clhin hospitals alc rehab steering committee phase one report orthopedics n.
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CLHIN Hospitals ALC Rehab Steering Committee Phase One Report – Orthopedics. July 13, 2012 - FINAL Malcolm Moffat, Co-Chair Helena Hutton, Co-Chair Zenita Hirji, Executive Project Lead. Presentation Outline. Provincial Context/Background Overview of ALC Rehab Project Purpose

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clhin hospitals alc rehab steering committee phase one report orthopedics

CLHIN Hospitals ALC Rehab Steering CommitteePhase One Report – Orthopedics

July 13, 2012 - FINAL

Malcolm Moffat, Co-Chair

Helena Hutton, Co-Chair

Zenita Hirji, Executive Project Lead

presentation outline
Presentation Outline
  • Provincial Context/Background
  • Overview of ALC Rehab Project
    • Purpose
    • Key areas of focus
    • Steering Committee composition
    • Draft workplan
  • Overview of Current State of Rehab in CLHIN
    • Draft ALC Rehab Survey Results
    • Performance Targets
  • Orthopedic Symposium
  • Draft Recommendations on Orthopedics
total joints hip fracture and stroke
Total Joints, Hip Fracture and Stroke
  • Three of the four conditions, knee replacements excepted, contribute significantly to the ALC challenges faced by acute care hospitals.
  • Collectively, they consume a significant amount of rehabilitative resource (55% of rehab provincial patient days)
  • They have well developed, recognized best practice guidelines for rehabilitative patient care
  • Uptake of the best practices across the continuum has been inconsistent throughout the province.
  • Challenges faced in the implementation of these best practices are indicative of systemic challenges in rehabilitative care.
slide4

Ontario studies provide strong evidence on the effectiveness of home-based rehab protocols following TKR/THR

“IP compared with home-based rehab following primary unilateral THR or TKR: a randomized controlled trial” N. Mahomed et al, 2008

  • CONCLUSIONS: Despite concerns about early hospital discharge, there was no difference in pain, functional outcomes, or patient satisfaction between the groups. We recommend the use of a home-based rehab protocol following elective primary joint replacement as it is the more cost-effective strategy.
correlation of joint replacements discharged home readmissions revisions 2009 10
Correlation of % Joint Replacements Discharged Home & Readmissions/Revisions (2009/10)

…with no observed relation to quality measures or length of stay

Top 15 Hospitals by Volume (2009/10)

5

slide6

In January, the Orthopedic Expert Panel made recommendations to the Ministry on provincial targets for discharge disposition and length of stay for THR / TKR patients

overview of alc rehab project
Overview of ALC Rehab Project
  • Goal: To reduce ALC days related to lack of access to Rehab by developing a systematic approach to facilitate equitable access to appropriate rehab at the appropriate time
  • Four clinical areas that are identified as being the greatest contributors to the ALC challenges:
    • hip replacement, knee replacement, stroke, and hip fracture.
alc rehab steering committee
ALC Rehab Steering Committee
  • Steering Committee established in January 2012
    • Reports up to CLHIN Hospital/LHIN/CCAC CEO Leadership Forum
  • Malcolm Moffat – Co-chair, CEO, St. John’s Rehab
  • Helena Hutton – Co-chair, VP, Southlake Regional HC
    • Alexis Dishaw, HRRH
    • Annette Marcuzzi, CLHIN
    • Dr. Brian Berger, YCH
    • Dr. Daniel Wong, NYGH
    • Dr. Roshan Shafai, SRHC
    • Julie Sullivan, MSH
    • Shannon Landry, SMH
    • Val Thompson, NYGH
    • Winston Cheuk, YCH
    • Yvonne Ashford, CCAC
    • Zenita Hirji, Executive Project Lead
workplan
Workplan

Phase One – Orthopedics (TJR and Hip Fractures)

  • Focus of phase one report will be on:
      • Reviewing the current state of TJR and Hip Fractures care management in CLHIN hospitals
      • Identify of gaps in best practice guidelines and achievement of performance targets, in this patient population
      • Capacity assessment and recommendations on strategies aimed at reducing ALC days for rehab and improving hospital performance on key metrics for TJR and Hip Fractures

Phase Two – Stroke

  • Focus of phase two report will be on:
      • Reviewing the current state of stroke care management in CLHIN hospitals
      • Identify of gaps in best practice guidelines and achievement of performance targets, in this patient population
      • Capacity assessment and recommendations on strategies aimed at reducing ALC days for rehab and improving hospital performance on key metrics on stroke care
hospital alc rehab survey results
HOSPITAL ALC REHAB SURVEY RESULTS
  • Purpose - To develop a Central LHIN snapshot of:
    • Inflow into IP Rehab - Patients designated as ALC and awaiting placement in an inpatient rehabilitation bed/facility (Survey One)
    • Outflow from Rehab - Patients in designated rehab beds awaiting placement in another care setting (Survey Two)
  • 2 surveys to be completed over two separate weeks: Week One - Jan. 30th to Feb. 5th) and Week Two (Feb.13th to 19th)
    • Total of 156 patients during two week period
    • Similar response rates for each week
  • Survey was designed by (and has previously been used in another study conducted by) the GTA Rehab Network
slide12

Top 70% of Primary Diagnoses associated with patients designated as ALC awaiting IP Rehab care - summarized in table

  • Stroke and Hip Fractures comprise 31% of survey diagnoses
  • No major ALC issues regarding access to IP rehab for primary hip and knee replacements

Summary of Primary Diagnoses – ALC Rehab

referral to rehab
Referral to Rehab
  • Reasons for “no referral” included the following:
    • Awaiting nursing and PT forms to be completed
    • Waiting nursing/PT/medical forms to be done
    • Pt. already applied to LTC -also applying to LTLD as per family's request
    • Application in process (waiting for medical, nursing, and PT forms)
    • RMR initiated. Forms being completed by team & MRP. Will "send" RMR as soon as all forms completed by team & MRP
  • 47% of patients were referred to more than one rehab facility
      • Majority of patients referred to only one rehab facility
survey results summary
Survey Results Summary
  • Hip Fractures and Stroke comprise 31% of the patient population designated ALC and awaiting placement in an IP Rehab facility
    • No major ALC issues regarding access to IP rehab for primary hip and knee replacements
  • For the most part, we know that the following special care needs comprise the highest volume of ALC patients waiting IP Rehab care
    • Incontinence
    • Wound Care
    • IV Peripheral
  • Wait times vary by age group and significant variation exists in wait times by facility (for both wait 1 and wait 2)
  • Wait 1 (ALC Designation to Rehab Referral)
    • 70% of Patients are referred to an IP Rehab facility within 3 days of being designated as ALC
    • 58% are referred within 1 day
  • Wait 2 (Rehab Referral to Acceptance)
    • 80% of Patients had referral response times of 2 days or less
  • Geriatric, Stroke, and MSK represent 62% of the most common type of rehab being referred to
  • Low volume of Rehab patients that are designated ALC and awaiting placement
    • average number of days waiting varies by facility
    • Longer waits for Home care and LTC placement from IP Rehab units/facilities
ip acute overall tjr volumes by hospital
IP Acute - Overall TJR Volumes by Hospital

Data Source: CIHI DAD – TJR includes primary, unilateral ,elective hip/knee replacements

  • Majority of discharges (65%) are TKR patients
inflow central lhin tjr surgeries by patient residence
Inflow-Central LHIN TJR Surgeries by Patient Residence

Data Source: CIHI DAD – TJR includes primary, unilateral ,elective hip/knee replacements

  • Approximately 900 to1000 patients who live outside the Central LHIN, get their TJR procedure done at a Central LHIN hospital
  • Impact on CCAC and OP Rehab Services
outflow central lhin residents who go outside lhin for tjr surgery
Outflow – Central LHIN Residents who go Outside LHIN for TJR surgery

Data Source: CIHI DAD – TJR includes primary, unilateral ,elective hip/knee replacements

  • Over 1000 patients per year that live in the Central LHIN get their TJR procedure at a hospital outside the Central LHIN
  • Inflow/Outflow almost balance – net zero effect
of patients discharged home by lhin
% of Patients Discharged Home by LHIN

Data Source: CIHI DAD – TJR includes primary, unilateral ,elective hip/knee replacements. Includes patients discharged home with or without services as per Orthopaedic Scorecard /HSAA definition

ip rehab tjr average admission age by lhin
IP Rehab - TJR Average Admission Age by LHIN

Data Source: CIHI NRS, 2010/11

ip rehab tjr median admission fim by lhin
IP Rehab - TJR Median Admission FIM by LHIN

Data Source: CIHI NRS, 2010/11

ip rehab hip fracture avg admission age by lhin 2010 11
IP Rehab – Hip Fracture Avg Admission Age by LHIN (2010/11)

Data Source: CIHI NRS, 2010/11

stakeholder engagement sessions
Stakeholder Engagement Sessions
  • Two Symposiums:
  • Physician Stakeholder Session – April 24th
    • Raise awareness amongst physicians of provincial efforts
    • Discuss impact of provincial initiatives on care planning
    • Provide an opportunity for physicians to render their input to how to implement the proposed changes
  • Administrative Stakeholder Session – April 25th
    • Raise awareness of provincial efforts
    • Provide an opportunity to hear about other LHIN-based efforts
    • Discuss potential impact of MOHLTC funding reform
    • Provide an opportunity for input on how to implement the proposed changes
recommendations
Recommendations
  • Series of recommendations arising out of stakeholder engagement sessions and steering committee deliberations
  • Key Areas:
    • System right-sizing
    • Standardized Care Plans
    • Patient Flow
    • Location of OP Rehab
    • Communication
    • Funding Reform
system right sizing
System Right-sizing
  • Primary, Unilateral Hip & Knee Replacements
    • In accordance with Ontario Bone & Joint Network best-practice guidelines and MOHLTC/Orthopedic Scorecard performance targets for orthopaedic care, the acute care system will reduce its reliance on inpatient rehabilitation for TJR patients, and move towards a 90% (+ 9) rate for discharge home (with appropriate supports)
    • Therapy for the 90% discharged home will include a combination of in-home CCAC services, hospital, community based outpatient services (details on patient care guidelines to follow)
    • In addition, a target ALOS of 4.4 days will be implemented for this patient population
  • Hip Fractures
    • Changes in management of TJRs will provide earlier access to inpatient rehabilitation for Hip Fracture patients
    • Increased use of inpatient rehabilitation for Hip Fracture patients, in accordance with best practice guidelines and standardized care pathways (to be developed)
  • These changes combined should create additional IP Rehab capacity for stroke patients (CLHIN Phase Two report on Stroke to be released in Fall 2012)
  • A Rehab Capacity and Sizing Working Group will be established to consider the implications for the siting of MSK and Stroke services within the Central LHIN.
standardized care pathway
Standardized Care Pathway
  • Need to develop standardized care pathways that can be used consistently across all CLHIN Hospitals in management of TJRs and Hip Fractures
    • Lack of existing documentation in current system is creating variation in care management of these patients
    • Need to build on existing best practice guidelines and care pathways developed in other LHINs i.e. TC LHIN toolkit
    • Pathway should include guidelines for home-based and/or hospital-based/other OP physiotherapy
    • Standardization of processes is required and clear targets need to be established throughout episode of care. For example, what should we expect with regards to patient outcomes at day 1, day 2, etc…
    • Messaging needs to be multi-lingual
  • Standardized pathways for TKR should include post-surgical guidelines for flexion and extension. For example,
    • If flexion does not reach 90 degrees within 4 weeks post surgery surgeons should be notified
    • flexion of 110-120 degrees at the end of the therapy
    • full extension of the knee prior to being discharged from therapy
standardized care pathway cont
Standardized Care Pathway (cont.)
  • Care pathways need to delineate clear decision-making criteria for pathway algorithms
    • For example, factors such as patient age, weight-bearing status, cognitive impairment, and other co-morbidities need to be factored into creation of pathway algorithms
    • Standardized way of triaging patients based on early and timely access to rehab
    • Should involve other members of clinical team in application of discharge criteria
  • Creation of implementation plan to ensure pathway adoption and necessary allocation/re-allocation of resources, where necessary
    • Resources may need to be re-allocated both within organizations and system-wide to meet pathway care requirements
    • Augmentation of OP physiotherapy/rehab will be required to ensure timely access to post-acute care
    • Impact on rehab skill mix also needs to be considered as more TJRs are referred to OP settings
patient flow
Patient Flow
  • Need to improve timeliness of rehab referrals and response times
    • ALC Rehab survey results showed that significant variation exists in wait times by facility (for both wait 1 and wait 2)
      • 70% of Patients are referred to an IP Rehab facility within 3 days of being designated as ALC
      • 80% of Patients had referral response times of 2 days or less
    • Weekend resources may need to be augmented to ensure timely referrals and improve overall patient flow effectively to establish 7 day a week business processes
    • Relatively efficient in overall management of ALC days for wait one and wait two (majority are short stay discharges)
    • Findings suggest that while rehab does account for substantial number of ALC cases, they are not the long stay ALC patients
  • Strong support for ensuring adherence to GTA Rehab Network protocols on referral to sub-acute system
    • Different standards are being applied on acceptance of referrals; even under RMR sub-acute facilities are asking for additional information
    • Inconsistencies and lack of standardization in application process
    • Some facilities have noted that it takes anywhere between 60-90 min per patient to issue out referral
patient flow cont
Patient Flow (cont.)
  • CCAC requirements for “medically stable” patient needs to be re-visited
    • Messaging that patient has to be identified as ALC before CCAC RAI-HC assessment can be undertaken is not correct
    • CCAC requirements state patient must be “medically stable” before assessments can be done
    • However, this does not facilitate efficient patient flow because patients often end up waiting (post ALC designation) for assessment to be completed
    • Need to investigate feasibility of implementing parallel processes so that assessments can be undertaken earlier in acute care episode to allow for effective discharge planning
  • RMR electronic referral must include TCLHIN rehab facilities and CLHIN acute hospital based rehabilitation units
    • Current system doesn’t necessarily ensure timely and transparent access to patients awaiting placement in IP Rehab
    • Hospitals with designated rehab beds/units often give preferential access to their patients
    • Enabling electronic referral to any rehab bed within the CLHIN system would create a level-playing field and ensure access to the “right bed at the right time”
    • At a minimum, standardized response times should be set for responses to referral requests and compliance to response time targets should be monitored
location of op rehab
Location of OP Rehab
  • Location of OP Rehab should leverage existing capacity and ensure equitable access across Central LHIN
    • TCLHIN report recommends using hospital based OP physio clinics to maximize cost –efficiency and facilitate standardized approach to rehab care
    • However, CLHIN geography is different; key principle needs to be geographical equity
    • CLHIN may not be able to locate OP rehab exclusively at Hospital sites due to rural geography, but also need to consider issues of critical mass in more rural areas; need to strike a balance between patient travel times and critical mass and possibly leverage home-based physio in more rural areas of CLHIN
    • Is it a possible for CCAC to have congregate care type clinics in more rural settings? can LHIN contract services from private clinics?
    • Parking discounts at hospital-based settings is a fundamental requirement to equitable access
    • Investigate access to care in evenings and weekends; clinic access should not just be Monday to Friday, but also on weekends and evenings – want to encourage people to get back to work
    • Optimize LTC facilities for those patients who came from LTC
location of op rehab cont
Location of OP Rehab (cont.)
  • Irrespective of OP Rehab setting, there needs to be standardized outcome measures collected at standardized times and LT follow-up is encouraged
    • Need to ensure that appropriate communication processes are set up with surgeon
    • Consider creation of accredited OP rehab care providers/facilities which are appropriately trained on care pathway and required physiotherapy regimen
    • Facility/providers should not be paid until outcome measures are achieved
    • Strengthen relationship outside of traditional rehab model –relationship to active facilities i.e. fitness centres? Community centres?
communication
Communication
  • Consistent strategy and messaging required to manage patient expectations regarding access to IP rehab post-surgery
    • no legislative requirement for patient to identify 3 choices for placement in IP rehab – only applies to LTC home placement
    • Need for consistent patient education strategy and information pamphlets and/or letters identifying OP rehab options and locations of OP physiotherapy clinics (within and outside of the hospital setting
  • Need for strong relationship between care provider and surgeons post-discharge
    • Consider establishment of clinic days where OP physio care providers and surgeon meet to discuss patient progress and treatment plans
    • Strong recommendation for IT communication enablers between CCAC, Surgeon’s offices, and hospital
funding reform
Funding Reform
  • Need for further clarity on MOHLTC Funding Reform and impact of newly proposed Quality Based Procedure funding on the delivery of orthopaedic care in Central LHIN
    • General belief that new funding model will create less variation and more standardized pathways and perhaps even Increase quality
    • Focus on outcomes will become paramount
    • Concern regarding double dipping (private funding under insurance plans for some patients vs. MOH public funding; Private funding options should be exhausted first prior to use of public funds
  • Impact of new funding model on hospitals and physicians not clearly understood
    • Will new funding model lead to creation of centres of excellence in certain procedures?
    • What impact will funding model have on use of Ortho implants? Hospitals may want to consider developing tighter protocols for when certain high-cost implants are used
    • Hospital Decision Support, Health Records and IT resources will be key to measuring hospital performance in new era of funding
    • Will we be re-distributing OR time depending on physician efficiency? Re-allocation of blocks due to funding mechanism, volume, quality, etc…?
next steps
Next Steps…
  • Communicate and obtain feedback on draft Phase One report to CLHIN system leadership and symposium attendees
  • Finalize Phase One report
  • Establish necessary working groups (revise workplan, as necessary) and focus on Implementation of recommendations
    • Capacity & Sizing Working Group
    • Pathway & Flow Working Group
  • Proceed into Phase Two review of Stroke services within CLHIN