps, and identify activities needed to implement the planned future vision. Specifically the RSTG considered: Siting, in principle, for musculoskeletal rehab services; LHIN wide, cluster and local access; Current and future (5 year) service capacity (supply) and demand (utilization); Emerging changes in clinical practice, care pathways, and the use of technology; Quality and other Performance Standards (e.g., effective, efficient, appropriate, safe, person-centred); Service program standardization across providers, where appropriate; and Health human resources The recommendations for musculoskeletal rehab services were developed in collaboration with the Orthopaedic Surgical Task Group s (OSTG) IOCP which is discussed in greater detail below. The RSTG has taken into account the need to support regional orthopaedic programming and has further developed some of the recommendations outlined in the IOCP. A number of RSTG members also sit on RM&R which allowed the group to understand how RM&R will change the way patients experience transitions in care. It is intended that RM&R s activities will complement the future vision articulated in this report. Membership RSTG membership was made up of representatives from a variety of Central East LHIN health service providers including: each of the LHIN s eight hospital corporations, community health service providers and the Central East Community Care Access Centre (CECCAC). Central East LHIN support staff also participated in RSTG meetings. Two co-chairs led the work of the RSTG. A list of participants is included in Appendix A. 6
Values A set of values were articulated by the RSTG and these values formed the basis of the group s work. These values were discussed in depth and agreed to early in the planning process. They describe the overall direction that the RSTG believed rehab service provision should evolve towards in the Central East LHIN. Equity of Access All patients will have equitable access to rehabilitation services available within the LHIN including inpatient, community, home based care, and outpatient services. Services that provide the level of care required, as defined by the literature and clinical expertise, will be made available to patients throughout the LHIN. Care will be based as close to home as possible and will not be dependent on where a patient enters the system. There will be equity of access for urban and rural patients. Services for Priority Populations/ Marginalized Populations Some of the most vulnerable patients in the Central East LHIN require musculoskeletal rehab. This includes patients with comorbidities, such as cognitive impairments, as well as patients whose socio-economic status or living situation means they require specialized care and additional services. Rehab services should be made available to these priority and marginalized populations in a way that meets all patients needs. Regional/Cluster/Local Models To ensure that quality care can be provided services will be designed using a model of regional, locals and local programs where there are sufficient volumes of patients to maintain efficiency and competence while respecting patients need to be close to home. Standardization for quality outcomes Rehabilitation services will be standardized across the LHIN, including access, care received and discharge, to provide efficient and effective care resulting in quality outcomes. Optimizing patient flow Patient flow will be optimized by providing appropriate levels of care to promote recovery. This will include the use of regional, cluster and local resources as defined in the evidence and ensuring appropriate volumes for quality care. Maximizing Health Human Resources All rehabilitation will be provided by an effectively functioning multidisciplinary team that best meets the needs of the patient while maximizing scope and utilization of health care professionals and support staff. Innovative strategies Innovative strategies will be used to maximize the effectiveness of rehabilitation services in managing patient volume and flow, enhancing sustainability and improving the quality of care. Appropriateness of Rehab Modalities (i.e. home-based, classes, inpatient) Evidence based care will be provided which includes realistic goal setting, home based programs and selfmanagement. 7
Preventative Care The rehabilitation care will have a focus on prevention including prevention of complications and future injury prevention. Pre-operative Care Rehabilitation in the Central East LHIN will start pre-operatively by preparing patients for surgery through education and ensuring appropriate levels of physical conditioning to optimize outcomes. 8
Current Context Health System Reform Ontario s health care system is ever-evolving and changing rapidly. Some changes occurring in coming years will have a great impact on musculoskeletal rehab services. While some details about important initiatives are unknown their anticipated effect was taken into account by the RSTG during this planning exercise. New Funding models in Ontario Patient-Based Funding (PBF) is being implemented across Ontario over the next few years and will provide the majority of the funding for future health care services. Please see the IOCP for further details. It consists of two key components - Health Based Allocation Model (HBAM) and Quality-Based Procedures (QBPs). Health Based Allocation Model (HBAM) HBAM considers many factors in a complex mathematical formula to decide on funding for services per region. Quality Based Procedures (QBPs) For procedures where it has been identified that there are high volumes and standard practices a new methodology has been developed where each procedure is funded at a predetermined rate. Within Ontario the volumes of hip and knee replacement surgery are controlled by the Ministry of Health and Long Term Care (MOHLTC) and the LHINs which then allocate volumes to the individual hospitals. Funding is provided as a quality based procedure with the following set rates per surgery: Figure 1: QBP Rates 321: Total Primary Knee Replacement 320: Total Primary Hip Replacement Surgery $6,254 Surgery $7,071 IP Rehab $4,872 IP Rehab $6,073 OP Rehab $554 OP Rehab $628 Physiotherapy On April 18 th, 2013 the Minister of Health and Long-term Care announced changes to funding for physiotherapy that would allow 218,000 more patients to benefit from physiotherapy services. Physiotherapy services are to be extended in a variety of settings including: group exercise and falls prevention classes, long-term care homes, patients homes, and in the community. LHINs will work with service providers to ensure that the $10 million provided for falls prevention and exercise classes is used to meet local need. Long-term care homes are to receive $68.5 million to directly fund physiotherapy and exercise. Community Care Access Centres are to receive $33 million to reduce wait-lists for physiotherapy. $44.5 million will support services in the community. This announcement is another tool that will allow for the implementation of the recommendations contained in this report. 9
Integrated Orthopaedic Capacity Plan In anticipation of service modifications required to implement HFSR the MOHLTC requested that the Local Health Integration Networks (LHINs) complete an Integrated Orthopaedic Capacity Plan to provide information on the future vision for hip and knee replacement service delivery in the LHIN, initially considering hip and knee replacement as well as hip fracture. In the Central East LHIN the IOCP provides recommendations on future service delivery models for all orthopaedic populations in the Central East LHIN. This work was undertaken by the Central East LHIN Orthopaedic Surgical Task Group (OSTG). The RSTG sought to align their recommendations with those made by the OSTG. Central recommendations made by the OSTG are outlined below. Key system change #1: Key system change #2: Key system change #3: Key system change #4: Key system change #5: Key system change #6: Key system change #7: Align surgical services using a LHIN-wide/cluster/ local framework which ensures optimal use of CE LHIN capacity and quality care while keeping the patient as close to home as possible Develop a systems approach to trauma access and repatriation Standardize care for orthopaedics, including hip and knee replacement and hip fracture, throughout the LHIN through coordinated care plans for inpatient care and rehabilitation. Identify a performance measurement system which includes outcomes for orthopaedics Complete a review and develop a plan for a coordinated intake system and an interdisciplinary assessment program if it is identified that they will assist in promoting access and standardization in care Align rehabilitation services to patients need and within their local community Complete a review and develop a plan for a coordinated staffing model which supports physician integration including coordinated coverage to maximize efficiencies. This may include LHIN-wide Credentialing, LHIN-wide On-Call; and LHIN-wide Operating Room Efficiency and Scheduling The table below provides a summary of the recommendations for how future orthopaedic services are to be aligned using a LHIN-wide/cluster/local framework. Patient population Non elective and Trauma Hip and Knee Replacement Hip and Knee Revision Ankle and Foot Arm, Elbow, Forearm, Hand and Wrist Knee (excluding replacement and revision) Shoulder Spine Recommendation Local Centres Cluster or LHIN-wide Centres providing equitable access to specialized surgical services Local Centres Cluster Centres LHIN-wide Centre for complex patients including infection Cluster Centres Local Centres aligned with plastic surgery and hand units Local Centres Cluster Centres LHIN-wide Centre 10
Resource Matching and Referral Resource Matching and Referral (RM&R) is an electronic information and referral system that contributes to the provincial strategies of reducing Emergency Room wait times and Alternative Level of Care days. It is being implemented provincially and all the LHINs have been divided into clusters that are working through a sevenstep model developed by the Toronto Central LHIN (see Figure 2 below). Figure 2 This solution will improve workflow and communication during the referral process, matching patients/clients to earliest available and most appropriate care/support setting. The objective of the current phase (Phase 5) of the project is to standardize and streamline referrals in preparation for the implementation of electronic RM&R solutions. The initial implementation of Provincial RM&R is focused on the following four referral pathways which offer the greatest potential opportunities for improving ALC wait times, with the objective of having one provincial form per care pathway: Acute (Medical and Surgical Inpatient) sending referrals to Rehabilitation Acute (Medical and Surgical Inpatient) sending referrals to Complex Continuing Care (CCC) Acute (Medical and Surgical Inpatient) sending referrals to Long-Term Care Acute (Medical and Surgical Inpatient) sending referrals to CCAC In-Home Services In the absence of clear directions since early 2012, the Central East LHIN had engaged RWS Advisory to develop a streamlined post-acute referral processes for the Acute to Rehabilitation and Acute to CCC referral pathways that can function in both the partial and full implementation states of a LHIN-and ultimately province-wide electronic RM&R solution. The CCC implementation will be rolled out first with implementation occurring separately in each hospital. The lessons learned from the first deployment will be used to guide/refine subsequent implementations. 11
Rehabilitative Care Alliance The recently initiated Provincial Rehabilitative Care Alliance is envisioned as: A task-oriented group that leverages existing rehabilitative care planning bodies and expertise to optimize rehabilitative care for patients/clients and caregivers (reporting to the LHIN CEO s through a Lead LHIN model). A collaborative with representation from LHINs, Ministry, CCAC and clinical experts from across the province. Working closely with various key stakeholders to effect positive changes that support and enhance the adoption and effectiveness of clinical and fiscal priorities within rehabilitative services. Complementing the work of groups formed under Ministry direction to define best practices for specific clinical conditions that will be funded as Quality Based Procedures (QBPs) under the multi-year Health System Funding Reform (HSFR) initiative. Being inclusive of rehabilitative services in all clinical settings, including a focus on Assess and Restore services, and ensuring that implementation can occur throughout the province. A key first step of the work involves consultation and engagement with provincial partners regarding top priorities that the Alliance should be working on. These priorities will form the work plan for the Alliance for the next two years. Given the formative nature of these activities, the mandate of The Rehabilitative Care Alliance will continue to evolve over the coming months. 12
Demographics and Demand for Musculoskeletal Rehab The Central East LHIN has the second largest population in Ontario. It is home to 1,572,500 people or 11.8 percent of Ontario s population. The Central East LHIN also has the fourth highest projected growth rate. It is expected that by 2021 the population will have increased by 17.0 percent, compared to a projected increase of 13 percent for Ontario overall (IHSP Environmental Scan). Figure 3 below shows the population distribution by age for each of the three Central East clusters as well as Ontario. The largest population age group is 40-59 for all clusters and Central East has a higher percent of residents than Ontario at large in every age group 50+. A growing and aging population will result in increased demand for orthopaedic surgery and musculoskeletal rehab, putting pressure on the system. It is important to note that annual growth rates and population distribution varies by geographic area. The 45-74 year age cohort will increase 5.5 percent in the North East, 11.8 percent in Scarborough and 15.0 percent in Durham by 2020, resulting in an overall population increase of 68,777 in that age cohort. The majority of patients that require orthopaedic services are between 50 and 70 years of age. Demand for musculoskeletal rehab is expected to increase overall, in all three clusters, as a result. Projections for Orthopaedic procedures contained in the IOCP indicate that demand for Hip and Knee Replacements, and the rehab associated with those procedures, will increase the most in the Durham cluster. 18% Figure 3: Population Distribution by Age Group 16% 14% Percent of Total Population 12% 10% 8% 6% 4% North East Cluster Durham Cluster Scarborough Cluster Central East LHIN Ontario 2% 0% 0-9 10-19 20-29 30-39 40-49 50-59 60-64 65-74 75+ Age Group Source: IHSP Environme ntal Scan, 2011 Census 13
The report Building a Model of Sustainable Access to Community Health Care Services noted that the CE LHIN s acute programs that require the greatest increase in shares over time are associated with circulatory, musculoskeletal and connective, and cancer care. This is driven by older patients that require a high-level of health care services. One percent (15,300) of the CE LHIN s population uses 53 percent of total services. Service use among the CE LHIN s population aged 65 and older is less concentrated: 1 percent of this population (2,100) uses 32 percent of all acute services received by the LHIN s 65 and over population. These patients are typically seniors that have multiple co-morbidities and challenging socio-economic conditions that require intensive use of health and social services. These patients often have CHF, COPD and/or dementia. Socio-economic pressures also play a role in patients utilization of the health care system. For example, a high number of elderly patients live alone in the Central East LHIN (see Figure 4 below). These patients tend to have fewer supports, and are at greater risk for falls. As the population ages in the Central East LHIN there will be a larger number of patients that require relatively intensive health and social services. Figure 4: Seniors Living Alone Percent of population 65 to 74 living alone 15.9% Percent of population 75 to 84 living alone 28.6% Percent of population 85+ living alone 40.9% Percent of population 65+ living alone 22.6% Source: Sub-LHIN Planning Area Profile of Seniors, Ce nsus 2006 The Central East LHIN spends more for seniors than high-performing LHINs. CE LHIN s spending per senior in 2009/10 was $5,579, similar to the provincial average but 12 percent more than spending by the high performing LHIN. From 2006/07 to 2009/10, CE LHIN s Acute and Home Care expenses increased by approximately 20 percent. Over the same period, mental health, CCC, and inpatient rehabilitation expenses increased by 8 percent, similar to the growth in age-weighted population. Inpatient rehab and CCC can often best support the needs of the frail seniors with complex needs. These beds are also less expensive than acute care beds; however investment in the Central East LHIN has been directed to acute care beds. It is essential that the capacity in inpatient rehab be appropriate for the Central East s aging population and that rehab capacity is sustainable. Increasingly, inpatient rehab focuses on the most complex patients. Due to technological advances patients with less complex needs can be rehabilitated in an ambulatory environment. Continuing to move those lower-intensity patients into ambulatory and community settings would allow inpatient settings to focus on seniors with complex needs. Thus retooling bed capacity could improve outcomes for those high-users and enhance capacity within the system by reducing ALC rates. Although all recommendations contained within this report are made to support increases in system capacity, Recommendation #1 specifically addresses this issue by identifying the need for increases in outpatient rehab services. 14
Current State of Rehab Services in the Central East LHIN Rehabilitation services are provided across the continuum of care. Patients may receive rehab within the hospital sector either in an inpatient Rehab Bed, a CCC bed or an Acute Care bed. Hospitals also offer rehab services on an outpatient basis. Currently, other patients receive publicly funded care on an outpatient basis through OHIP funded physiotherapy clinics. Rehab is also provided by the CCACs in patients homes for those who cannot access outpatient clinics. Rehab professionals also work within Long-term Care Homes and these services may be funded by OHIP. Those that can afford it may also obtain rehab privately. In the Central East LHIN rehab services are currently provided in each of these settings depending on patients clinical needs, their personal circumstances and where they live. This report focuses on the care provided to musculoskeletal patients that received orthopaedic surgery. Other musculoskeletal patients were considered where appropriate including non-surgical patients and those that received plastic surgery. Acute Orthopaedic Care The appropriate level of musculoskeletal rehab services must be available to support Orthopaedic Surgical care, thus an understanding of the surgical services provided in the Central East LHIN was required. Within the Central East LHIN there are 5 hospitals that provide orthopaedic services with a total of 8 primary sites. These are: Lakeridge Health Corporation Oshawa and Bowmanville The Scarborough Hospital both the Birchmount and General sites Peterborough Regional Health Centre Rouge Valley Health System Centenary and Ajax sites Ross Memorial Hospital, Lindsay There are an additional 3 hospitals: Campbellford Memorial Hospital (Campbellford), Haliburton Highlands Health Services Corporation (Haliburton) and Northumberland Hills Hospital (Cobourg) where trauma patients may enter the health care system. Please see the IOCP for information regarding orthopaedic surgical volumes and performance. That data was utilized by the RSTG in planning. Interestingly, a disproportionately low number of elective orthopaedic procedures are done in the Central East LHIN given the population (see Figure 5 below). With the exception of Primary Unilateral Knee Replacement, only orthopaedic procedures that are associate with a trauma or non-elective patients have volumes that appear to be in-line with the Central East LHIN s population, 11.8 percent of Ontario s population. This conforms to the premise that many Central East LHIN residents seek surgery in other LHINs, such as the Toronto Central LHIN. Based on population characteristics it is expected that Central East LHIN residents require orthopaedic care in similar, or higher, numbers as other LHINs. For example, as mentioned in the IOCP the Central East LHIN has a larger proportion of residents over the age of 50. Also, the Central East LHIN has roughly 11.7 percent of Ontario s population in this age group (IHSP Environmental Scan). Figure 6, below, demonstrates that a fairly high number of Central East LHIN residents seek care in other LHINs. Since 2009 between 3,730 and 4,137 patients have gone outside of the Central Eat LHIN to obtain orthopaedic care each year. This compares with between 1,578 and 1,638 patients that have travelled from elsewhere each year to obtain orthopaedic care within the Central East LHIN since 2009. 15
The outflow of patients to other LHINs has important consequences for rehab services in the Central East LHIN. Many patients who receive surgery in other LHINs will likely seek rehab closer to home; and the RSTG agreed that, in principle, rehab should be available as close to home as possible. Patient flow from surgery to rehab across LHINs is not tracked. The exact volumes of patients that receive surgery in other LHINs and then return home for rehab is unknown. However, given that fewer surgeries are performed in the Central East LHIN than its population warrants it is plausible that a push towards more community-based rehab will result in demand for rehab services that will be larger than current surgical volumes and projections suggest. 16
Figure 5: Proportion of Ontario s Orthopaedic Procedures Performed in the Central East LHIN Acute V olume of proce dures performed annually by Orthopaedic QBP* Location Primary Unilateral Hip Replacem ent Primary Unilateral Knee Replacem ent Revised Hip Replacem ent without Infection Revised Knee Replacem ent without Infection Hip Replacem ent with Trauma/C omplicati on of Treatmen t Fixation/R epair Hip/Femu r Replacem ent/fixati on/repair of Tibia/F ibu la/ Knee Fracture of Femur Major Foot Interventi on except Soft Tissue without Infection Shoulder/ Rotator Cuff Interventi on Reduction /Fixation/ Repair Upper Body/Lim b except Fixation/R epair of Shoulder Reduction /Fixation/ Repair of Ankle/Foo t Other Fracture/ Dislocatio n of Arm/Shou lder Fracture/ Dislocatio n/rupture of Pelvis/Sac rum/cocc yx Central East LHIN Total 857 2,150 61 95 485 846 271 208 87 94 305 326 75 234 Ontari o Total 11,430 21,367 1,215 1,062 4,055 7,319 3,016 1,767 1,162 1,166 4,020 3,415 1,026 2,210 Central East percent of Total Procedures 7% 10% 5% 9% 12% 12% 9% 12% 7% 8% 8% 10% 7% 11% Source: HAB Year Figure 6: Orthopaedic* Care Inflow and Outflow CE Residents receiving care in the CE Residents receiving care CE LHIN outside the CE LHIN Non-CE Residents receiving care inside the CE LHIN 2009 7,129 3,730 1,638 2010 6,998 3,775 1,627 2011 6,986 4,137 1,578 Source: intellihealth *a list of CMGs that are included is contained in Appendix B 17
With the implementation of QBPs targets have been set for discharge disposition of 90 percent home and for length of stay of 4.4 days for patients discharged home. Currently, all hospitals in the Central East LHIN have exceeded these targets (see Figure 7 below). This is due, in part, to some of the innovations and best practices discussed below. Figure 7: Orthopaedic Quality Score Care Hip and Knee Replacement Q4 2012/13 Quality Dimension Efficiency Patients Discharged Home Hospital Name Total Volume Length of Stay - All Patients (Average Days) Average Length of Stay in days (Target 4.4 days) Median Length of Stay (Days) 90th Percentile Length of Stay in days (Target 7 days) Percent completed within 4.4 days Percent completed within 7 days Proportion of Patients Discharged Home (Target 90percent ±9%) Central East 220 3.8 3.6 4 5 87.4 99.5 90.0 ROSS MEMORIAL HOSPITAL 22 2.8 2.8 2 4 90.5 100.0 95.5 PETERBOROUGH REGIONAL HEALTH CENTRE 52 4.2 4.1 4 5 80.9 100.0 90.4 LAKERIDGE HEALTH CORPORATION 43 3.5 3.5 3 5 85.4 100.0 95.3 ROUGE VALLEY HEALTH SYSTEM 59 3.5 3.3 3 4 92.3 100.0 88.1 SCARBOROUGH HOSPITAL (THE) 44 4.5 4.0 4 5 89.2 97.3 84.1 18
Inpatient Rehab Inpatient care is provided in a hospital bed and often includes assessment and treatment (including Physiotherapy and Occupational Therapy), discharge planning, exercise prescription and referral to other services as required. Musculoskeletal inpatient rehab is offered by five hospital corporations in the Central East LHIN: Rouge Valley Health System (Centenary and Ajax/ Pickering Sites) Lakeridge Health (Whitby and Oshawa Sites) Peterborough Regional Health Centre Ross Memorial Hospital Northumberland Hills Hospital These five hospitals all have dedicated rehab units, although care is often provided in other beds as well. The type of patient that is typically treated in various units is presented below in Figure 8. Campbellford Memorial Hospital does not have defined rehab services but does provide inpatient physiotherapy in their Acute Care beds. The Scarborough Hospital does not offer inpatient rehab for orthopaedic patients - patients who require inpatient rehab are referred to Providence, Bridgepoint, Baycrest, or St. Johns prior to surgery. The Scarborough Hospital does have a large inpatient amputee program. Patients are seen by PT, OT and Rehab Assistants daily and are instructed in stump care, wrapping, transfers, equipment, and ADL s. At Lakeridge Health and Peterborough Regional Health Centre amputee patients return to inpatient rehab for prosthetic training following surgery. Occupational Therapy, Physiotherapy, Prosthetist, Nursing, Physiatry, Rehabilitation Assistant focus on returning the patient to normal movement and mobility. Once the patient is safe to mobilize independently, the patient is discharged home. Outpatient services are offered at Lakeridge Health for continued gait training. 19
Figure 8: Conceptual Framework: Functional Groups Group No. 1 Functional Group Description Slow progress/low capacity for functional improvement Potential for Functional Recovery Medical Complexity Psychosocial Complexity Low High High Lakeridge Health Geriatric Assessment and Rehabilitation Unit Ross Memorial Hospital Complex Continuing Care complex medical Peterborough Regional Health Centre Complex Continuing Care, functional Enhancement Unit (Medicine) Rouge Valley Health Centre Northumberland Hills Hospital Restorative care beds 2 3 4 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 High High Low High High High High Low Low Geriatric Assessment and Rehabilitation Unit Integrated Stroke Unit Restorative Care Unit Integrated Stroke Unit Inpatient Rehabilitation Unit Complex Continuing Care Functional Enhancement/ Assess and Restore Inpatient Rehabilitation Inpatient Rehabilitation or community based rehabilitation Complex Continuing Care Rehabilitation Beds Rehabilitation Beds GATU FE TRCP STR Restorative care beds Rehabilitation beds Rehabilitation beds 5 Lifelong condition/periodic need for rehabilitative interventions Low* High* High* Complex Continuing Care (Whitby, Bowmanville and Oshawa sites) * inferred from framework description in rehabilitation & CCC Expert Panel Update Presentation, February 2012 Complex Continuing Care Functional Enhancement/ Assess and Restore Complex Continuing Care Transitional ALC ( RVC and RVAP) 20