Community Support Services Enabling patient flow and supporting hospital avoidance

1. Community Support Services Enabling patient flow and supporting hospital avoidance Presented to: The Community Support Services Network of South East Ontario June 26th, 2007

2. 2 Today�s Objectives Why are we discussing this? Background Facts & Figures Alternative Level of Care (ALC) The South East LHIN Perspective Initiatives Patient Flow Improvement Funding The �Flo� Collaborative Contingency Planning Moving Forward More than �things to think about�

3. 3 What can we do �together�? Home and community care services can help solve key health system bottlenecks (ALC beds, ED pressures, LTC facility waitlists) by: maintaining the well-being and autonomy of individuals and their care givers preventing unnecessary hospital and emergency service use substituting for care in a hospital or long-term care facility

4. 4 So what are the services we are talking about? Home care � CCAC services Professional health care services including nursing, OT, PT, social work, speech/language Home support linked with assistance with personal activities of daily living including eating, bathing, toileting (ADLs) Community support services assistance with functional activities of daily living including meal preparation/meals on wheels, home help/homemaking, laundry, shopping, transportation friendly visiting, telephone reassurance, caregiver support groups, family support

5. 5 Some Facts�how big is this issue? Frail Elderly (15% of the 65+) or 3% of total population use nearly 30% of provincial health care funding Approximately 3,000 ALC patients currently in acute care beds � 19% of acute care beds in Ontario 50,000 referrals for LTC home placement in Ontario 44,000 admissions each year Average age on admission to a 87 years Occupancy rate for LTC home beds has increased in the last 3 years from 95.6% to 98% ? generally, the only reason a client gets placed in a LTC home is due to the death of a current resident

6. 6 Alternative Level of Care (ALC) A hospital designation for patients who have completed the acute phase of treatment and are ready for discharge to another type of care but remain in hospital waiting for that level of care to be available (CIHI) A long-standing, significant and persistent problem across in Ontario hospitals in the SE LHIN have been identified as struggling with this pressure for the last few years The ALC situation in acute care hospitals is a symptom of larger system issues: patient flow and access (continuum of care) availability of placement (e.g. LTC home, rehabilitation) service options (e.g. CCAC, CSS) system capacity and resources The consequence of these pressures are directly felt by users of the hospital system: long waits in Emergency Departments delays in ambulance offloading of patients cancellation of scheduled surgical procedures (no beds for post-op care)

7. 7 ALC is more than �beds� Represents patients who need specific combinations of services and care in order to thrive after their acute treatment to regain maximum health & functional status  Includes hard to place populations (dementia, behavioural issues, ABI) Requires health service providers to actively coordinate with each other to ensure clients are not designated ALC, and to minimize the time patients are designated ALC through expedited service provision and return to community strategies Impacted by community resources failing to meet client needs (ie, inappropriate care for the patient, care needs misunderstood by referral source/provider, underdeveloped resources in the community, perception of too complicated to access) patients exercising their choice for a preferred LTCH patient / family expectations regarding appropriateness of waiting in hospital until LTCH is available

8. 8 Wrong Care/Wrong Place: The impact on Patients De-conditioning / muscle atrophy, resulting in: falls decreased functional ability (dressing, toileting, transfers) Slowed recovery from even minor health changes Exposure to hospital based infections (c.diff) Changes in medication Delirium Malnutrition Bad for People � Bad for the System

9. 9 Health Service Providers Hold the Answers As providers, you collectively have the ability to make a profound impact on this issue, making the health care system more responsive, and improving the quality of life for those needing your services The South East LHIN is looking to all HSPs to be part of the solution to the patient flow issues (e.g. ALC) including strategies to support appropriate hospital avoidance Closer collaboration, innovation, creative problem solving from all HSPs will result in a workable and sustainable solution to this issue The SE LHIN will support you in this by facilitating dialogue, providing communication expertise, and where appropriate working with you to realigning resources to meet patients and the broader community needs� The power to make changes in the SE rests with you!

10. 10 The Time is now for Change! Facilitating the change from silo & organizational thinking to a �systems-approach� is the LHIN raison d�etre We have all, in our various roles, talked about the need for change --- the need to actually do things differently --- but there are very few examples where we have actually taken that deep breath and jumped! This is your opportunity to look within our local (SE) health system and find our solutions, rather than wait another 30+ years for a �one-size fits all� silver bullet We need innovative ideas, leadership, expertise, and a commitment from you to challenge your organization to do what the system needs now

11. 11 Assessing needs what makes a difference? Focus of CSS Health promotion/illness prevention Maintenance of well being  What does that mean to individuals 75-80+ (frail & potential frail elderly) Includes not only education, social and recreational interventions but increasingly requires direct intervention and support with instrumental activities of daily living (IADLs) meal preparation ordinary housework and home maintenance managing finances managing medications phone use stairs shopping transportation  Is enough focus being provided to these needs in your organizations?

12. 12 Announcement:Patient Flow Improvement Funding $1.6M investment announced to improve the flow of patients from hospitals back to the community or other non-hospital facility $1.3M for 2007/08 Specific investments included: increasing home care and community support services assignment of CCAC case managers to hospital emergency departments to assess and divert clients to more appropriate community services geriatric emergency management funding to increase emergency department services for seniors with complex functional and psychological challenges

13. 13 ED Action Plan &Community Services for ED Pressures A project approach has been designed to facilitate a quick and effective process by which HSPs (funded and affected) will together create an integrated plan for this funding Participants (2 members each) SE Community Care Access Centre Community Care Service Providers Kingston General Hospital Quinte Health Care Corporation Providence Continuing Care

14. 14 Project Status Two meetings have occurred in June and a further meeting is anticipated in early July to finalize the plan Proposals for the available one-time funding have been developed and are being consolidated as an integrated plan that focuses on improving the outcomes particularly for the frail elderly accessing ED services in the SE (emphasis at KGH & QHC Belleville sites)

15. 15 Key Elements of Proposed Plan Expanded Assessment Capacity by CCAC ED-based assessors enhanced geriatric training enhanced hours of availability targeted identification / �at risk� triggers Enhanced Services �Bridging� Project short-term intensive home & community support program (30 days) includes for CCAC & CSS services Elderly in Emergency Tool Kit reference materials in a user-friendly format for elderly & caregivers

16. 16 What might this look like for your agencies Short term Enhanced �Bridging� Project Up to 30 days of enhanced services, both CCAC and CSS to avoid ER or potential hospital admission or to return someone home from ER Reducing barriers to CSS services client co-payments are proposed to be funded from new one time CSS funding (e.g. respite, transportation, meals, homemaking) increased assessment and service planning by CSS co-ordinator increased communication and co-ordination with CCAC case manager Elderly in Emergency Toolkit Improved visibility of CSS services for health care professionals, patients, care givers Other Proposal based funding for strategies that would be consistent with ED and hospital avoidance/transition home

17. 17 The �Flo� Collaborative The Ontario Health Performance Initiative (OHPI) is launching a major quality improvement initiative, entitled The �Flo� Collaborative to improve patient transitions from acute care hospitals to subsequent care destinations

18. 18 Telling the Story�. The �Flo� analogy was developed to tell the story of a real patient experiencing an acute event who requires care in an alternate setting following a hospital stay Flo is an 85- year old woman admitted to hospital from her home with multiple co-morbidities. her frailty and declining cognitive status necessitate transfer to a nursing home Flo continues to need quality care in the right setting and the system needs to support her and her family in getting there The �Flo� Collaborative is intended to help Ontario�s healthcare system continue to provide the care that Flo, and thousands of other people like her require. The aim is to accomplish this by making transitions from acute hospitals to other settings faster, and with fewer hassles, bottlenecks and delays for Flo, her family and the staff who care for her

19. 19 The SE LHIN &�Flo� The provincial process for recruitment of organizations into the Collaborative is underway Invitations sent by LHINs in late May to acute care hospitals, CCACs and other organizations (e.g. rehabilitation facilities) based on a combination of factors including provincial contribution to ALC days SE LHIN identified the following organizations based on the inclusion criteria for invitation: QHC, KGH & SE CCAC Next Steps June to August: understanding the collaborative, commitment, and impact on organization August 1, 2007: formal application to participate in the collaborative Mid-August: provincial selection of organizations/partnerships that will proceed (Limited to approximately 30) September 2007: Kick off event

20. 20 Is the only option a �trip to ER� or hospital admission? Contingency Planning � we need to start talking seriously and consistently to our community about� What happens if I�m or my caregiver is sick and needs help for a week? for a month? longer? What�s the plan & how does it get put in motion?

21. 21 Moving Forward We need more than just �thinking about doing things differently�.we need ACTION! Are the services we are currently focusing on the ones that are needed What does �prevention & maintenance� mean to an individual 80+? Is it activation & socialization or is it equally IADLs (shopping, cleaning, home maintenance) Is our current process of connecting with CSS services working as well as it can? Are the processes designed for the CSS organization or are they designed for the ease of those needing to access the services, including hospitals, CCAC, patients and families How do we work together effectively to engage HSPs in a manner that is effective & efficient? How as a group of CSSs do you want to work together to ensure that informed decisions are made by the LHIN recognizing that we can�t ALL be at the table for every decision Need to have feedback on the ED Action Plan process

22. 22 Questions?