Home FirstMaximizing use of LHIN investments while creating better outcomes for seniors and

reducing ALC

August 19, 2009

Mississauga Halton Community Care Access Centre

• MH CCAC has over 12,000 individuals on its caseload every day

• MH CCAC has 9 offices across the MH LHIN areas, with 6 of those offices located within the 3 MH LHIN hospital corporations:

• Halton Healthcare Services (3 sites): 13 Case Managers & 3 Team Assistants• Trillium Health Centre (2 sites): 24 Case Managers & 4 Team Assistants• Credit Valley Hospital (1 site) 17 Case Managers & 4Team Assistants

• MH CCAC has over 325 Client Services Staff including Case Managers, Placement Coordinators, Geriatric System Navigators, Care Connectors and Team Assistants

Halton Healthcare Services• 459 bed 3-site community hospital

• Hospital sites located in Oakville, Milton and Georgetown

• Beds: 307 Acute Care; 71 CCC; 39 Rehab; 42 Acute Mental Health

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In 2008-09:•24,733 in-pt discharges•121,728 ED visits•180,961 ambulatory visits•23,798 OR cases•168,315 total patient days

Halton Healthcare Services - Background

• January 2008 – Launch of Patient Flow Program.

• Corporate patient flow leadership and accountability.

• Patient Flow Program strategy: Bed Management:

optimization of internal processes

Data Driven continuous patient flow improvement

ALC: maximization of all opportunities for improvement

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Background: ALC Situation

From Sept 2007 - 2008 the number of ALC Days nearly doubled from 9.3% to 17.5%

Using real-time data (for open cases), during 2008: on average, the number of ALC-LTC waiting in hospital grew monthly by 11 patients

September 2008: ALC-Long Term care = 87 pts

Acute Care ALC reached 28%

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0

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20

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50

60

70

80

Aug-07 Sep-07 Oct-07 Nov-07 Dec-07 Jan-08 Feb-08 Mar-08 Apr 08 May-08 Jun-08 Jul-08 Aug-08

LTCCONV CARESDLCCCREHABPALLHOMEOTHERLinear (LTC)

HHS ALC Patients by Disposition

ALC-LTC

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Aug 2007 – Aug 2008 Source: Meditech open cases

The “a-ha” moment

The HHS Patient flow program was delivering results – yet still challenged with alarming growth in patients waiting LTC

In Sept 2008 the OTMH site of HHS was designated 1A resulting in 23 LTC placements – approx 20% reduction – still 65 patients waiting in hospital for LTC

Given the ALC-LTC historical rate of growth – it was estimated that the improvement would be sustained no longer than November

Now what………..

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The “a-ha” moment

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Our “A-ha”: To decrease hospital ALC-LTC we need to address both the numerator and denominator of the ALC-LTC growth equation: # patients placed AND # patients newly designated LTC in hospital who subsequently wait in hospital for LTC placement

Home First Concept• ALC to LTC in Hospital should be considered ONLY

as a Last Resort

• LTC placement is a social process and the hospital is not the right place for this transition to occur

• Legislation is designed for LTC placement from home

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Right Person

Right Place

Right Time

Home First Principles

If the patient was admitted to hospital from “home”…all efforts will be made to discharge the patient back to their “home”

Long Term Care process designed for decisions to be made at home not in hospital

All discussions regarding LTC or other community options will occur outside of acute care

We will always consider...”Home First”

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Home First Initiative – Implementation

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Home First Workflow Process Changes

Before……

Hospital ALC initiatives and improvement activities had focused on creating efficiency and decreasing the time for the LTC process to occur.

HHS SW/DC planners were proficient in facilitation of LTC placement processes, ALC designation and co-payment procedures

After……

Do what was counter-intuitive – interrupt the efficient LTC discharge planning

All patients would be assessed by CCAC to go “Home First” prior to LTC designation

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Home First Role of the Health Care Team Members

Identify barriers that may prevent timely discharge and refer to appropriate Health Care Professionals to resolve discharge related issues.

Consistent messaging to Patient/Family that patient will be discharged home from hospital.

Facilitation of complex discharge planning in those situations where patients must be transitioned from hospital

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Home First Physician Engagement is key

Communication strategy involving initial and follow-up meetings and written communiqués with physicians.

Physicians require a hospital point person to address any concerns, challenges, complaints – and to remove potential barriers between hospital-CCAC-pt/family.

Script from physician to patient might include:

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Your active medical treatment at HHS is complete. I will be instructing the health care team to meet with you/family to assess what options for discharge from hospital are best for you. Staying in hospital is not an option as your treatment is complete. You will be discharged home with community and family support where you can make longer term decisions.

Home First Role of the Hospital CCAC Team

• Hospital Case Manager (HCM) will assess all options for discharge home to support patient in a safe transition

• Many options may be considered in collaboration with the Hospital health care team, if home is the goal but patient needs more time. (e.g. slow stream rehab, admission to the Restore program or Convalescent Care)

• If at this time, no option exists for patient to return home the LTC application process begins

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Home First Role of the Hospital CCAC Team

Patients referred to CCAC through Home First approach would previously have been referred to CCAC for LTC

Workload re-distributed from RAI/LTC application to assessment for in-home services

Plan may take time to put together...but patient is not waiting in hospital for LTC

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Home First Role of the Community CCAC Team

Once home, all patients are assessed using the RAI- HC assessment tool

Application for LTC is completed and/or referrals to other programs/community resources are made

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Home First Involvement of the Entire Health Care Team

Complex discharge plans: At times the plan is not a “one step” plan.

The journey home may require some stops along the way. For Example: Slow Stream Rehab Restore Home (on W@H) LTC

Every opportunity is explored with the patient/family and all members of the health care team work collaboratively consistently messaging “Home First”.

The goal is for the LTC process, if needed, to occur outside of acute care.

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Home First Culture Change

Historically, education and messaging around ALC to staff and Pts/families focused on: hospital utilization data including ALC days, Length of Stay and the need to reduce ED wait times and increase access

Home First messaging focused on Safety and Quality of Life benefits for discharge home post acute-care stay.

Key Learning: Help health care professionals and

families understand that going home is in fact best for patients.

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Home First Culture Change

Why waiting at home is the BEST solution:

A reduced risk for hospital acquired infections

A reduced risk for hospital associated de-conditioning

The option to wait for a preferred choice of Long Term Care

Time to optimize functioning post-acute hospitalization prior to making permanent major housing decisions

Home provides the best environment to experience the significant life transition of moving to (in most situations) your final residence, a nursing home.

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Rapid Cycle Improvement Processes

• Use of Rapid Cycle improvement methodology was critical to the success of this initiative

• Improvement occurred through small, rapid rolling PDSA cycles of change, measuring change and providing regular feedback to all stakeholders.

• Culture change requires close attention and support to be sustained. Pay close attention to the data, workflow processes and the changing environment.

“Expect what you inspect” L. Gerstner

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Home First Measures (Process & Outcome)

ALC Patient Days % ALC Acute# admit to no bed pts in ED 0800h # ALC-LTC

# new referrals to LTC # discharges ALC-LTC# new referrals to Wait at Home Disposition outcomes from W@H

Barriers to Home First TAT for CCAC hospital assessment

Post implementation: staff feedback Post implementation: MD feedback

Recidivism Rate Pt Satisfaction - informal only (to date)

CCAC W@H Service Level - LTC CCAC W@H Service Level - Enhanced

HHS New Referrals Monthly ALC-LTCH H S N e w R e f e r r a ls M o n th ly A L C - L T C 2 0 0 7 -0 9

0

5

1 0

1 5

2 0

2 5

3 0

3 5

4 0

4 5

S e p -0 7

O c t -0 7

N o v -0 7

D e c -0 7

Ja n -0 8

F e b -0 8

M a r-0 8

A p r-0 8

M a y -0 8

J u n -0 8

Ju l-0 8

A u g -0 8

S e p -0 8

O ct -0 8

N o v -0 8

D e c-0 8

J a n -0 9

F e b -0 9

M a r-0 9

A p r -0 9

M a y-0 9

J u n -0 9

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Source: Meditech open cases

HHS ALC-LTC 2007 - Home First - 2009

101520253035404550

5560657075808590

Nov

-07

Dec

-07

Jan-

08

Feb-

08

Mar

-08

Apr

08

May

-08

Jun-

08

Jul-0

8

Aug

-08

17-S

ep-0

8

Sep-

08

Oct

-08

Nov

-08

Dec

-08

Jan-

09

Feb-

09

Mar

-09

Apr

-09

May

-09

Jun-

09

87 ALC-LTC

1A CrisisSept 17-Oct 18

Home First

1A CrisisJan 26 -Feb 27

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Source: Meditech open cases Midnight census last day of month

OTMH Admitted Patients in ED at 0800h

ER Admits to No Bed

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30

Jun-08Jun-09

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Source: Meditech

HHS % ALC (Acute) 2008-09 24% 3-5%

87 LTC

1A Crisis

Home First

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5

10

15

20

25

30

Jun-

08

Jul-0

8

Aug

-08

Sep-

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Oct

-08

Nov

-08

Dec

-08

Jan-

09

Feb-

09

Mar

-09

Apr

-09

May

-09

Jun-

09

Source: Meditech open cases Midnight census last day of month

CCAC Patient Measures WAH – Long Term Care (Nov-June)

WAH – Long Term Care n = 12 patients

Crisis Placed within 60 days 4

Placed to facility of choice within 60 days 4

Remain on LTC waitlist (category 3) 2

Returned to hospital to await LTC 1

Came off waitlist for LTC 1

Deceased 0

Service Level Note: *4 patients managed on enhanced service until placed (up to 56 hrs/wk)*6 patients managed on routine service (60 hrs or less/month)

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CCAC Patient Measures WAH – Enhanced (Nov-June)

WAH – Enhanced n = 21 patientsApplication completed for LTC at home 13Remain on LTC waitlist (category 3) 10Placed by choice 0Returned to hospital to await LTC 0

Came off Wait list for LTC 0Deceased 3Discharged from CCAC within 60 days – service not needed 3Service Level Note: *5 patients managed on enhanced service (up to 90 hrs/month)*10 patients managed on routine service (60 hrs or less/month)

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Presentation by:

Leslie Starr-HemburrowDirector, Patient Flow & Projects

Halton Healthcare Services

Janet ParksDirector, Client Services

MH Community Care Access Centre

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