a new philosophy towards solving the alc crisis (home first)/me… · a presentation to ottawa...

A New Philosophy Towards Solving The ALC Crisis(Home First)(Home First)

A Presentation to Ottawa Council on Aging-Fall ForumForum

by Narendra Shah, MHSc, CHE

Chief Operating OfficerChief Operating OfficerMississauga Halton LHIN

October 1, 2010

1

What does Alternate Level of Care (ALC) signify to you?

2Narendra ShahOct 1, 2010

Implications of Alternate Level of Care2,700 beds occupied

p

occupied in 09/10

HomeFi t

ALC is about Safety and Quality of Care

ALC is about “Patient and Family First”

First

ALC is about Care of “Seniors”—mostly >75

years age group (70-80 %)


Seniors and ALC in Ontario Hospitals in 2009/10in 2009/10

• Seniors made up 60% of all acute hospital days - while they represented 13% of Ontario’swhile they represented 13% of Ontario s population

• 50,000 ALC patients were discharged from , p gOntario hospitals - most admitted from ERs

• 85 % of ALCs > 65 years of age; majority (72% in MH LHIN) > 75 years of ageFirst Message

• Seniors is your core business• Screen and flag all 75+ in ER who are admitted

g

gfor proactive discharge planning with CCAC

Narendra ShahOct 1, 2010

4

Challenges Posed by LTC Homes Demand In Ontario March 2010In Ontario-March 2010

• LTC wait list in Ontario increased by 2.4 % in 2009/10 to over 25,000 seniors are on the wait list. This is a ,serious matter that raises questions

• Are all 79,000 residents currently in LTC homes in the right setting?g g

• Has there been a rigorous review to ensure those on wait list have no other alternatives other than LTC home?

• Should Ontario build 1,000’s of more LTC beds in the next 5-10 years? Is this the right response?

• To create a sustainable system with a focus on right• To create a sustainable system with a focus on right care at the right place, the clear response is we need to find alternatives to LTC home in community and homeshomes


LTC HomeHome

Restorative Care in

Where do elderly patients prefer to go after post acute care?

Restorative Care in the Community

post acute care?


Home First is About Patient First All t l ill ti t t t t h ( it ) ft th All acutely ill patients want to return home (community) after the

post acute phase. No patient expects to go to a LTC home

HOME FIRST is about best way for transition from hospital to home HOME FIRST is about best way for transition from hospital to home as soon as possible after the decision is made that the patient “no longer requires inpatient care”

I t i t it i b t h b t t t k f hi h d In most instances it is about how best to take care of high need seniors post hospitalization in the community/home with appropriate supports

It is about changing the “provider driven/knows best” discharge approaches that at times is not reflective of right care, right time, right place at right cost AND not inclusive of patient/family engagementengagement

Focus has to be on going “Home” as the destination

Second MessageFocus has to be on going Home” as the destination -mobilize necessary community supports to enable safe care


6

Home First Requires a New Approach Requires significant transformation – fundamental change in q g g

processes and culture by BOTH hospitals and CCAC:

The default to LTC must change-there are other alternativesalternatives

It is about culture shift (to recognize opportunities for re-integration into home/community) for hospital (physicians, nurses), and change in discharge and workflow processes for the BOTH CCACs and hospitals

Hospital is a “transition” place not for long-stay and not a p p g ydestination

It is about appropriate and consistent patient/family education and take timeeducation and take time

Both Hospitals and CCAC need to transform and operate asThird Message

Both Hospitals and CCAC need to transform and operate asone team with one vision and the same sense of “time clock”on discharge planning 8


Home First From a Quality Paradigm Hospitalization can be hazardous for older adults (Suesada et.al., 2007; p ( , ;

Gillick et. al., 1982; Brown et. al., 2004 Hospitalization of elderly often leads to decreased functional mobility,

decreased ventilation, delirium, accelerated bone loss and incontinence (C dit 1993)(Creditor, 1993)

Staying in a hospital longer than medically necessary can be detrimental to a patient’s health for a number of reasons:

• Risk of hospital acquired infections• Risk of hospital acquired infections• For seniors, a decline in physical and mental abilities due to lack of

activity• Much needed acute beds for patients waiting to be admitted• Much needed acute beds for patients waiting to be admitted

Home provides the best environment to experience a significant lifetransition, such as a move to a LTC home

Fourth MessageBoth hospitals and CCAC must see ALC as a top priority both from a quality and sustainability perspective; and ensure processes, communcations and

i l i l di d il bili id A C

Fourth Message

structures are in place including daily accountability - consider an ALC czarreporting to CEO of each hospital! 9


Balancing Quality and RiskBalancing Quality and Risk

Wh t i i k i t f litWhat is more risky in terms of poor quality of care - continued stay in hospital as an ALC di h t i tALC or discharge to an appropriate community/home setting?


Right Investments in Community Programs for High Need Seniors to Enable “Home first”

Shift away from a facility-based health care system by investing in community-based care:

Reduce ALC days and LOS in hospitals Ensure RIGHT persons are placed and Reduce wait list for LTC

homes

Facilitate and maximize post-acute care services through an emphasis on alternate models - transitioning to lower or more appropriate levels of carealternate models - transitioning to lower or more appropriate levels of care

Use evidence-based common assessment tools to ensure right persons at the right time are eligible into these community programsg g y p g

Increase capacity to serve high need seniors (MAPLe 4,5 and 3’s) for appropriate home and community based services to extended hours including evenings, weekends and 24/7 where appropriate and feasible

Fifth MessageInvest in the right community programs to care for highneed seniors & re-focus CCAC and community support services to serve high need seniors


MH CCAC Enhanced Home Care Services to Frail Seniors - 2009-10Seniors 2009 10

Home First Program – Hospital ReferralsStay at Home Program

WAH – LTC WAH – Enhanced

MAPLe Score 09/10 Actual # Clients (March 31, 2010)

1 2 3 0

2 5 3 0

3 57 63 29

4 107 124 126

5 70 51 58

TOTAL Clients 241 243 313

73.4% 71.7% 86.4%

TOTAL Clients 241 243 313

Client Avg MAPLe (per above)

3.99 3.89 4.14

Client Avg/Mon. Before 60 Days After 60 Days Before 30 Days After 30 Days Before 30 Days After 30 DaysPSW hours 130 108 88.2 85.7 83.7 85.6

Client Avg LOS on Enhanced Service

2.2 months 3.9 months 6.3 months

1212

Source: MH CCAC, July 28, 2010


Major Transformation of “Supportive Housing” to– ‘Hub & Spoke’ 2008/09/10/11 R lt2008/09/10/11 Results

(1) MAPLe Pre‐SDL Client

GroupSDL Client Group

1 45 9

Age Pre‐SDL Client Group

SDL Client Group

<65 4 045 92 28 303 104 1774 64 1355 22 60

A S 2 96 3 50

4 065‐74 27 5675‐84 90 15785+ 207 193

Avg Age 85.9 8486.2%47.5%

Avg Score 2.96 3.50

TOTAL Clients 263 411TOTAL Clients 328 406

Referrals FY 08/09 Q1 09/10 Q2 09/10 Q3 09/10 Q4 09/10 Q1 10/11 TOTAL

Hospital 0 11 5 23 81 15 135Hospital 0 11 5 23 81 15 135

Non‐Hospital

Restore 0 0 2 0 2 0 4

CCAC 88 30 83 80 76 17 374

Other 0 1 0 13 11 65 90

Sub‐total 88 31 85 93 89 82 468

TOTAL 88 42 90 116 170 97 603

(1) As per available data

In buildings with high concentration of seniors

13

In buildings with high concentration of seniors


Supports for Daily Living – Mobile2009/10 Results & 4 months of 2010-11

MAPLe SDL Client April to July Total SDL Client April to July Total

Score Group 2009/10p y4 Months 16 Months

1 ‐ 3 39 19 58

4 45 29 74

5 15 11 26

Avg Score 3.75 3.8

Age Group 2009/10

April to July4 Months

Total16 Months

<65 2 1 365‐74 24 10 34

75‐84 34 25 5985 39 23 62

High Needs63 3%

> 75 yrs76 6%Avg Score

TOTAL Clients 99 59 15885+ 39 23 62

Avg Age NA NA NATOTAL Clients 99 59 158

63.3% 76.6%

Referrals 2009/10Total

April to July 2010

Total16 months

Hospital 41 35 76Restore 2 3 5CCAC 51 18 69Oth 5 3 8

51.3% from Hospitals

Other 5 3 8

TOTAL 99 59 158


R t P R lt 2008/09 d 2009/10Indicators 2008/09 2009/10 2010/11

Q1

Restore Program Results – 2008/09 and 2009/10• Restore has saved the

i l f 35Q1

Admissions

Total Admissions 160 148 32

Average Length of 44 56 56

equivalent of 35 acute carebeds over 2 years

• A total of 250 people have been diverted from LTC

[95% from hospitals]

Average Length of stay

44 days

56 days

56 days

DischargesDischarge HomeDischarge to LTC

78%11%

72%15%

65%25%

been diverted from LTC Placement

• Allows patients the opportunity to regainDischarge to LTC

Other11%10%

15%13%

25%10%

Admission MAPLeScores 3,4,5 97% 100% 90%

Cli t S ti f ti

opportunity to regain independence and go home, delaying LTC placement

• Interdisciplinary approach to Client Satisfaction

Good to ExcellentSatisfactory

Somewhat Satisfied

74%10%16%

81%14%5%

80%20%

p y ppprogram goal development and discharge planning support


Results - Monthly Average of ALC Hospital (Acute, CCC & Rehab) Patients Open Cases, 2009-10

Source: MH LHIN Daily ALC Census

Change in LTC Demand in 2009/10MH LHIN i 2009• MH LHIN in 2009

• Province

How?

Total Long-Stay Waitlist Ontario MH LHIN

Mar-08 23,006 1,040

• Alternatives to LTC (SDL, Restore) • Emphasis upon “Home First” from hospital

has decreased demand

Mar-09 24,648 1,279

April -10 24,033 1,155*

% Change in 2009 -2.5% -9.6%

LTC beds per 100 people 75+ years 9.0 7.2 Reduction in New LTC Applicants

All Sources -13.0%

In Hospital 28 7%

Acute Care FY 07/08 FY 08/09(1)

FY 09/10% Change to 09/1007/08 08/09

In Hospital -28.7%

ALC-LTC Days 11,092 20,615 8,277 -25.4% -59.8%Patients 359 502 330 -8.1% -34.3%

17

Acute ALC Rate for Ontario ‐ Fiscal Years 2008/09 & 2009/10 90 beds

FYear

LHINALC LOS

(c)Total LOS

ALC %

Total Days

(a)

ALC LOS

(d)Total LOS

ALC % Total

Days (b)

ALC % change

from 08/09

(b) - (a)

ALC Days

reduction

08/09 -

09/10

2008/09 2009/10

Rank

(06) MISSISSAUGA HALTON 47,650 372,563 12.8% 32,903 357,384 9.2% 1 -3.58% -14,747

(05) CENTRAL WEST 24,229 213,479 11.3% 22,085 217,939 10.1% 2 -1.22% -2,144

(01) ERIE ST. CLAIR 30,352 280,473 10.8% 29,423 271,106 10.9% 3 0.03% -929

(07) TORONTO CENTRAL 104,207 985,274 10.6% 111,121 993,172 11.2% 4 0.61% 6,914

(02) SOUTH WEST 66,875 532,356 12.6% 60,868 527,293 11.5% 5 -1.02% -6,007

(08) CENTRAL 69,915 535,295 13.1% 81,788 541,075 15.1% 6 2.05% 11,873

(11) CHAMPLAIN 95,851 677,890 14.1% 108,643 694,596 15.6% 7 1.50% 12,792

(10) SOUTH EAST 46,299 266,495 17.4% 43,098 256,069 16.8% 8 -0 54% -3 201( ) SOU S 46,299 266,495 17.4% 43,098 256,069 16.8% 8 0.54% 3,201

(03) WATERLOO WELLINGTON 52,047 258,812 20.1% 41,369 234,549 17.6% 9 -2.47% -10,678

(14) NORTH−WEST 32,244 177,120 18.2% 30,926 175,314 17.6% 10 -0.56% -1,318

(09) CENTRAL EAST 85,018 551,468 15.4% 102,922 551,120 18.7% 11 3.26% 17,904

(12) NORTH SIMCOE MUSKOKA 38,628 204,832 18.9% 41,950 211,635 19.8% 12 0.96% 3,322

(04) HAMILTON NIAGARA HALDIMAND

BRANT (HNHB) 189,902 785,757 24.2% 158,726 756,499 21.0% 13 -3.19% -31,176

(13) NORTH−EAST 127,790 456,627 28.0% 125,594 448,598 28.0% 14 0.01% -2,196

Total 1 011 007 6 298 441 16 1% 991 416 6 236 349 15 9% 0 15% 19 591Total 1,011,007 6,298,441 16.1% 991,416 6,236,349 15.9% -0.15% -19,591

*Exclude new born and still born

2,700 beds

Hospital Role in Home First-Prevent “Creation” of ALCs

Ensuring that while in hospital maintain and improve quality by reducing Ensuring that while in hospital maintain and improve quality by reducing functional decline for all seniors is an integral part of quality hospital care

Transform discharge planning process in hospital to ensure patients are looked at proactively for all post acute care in options in the communitylooked at proactively for all post acute care in options in the community before LTC home option is even identified (required under CCAC Act and LTCHA, 2007 – eligibility for LTC)

Upfront identification of all patients with estimated date of discharge Upfront identification of all patients with estimated date of discharge

Focus on integrated pro-active discharge planning and have daily joint “integrated discharge rounds” with CCAC

Ensure “ALC” means no longer require hospital care. If a patient’s condition changes revise it back to acute care-sloppy coding of ALC benefits no one!

The importance of change in practice by the physicians, nurses and others p g p y p y ,including timely assessment for discharge, appropriate communication on next steps and ensuring no mention is made directly to the patients or family about going to a LTC home

Daily “Dashboard” monitoring & self-identification of corrective actions/solutions


CCAC Role – Home First CCAC also has a responsibility in the quality of care of patients who no

longer require hospital care

Proactive engagement with hospitals to address prospective high need Proactive engagement with hospitals to address prospective high need seniors discharges before they get labelled “ALC”

Patients will be timely assessed and discharged by CCAC to go home with appropriate home care and other community care resources

Daily “Dashboard” monitoring & self-identification of corrective actions/solutions

ALC to LTC in hospital should be considered ONLY as a last resort ALC to LTC in hospital should be considered ONLY as a last resort. Leverage all community resources to support high need seniors in their homes

Decision to pursue LTC placement is a major life transition matter and p p jthe hospital is not the right place for this transition to occur- legislation is designed for LTC placement from home - discharge home first

Re-profile existing CCAC base funds and augment with additional funds (e g from A @ H; ER P4R) to provide enhanced home carefunds (e.g. from A @ H; ER P4R) to provide enhanced home care.


“IT IS EASIER FOR COMPANIES TO COME UP WITH NEW IDEAS THAN LET GO OF OLD ONES”----PETER DRUCKER [QUALITY GURU]

ConclusionsW f t i i “ ” b i t d t th i• We forget seniors is our “core” business yet we do not manage their care and needs well with billions spent on their care

• This is less about “more money” and more about attitude and the need to reform our organizations with a focus on quality care for seniors –right care, right time, right place and at right cost

• Let’s not make the obvious problem unnecessarily complex

• ALC is indeed a solvable matter - as long as all sectors work with one unified purpose - best quality for our seniors at least cost

NEW PARADIGM FOR ALC REDUCTION• No ALC = BEST QUALITYNo ALC BEST QUALITY• Poor Practice is when you declare an ALC

Let’s implement the obvious

“The missing link between aspiration and results is execution”‐ Ram Charan

[email protected]

23Narendra ShahOct. 1, 2010

a new philosophy towards solving the alc crisis (home first)/me… · a presentation to ottawa...

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