Integrating Home and Community Care for Vulnerable Populations

Transcription

1 Leading knowledge exchange on home and community care Integrating Home and Community Care for Vulnerable Populations A. Paul Williams, PhD. Full Professor & CRNCC Co-Director, University of Toronto El Instituto Nacional de Salud Pública (INSP) Ciudad de México, México Febrero, 2009 The CRNCC is funded by the SSHRC and Ryerson University

2 The Evidence Game Move toward evidence-based decisionmaking, practice guidelines, benchmarks, performance measures, outcomes If you can t measure it, you can t manage it If you can t manage it, you shouldn t fund it

3 Playing The Evidence Game Evidence game inherently difficult in home and community care (H&CC) Care does not necessarily lead to cure Outcomes difficult to measure (garbage bags vs. autonomy, quality of life, dignity) Unit of care is not just the individual Mix of providers Multiple client groups with widely varying needs and preferences

4 Beyond Health Care H&CC outside hospital and doctor care Not medically necessary Limited consensus on role of government, private markets, individuals, families, communities

5 Multiple Roles Substitute for acute care Meet the needs of people who would otherwise have to enter, or remain in, acute-care facilities Substitute for LTC Meet the needs of people who would otherwise require residential care (e.g., nursing homes) Preventive/maintenance Help to maintain the health and functional capacity of people living independently

6 Diverse Needs Groups Individuals with such high needs that they are at risk of losing independence and requiring care in an institution As well as those who require minimal assistance with activities of daily living Most are older people But other needs groups, including persons with disabilities and a growing number of medicallyfragile children and their families, also utilize H&CC

7 Home & Community Care (H&CC): A Complex Terrain Home care Mostly professional, often post-acute, health care services (e.g., nursing, rehabilitation, social work)

8 Home & Community Care (H&CC): A Complex Terrain Community supports Assistance with personal activities of daily living (ADL): eating, bathing, grooming, walking, dressing, toileting, personal hygiene Assistance with instrumental activities of daily living (IADL): preparing meals, vacuuming, laundry, changing bed linens, bathroom and kitchen cleaning, managing finances, using the telephone, shopping, transportation

9 Leading knowledge exchange on home and community care Mobilizing Knowledge The CRNCC is funded by the SSHRC and Ryerson University

10 One Response: CRNCC CRNCC grew out of March 2005 symposium From Ideas to Action: Community Services in the Continuum of Care With Neighbourhood Link/Senior Link Minister of Health s challenge: Give me the evidence to make the case!

11 CRNCC: What We Do Link people to knowledge about H&CC Raise the profile of H&CC Build community capacity to generate, mobilize knowledge Provide evidence to inform decisionmaking

12 From CRNCC s Toolkit: In Focus Fact Sheets Short, concise summaries in lay language, cutting edge international evidence Balance of care Supportive housing Diversity All topics identified and developed in partnership with the field Distinguish evidence-based best practices from marketing best practices

13 Ideas to Action Symposia Series Look Globally-Act Locally: Integrating Care in the Community for Vulnerable Populations Symposium (October 15, 2008) National and international experts presenting evidence on what works when and why

14 Profiles Series Promising (although sometimes not fully evaluated) innovations in H&CC CREMS (Community Referrals by EMS): direct referrals to Toronto home care by paramedics who respond to 911 calls Innovations from Beijing: street corner exercise yards for older people, communal kitchens, home hospital beds

15 Leading knowledge exchange on home and community care The Evidence The CRNCC is funded by the SSHRC and Ryerson University

16 Credible and Growing Evidence for Integrated H&CC Growing evidence that targeted, managed & integrated H&CC consistently Maintain the health, well-being and autonomy of at risk older persons and caregivers Help solve key health system problems (e.g., ALC beds, inappropriate ER use, LTC waits)

17 Targeted, Integrated, Managed Care Kaiser Permanente Triangle Source: UK Department of Health (2005)

18 US: On Lok/PACE On Lok/PACE (Program of All Inclusive Care for the Elderly) 1970s, San Francisco, Chinese community Currently 35+ PACE replication projects in U.S. Service model Organized around adult day care centre Individuals transported to services Continuum of services including health care Needs assessed and managed on an ongoing basis by multi-disciplinary team

19 On Lok/PACE Target group At risk seniors Average 80 years of age 8 medical conditions (e.g., diabetes, dementia, heart disease, cerebrovascular diseases) Most lived alone 40% poor enough to qualify for public income supplements All clients qualified for admission to nursing homes

20 On Lok/PACE Funding model Government funded PACE clients at 95% of the cost of nursing home care

21 On Lok/PACE Outcomes Resources shifted toward lower level community supports (e.g., transportation) Just over a fifth (22%) to health care (e.g., hospitals, long-term care, x-rays, lab tests, medications and medical specialists)

22 On Lok/PACE Outcomes Better health status and quality of life, lower mortality rates, increased choice in how time is spent, greater confidence in dealing with life s problems Care costs 21% lower for participants Inpatient care costs (hospital and skilled nursing) 46.1% lower 5-15% cost savings over standard fee for service care

23 Canada: Veterans Independence Program VIP is a comprehensive suite of services to 103,000 overseas veterans All are LTC eligible Case managers build care packages around client needs using set budgets Clients may choose to manage care themselves Thanks to Dr. David Pedlar go to

24 Veterans Independence Program Nursing Home Care in the client s community may be provided if / when the client can no longer remain at home Ambulatory Health outside the home (e.g. adult day care, health assessments, diagnostic services, and travel costs to access these services) Health and Support Services (e.g. nurses to administer medication, occupational therapists)

25 Veterans Independence Program Home Adaptations (e.g. bathrooms, kitchens, doorways modified to provide access for basic everyday activities like food preparation, personal hygiene, sleep) Personal Care (e.g. bathing, dressing) Access to Nutrition (e.g. Meals-on-Wheels) Housekeeping (e.g. laundry, vacuuming, meal prep) Grounds Maintenance to assist with grass cutting and snow removal Transportation (e.g. for attending senior citizen centers and churches, shopping, banking, and visiting friends)

26 Veterans Independence Program Problem: growing wait lists for LTC beds Intervention: home care option offered to wait listed clients care managers have integrated client budgets encouraging appropriate care across continuum Outcome: most wait listed vets preferred to stay at home with added support -- grounds maintenance, housekeeping, most used Impact: program implemented nationally in 2003, evaluation just completed

27 Toronto: Supportive Housing Studies Comparative study of older persons in social housing and supportive housing ( & ) Three pairs of buildings, 3 areas of Toronto Comparable incomes, living arrangements, access to H&CC Key difference: in social housing H&CC may be available in supportive housing, case managers link clients to services Source: Lum, Ruff & Williams, go to

28 Age 45% 40% (2004 baseline data 2006 data in brackets) 40% (32%) Percentage of Respondents 35% 30% 25% 20% 15% 23% 16% 22% 25% 14% (17%) 20% 25% 16% (21%) 17% 19% 23% (23%) Social Housing Supportive Housing Toronto 10% 5% 6% 2% (6%) 6% (2%) 10% 9% 8% 0% 60 to to to to to Age Group

29 Health Risks Disease Social Housing Supportive Housing Seniors Population in Canada (1996) Arthritis 61% 69% 42% High Blood Pressure 56% 59% 33% Back Problems 60% 51% - Heart Problems 36% 38% 16% Osteoporosis 21% 44% - Diabetes 23% 16% - Stroke 10% 10% - Tumour/ cancer 8% 15% - (2004 baseline data) 29

30 Supports for ADL 40% 35% (2004 baseline data 2006 in brackets) Percentage of Respondents 30% 25% 20% 15% 10% 17% 28% (30%) 9% (11%) 12% (13%) Social Housing Supportive Housing 5% 0% 0% 2% (4%) 4% 0% 1% (2%) 5% Eating Bathing/Showering* Dressing Bathroom Taking Medications 30

31 Supports for IADL Percentage of Respondents 100% 90% 80% 70% 60% 50% 40% 30% 20% 42% 80% (82%) 30% (2004 baseline data 2006 in brackets) 65% (60%) 73% (66%) 35% 34% 47% (33%) 68% (64%) 38% 39% 67% (66%) Social Housing Supportive Housing 10% 0% Housework Laundry Vacuuming Changing Bed Linen Cleaning Bathroom Cleaning Kitchen 31

32 Mental Health: Confidence in Getting Help When Needed 100% (2004 baseline data 2006 in brackets) 90% 80% Percentage of Respondents 70% 60% 50% 40% 30% 20% 63% (56%) 37% (44%) 86% (94%) Yes No/Don't Know 10% 0% 14% (6%) Social Housing Supportive Housing 32

33 Crisis Management Social Housing Supportive Housing 17% 33% 34% Call 911 3% 64% 24. Hr. Emergency Response/CSA Family, Friends and Others 49% (2004 baseline data) 33

34 Leading knowledge exchange on home and community care Take Away Messages The CRNCC is funded by the SSHRC and Ryerson University

35 Aging at Home a Preferred Option Most older persons would prefer to age at home, as independently as possible, for as long as possible Unmet IADLs consistently appear as a major factor in loss of independence Particularly when provided to at risk older persons, IADL supports can be a good investment for individuals and system 35

36 But Siloed systems problematic Little ability to track individuals, compare costs and outcomes Providers/case managers have restricted tool kits limited ability to build integrated care packages around needs from the bottom up Incentive to ratchet up to acute care, LTC

37 Fundamentals Target at risk populations as a priority For moral and ethical reasons Because they are intensive users of costly services Doesn t mean that others get nothing redeployment of saved resources key

38 Fundamentals Integrate care across the continuum Facilitate appropriate, cost-effective care substitutions within, across sectors Establish cross-sector benchmarks (e.g., ALC rates, ER admissions)

39 Fundamentals Actively manage services At risk individuals, those in crisis, least likely to be able to navigate the system Build the system from the ground up around the needs of individuals and their carers Combine financial and clinical accountability for an identified population

40 Making the Case for Home and Community Care Knowledge networks like CRNCC help bridge the evidence gap, make the case for H&CC in integrated systems Top line: people Bottom line: health system sustainability

41 Leading knowledge exchange on home and community care Please join us -- membership is free The CRNCC is funded by the SSHRC and Ryerson University