TC LHIN Quality Indicators: Big Dot (System) and Small Dot (Sector Specific) Indicators. November 29, 2013

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1 TC LHIN Quality Indicators: Big Dot (System) and Small Dot (Sector Specific) Indicators November 29,

2 Contents 1. TC LHIN Quality Framework, Themes and Focus Areas 2. Big Dot System Indicators 3. List of Big Dot Indicators and Related Small Dot (Sector Specific) Indicators 4. List of Acronyms 5. Brief Summary About Databases Used for the Indicators 2

3 Elements of TC LHIN s Quality Framework Four main criteria in assembling indicators: Comprehensiveness across sectors Alignment with TC LHIN priorities, MOH, HQO, primary care and public health Focus transitions, chronic diseases, high potential to impact, system-wide Validity and Feasibility measurable, reliable, actionable etc Used principles from Institute for Healthcare Improvement (IHI) Framework and elements of other frameworks to guide work Acknowledge the significance of equity to quality Iterative process; will improve and be modified as evidence emerges 3

4 Themes and Focus Areas Overarching theme: To improve overall health status of people living within the TC LHIN as well as residents from outside our LHIN who receive care from our health service providers, and to improve outcomes and experience of care. Three inter-related themes and Six system indicators Theme 1: Appropriate Access to Care Focus on avoidable time in hospital Avoidable inpatient time Avoidable Emergency Department (ED) use Theme 2: Transitions of Care Focus on Patient Experience Communication/Information transfer to patient during transition Timeliness of hand-off of transition communication between providers Length of time waiting from time of referral to receiving next service Theme 3: Care for Patients with Complex and High Care Needs Appropriate management of patients with complex high care needs 4

5 Six Big Dot Quality System Indicators 1. Inpatient Readmissions within 30 days of discharge for selected Case Mix Groups (CMGs) (Stroke, Chronic Obstructive Pulmonary Disease, Congestive Heart Failure, Cardiac CMGs, Pneumonia, Diabetes, Gastro Intestinal, Asthma, Mental Health, and Addictions) 2. Repeat unscheduled Emergency Department use within 30 days for any reason (may focus on CTAS 4 & 5) 3. Percentage of hospital patients (ED or inpatient) who knew important discharge aspects e.g. danger signals to watch after going home, medication related information, when to resume usual activities, who to call if they need help (NRC Picker and other surveys) th Percentile Decision Time (Number of days from the date that the referral is sent to final response (Accept, Deny)). (Acute/Rehab/CCC//CCAC/CSS/CMHA) (RM&R and other databases) th Percentile Waiting Time from acceptance to admission (Acute/Rehab/CCC//CCAC/CSS/CMHA) (RM&R and other databases) 6. Percent of patients with complex high care needs identified that are targeted/receiving appropriate care (e.g. intensive case management (Developmental) 5

6 Approach Hospital MHA Big dot Indicators The large system-level indicators that reflect core issues that are most vital to system s objectives CSS Small dot indicators Contribute to the achievement of system indicators. They are indicators for different sectors/parts of the system Primary Care Public Health CCAC CHC 6

7 Example of Connecting the Dots Hospital MHA 1a) Percent of patients with full medication reconciliation completed at discharge from any hospital to another setting 1b) Percent of patients with a completed discharge summary upon discharge from hospital 1a) Rate of unplanned ED visits for frequent users from Toronto Community Addictions (TCAT) project clients 1b) Rate of unplanned ED visits for frequent users of Addictions Supportive Housing (ASH) project clients 1a) Number and percent of residents with acute inpatient hospital admission by reason for admission 1.) Inpatient Readmissions within 30 days of discharge: 1b) Percentage of inpatient hospital readmissions within 30 days for residents Stroke COPD CHF Cardiac Pneumonia Diabetes GI Asthma MH CSS 1a) CSS clients discharged from hospital who are readmitted within 30 days for any reason -Supportive Housing -Enhanced Adult Day Programs 1b) Percent of patients with a completed discharge summary upon discharge from hospital -Supportive Housing -Enhanced Adult Day Programs Primary Care Public Health CCAC CHC 1a) Percent of CCAC clients admitted to CCAC from an acute hospital who have a readmission within 30 days of CCAC admission 1a) Percentage of CHC clients who were able to see their health care provider on the same or next day the last time they were sick or needed medical attention 1b) Inpatient readmission for CHC clients within 30 days 7 of discharge from hospital

8 1. Inpatient Readmissions within 30 Days for selected CMGs Sector Hospital CSS CCAC CMHA CHC Sector Specific Indicators 1a) Full medication reconciliation completed at discharge from any hospital to another setting 1b) Average length of stay in hospital (Explanatory) For Development: 1c) Completed discharge summary upon discharge from the hospital 1a) residents with acute inpatient hospital admissions by reason for admission (explanatory indicator) 1b) Unscheduled acute inpatient readmissions within 30 days for residents 1a) CSS clients discharged from hospital who are readmitted within 30 days for any reason 1b) Average number of readmissions for CSS clients discharged from hospital who are readmitted within 30 days for any reason 1) Percent of CCAC clients 80 years + admitted to CCAC from an acute hospital who have a readmission within 30 days of CCAC admission 1a) Self-reported hospitalization rate for CMHA clients from selected services (OCAN indicator under development) 1b) Rate of unmet needs (for selected domains) for CMHA clients by length of stay in program (OCAN indicator under development) 1a) CHC clients who were able to see their Health Care Provider on the same or next day the last time they were sick or needed medical attention 1b) CHC clients with unscheduled inpatient readmissions within 30 days of discharge from acute care Subsector/ Data source All Hospitals Hospital reporting CIHI DAD All Facilities CIHI CCRS-, DAD Supportive Housing; eadp Manual data extraction by agencies CCAC - CHRIS OCAN database All CHCs (client survey under development) CHC + ICES data linkages 8

9 2. Repeat unscheduled ED visits within 30 days for any reason Sector Sector Specific Indicators Subsector/ Data source Hospital 2a) Frequency of individuals with multiple unscheduled emergency department visits All hospitals CIHI NACRS & Hospital reporting 2a) resident transfers to Emergency Department (by: reason for transfer, time of visit, and admitted vs not admitted, Home Case Mix Measure) 2b) Nurse Led Outreach Team (NLOT) visits which prevented ED visit (by: time of visit and reason for visit) All Facilities CIHI CCRS-, NACRS NLOT Teams Future consideration 2c) Percentage of psychogeriatric team visits which prevented ED visits, by time of visit and reason for visit CSS 2a) CSS clients with repeat unplanned emergency department visits within 30 days for any reason 2b) Average number of repeat ED visits for CSS clients with repeat unplanned emergency department visits within 30 days for any reason Supportive Housing; eadp Manual tracking CCAC 2) Hospital ED visits for clients aged 80+ referred from acute care to CCAC within first 30 days of admission to CCAC CCAC data CMHA 2a) ED visits for Toronto Community Addictions Treatment (TCAT) project clients (frequent users of ED) Agency specific reporting 2b) ED visits for Addictions Supportive Housing (ASH) project clients (frequent ED users) 2c) Self reported ED visit rate of CMHA clients from selected services (OCAN indicator under development) CATCH, ASH, TCAT OCAN CHC 2) Percent of CHC ongoing primary care clients who visit the ED with a CTAS score of 4 or 5 (nonurgent). All CHCs CHC + ICES databases 9

10 3. Patient Satisfaction related to the percentage of hospital patients (ED or inpatient) who knew various important discharge aspects Sector Sector Specific Indicators Hospital Same as Indicators #1 3a) residents/family who would recommend the home through resident/family survey Subsector/Dat a source All Facilities CSS CCAC CMHA CHC 3b) Future consideration - Percentage of new residents and/or substitute decision makers who feel they know important information on admission to. (Developmental new data collection in H Annual Surveys) 3a) CSS clients who had care plans developed with information from discharge communications 3b) Clients receiving CSS services who transition to hospital with relevant care information 3) Client experience measured through Client Surveys. a) Overall experience b) Satisfaction with service providers c) Satisfaction with how the CCAC handled client care 3a) Client satisfaction for CASH (supportive housing) and Access 1 (intensive case management & ACTT) clients Explore the DTFP and MHA client experience survey under development 3) Client experience - Percentage of CHC clients who said their health care provider: a) Always explains things in a way that is easy to understand b) Always tells them about treatment options and involves them in decisions about the best treatment c) Always spends enough time with them Questions have been added in their client experience surveys Client Survey Supportive Housing; eadp Manual data collection Client Survey Project Client Survey All CHCs Client Survey *Indicators may be modified or new indicators recommended based on the results of the TC LHIN Patient Experience Measurement initiative currently underway 10

11 4. 90 th percentile Decision Time for patients leaving the hospital to the community or another sector (Acute/Rehab/CCC/CCAC// CSS/CMHA) (RMR and other Databases) Sector Hospital Sector Specific Indicators 4a) Completed referrals from acute to rehab and CCC with first response as final decision rendered within 2 days of referral being received. 4b) Referrals from acute to rehab and CCC that were denied by denial reason 4c) Length of time to Request Information (from Receiver to Sender) 4d) Length of time to Respond to RFI (from Sender to Receiver) 4e) Completed peadiatrics referrals to CCAC with decision rendered within 2 days (acceptance/denial) 4a) Total Response time compliance: I. Referrals with first response (Acceptance/Denial/ RFI) rendered within 5 days of referral being received. II. 90 th Percentile /Median Response time (from date completed application sent by CCAC to time of first response by -Accepted/ Denied/ or Request for Information) 4b) referrals with Request for Information (RFI) (i.e. incomplete information) (explanatory indicator CCAC Process indicator) Subsector Reporting Acute/Rehab/CCC Exclude paediatrics, MHA, Paediatrics only All Facilities RMR CSS 4) 90 th Percentile /Median Response Time for patients leaving the hospital to the community (CSS) CNAP RMR Services CCAC CMHA* CHC *Indicators still being finalized 4) Processing time for CCAC referrals (referral time to outcome decision admit/non-admit/ eligibility determination) 4a) Average/median Decision Time for MHA supportive housing, broken down by high support housing vs regular support housing (CASH) 4b) Average/median Decision Time for CMHA intensive case management and ACTT services (Access 1) No Indicator - CHCs are not yet part of RMR and do not have standardized intake processes or database to track waiting timeframes consistently RMR Supportive Housing, Case Management, ACTT CASH, Access 1 11

12 5. 90 th Percentile admission wait time (for Acute/Rehab/CCC// CMHA); Assessment time (for CCAC/CSS) (RMR and other databases) Sector Hospital Sector Specific Indicators 5a) 90 th Percentile admission wait time of referrals from acute to rehab/ccc (Exclude paediatrics, MHA) 5b) Average wait time for transfer of paediatric patients to CCAC (For Paediatrics only) 5a) Number of Clients Waiting for Placement. Stratified by Source (community, hospital, other ), and by special care needs identified in the matching profile Subsector Reporting Acute/Rehab/CCC - RMR Paediatrics only 5a) Number of clients admitted and 90 th Percentile/Median days waiting for from acceptance to admission to H. Stratified by source (community, hospital, other ), and by special care needs identified in the matching profile (e.g. behavioural, Dialysis, mobility etc.) All Facilities RMR CSS 5c) Number and percentage of crisis admissions to (from community, hospital, other H, other CCACs) (explanatory indicator CCAC process indicator) 5d) 90 th Percentile/Median time for filling vacancies in Homes: i) Time from when bed is posted as internal to when the status is changed to available for CCAC to fill. ii) Time from H declares bed available to CCAC to time bed is filled (accepted) 5a) 90th percentile/median Assessment Time for patients leaving the hospital to the community (CSS) 5b) 90 th percentile Wait Time for CSS Services (developmental) (Year 2) CNAP RM&R Services CCAC Same indicator as for big dot indicator #4 CMHA* 5a) Average/median wait time for MH supportive housing: from date client placed on wait list to occupancy date (CASH), broken down by client socio-demographic characteristics, level of support, geography and language needs 5b) Average/Median Wait time for Open MH & A supportive housing and Intensive case management and ACTT 5c) Average and Median SH vacancy response time (i.e. median number of days to process MH & A supportive housing vacancy) 5d) Average and Median wait time from referral sent to Partner agency to MH& A SH housed outcome date/icm or ACTT admission date 5e) Supportive housing/icm/actt provider decline rate by reasons for denial, broken down by client socio- demographic characteristics 5f) Client refusal rate (SH/ICM/ACTT) by provider, reasons for refusal, broken down by client socio- demographic characteristics MH and A Supportive Housing, Case Management Future: All Addictions CASH, Access 1 5g) Supportive housing/icm/actt successfully placed/housed CHC 5a) Percentage of clients newly registered to the CHC in the past year over number of total clients. 5b) Length of time clients have been receiving primary health care at the CHC stratified by those with chronic conditions (0-3, 3-7 and 7+ years). All CHCs CHC data 12

13 6. Percent of identified patients with complex high care needs that are targeted/receiving appropriate care Sector Hospital CSS No indicators Sector Specific Indicators 6a) Number and percent of resident ED visits due to behavioural issues 6bi) referral applications denied by reason for denial (include special care needs and others) (i.e. not able to get appropriate care in H). 6bii) Percent of applications with behavior special needs denied admission to (new BSO indicator) 6c) referrals bypassed by bypass reason (e.g. Behaviour, special care needs, others) Future consideration 6d) residents who died in the home (proxy of end of life care) (Explanatory) No indicators Subsector Reporting & Data source All Facilities CCRS-, NACRS RMR RMR CCAC 6) Clients placed in with MAPLe scores high or very high as a proportion of total clients placed CCAC data CMHA CHC No indicators 6a) Inter-professional care for clients with chronic health conditions. % of clients with 2 or more chronic conditions who received services from health care providers other than MD\ NPs. 6b) Regular testing that is appropriate for diabetes patients: HbA1C within 12 months - % with at least 2 tests Retinal examination within 24 months - % with at least 1 exam LDL cholesterol within the past 12 months - % with at least 1 test 6c) Influenza Vaccination Rate, stratified by clients who are pregnant, children 6 months-4 years, seniors 65+, defined chronic conditions) 6c) Periodic Health Exam Rate, stratified by those with chronic conditions (type 2 diabetes, schizophrenia, bipolar and/or borderline personality disorder) All CHCs CHC data and ICES databases MSAA indicator data *All sectors initiated discussion related to this indicator and identified potential complex populations. These will be further refined and presented at future date. 13

14 List of Acronyms Acronym Full Name Acronym Full Name ACTT Assertive Community Treatment Teams HQO Health Quality Ontario ASH Addictions Supportive Housing ICES Institute for Clinical Evaluative Services CASH Coordinated Access for Supportive Housing ICM Intensive Case Management CATCH Coordinated Access to Care from Hospital IHI Institute for Healthcare Improvement CCAC Community Care Access Centres LDL Low Density Lipoprotein CCRS Continuing Care Reporting System Long-Term Care CHC Community Health Centre MAPLe Method for Assigning Priority Levels CHRIS Client Health and Related Information System MHA Mental Health and Addictions CIHI Canadian Institute for Healthcare Information MOH Ministry of Health and Long-Term Care CMG Case Mix Group MSAA Multi Service Accountability Agreement CMHA Community Mental Health and Addictions NACRS National Ambulatory Care Reporting System CNAP Community Navigation Access Program NLOT Nurse Led Outreach Teams COPD Chronic Obstructive Pulmonary Disease NRC Picker National Research Corporation Picker CSS Community Support Services OCAN Ontario Common Assessment of Need CTAS Canadian Triage and Acuity Scale RM&R Resource Matching and Referral DAD Discharge Abstract Database SH Supportive Housing eadp Enhanced Adult Day Program TC LHIN Toronto Central LHIN ED Emergency Department TCAT HBA1c Hemoglobin A1c Toronto Community Addictions Treatment 14

15 Description of Databases Used For Quality Indicators Data Source Patient Experience Surveys NRC Picker Hospitals Canadian Institute for Health Information: National Ambulatory Care Reporting System (CIHI NACRS) Canadian Institute for Health Information: Discharge Abstract Database (CIHI DAD) Ontario Mental Health Reporting System (OMHRS) Hospital Databases Community Mental Health and Addictions Coordinated Access for Supportive Housing (CASH) Access 1 Description NRC Picker Canada (NRCC) is focuses on healthcare measurement and improvement solutions across the continuum of care. They have different surveys for different sectors e.g. Acute inpatient, Emergency department, rehabilitation, complex continuing care (CCC), Long term care and home care. They help health care organizations to conduct patient/family and employee surveys that can highlight an organization s strengths or problem areas. Includes information on use of hospital EDs, including, number of visits, clinical characteristics of patients, length of stay, discharge disposition, etc. Includes information on hospitalizations to acute care hospitals, including, number of admission, clinical characteristics of patients, length of stay, ALC, discharge disposition, etc. Includes information on hospitalizations to adult mental health and addiction beds, including, number of admission, clinical characteristics of patients, length of stay, assessments conducted, ALC, discharge disposition, etc CASH Database was established in November, 2009, and includes data for 29 supportive housing providers who provide supportive housing services in Toronto Central LHIN. CASH is a central access hub to supportive housing in Toronto. The key functions of the hub are: Information and referral, assessment and triage, match coordination, waitlist management and coordination, monitoring of services. CASH database includes information on the different functions of the hub. Access 1 is a central access hub for Intensive Case Management (short-, long-term) in York Region and Toronto Central LHIN. The hub provides the following functions: Information and referral, Faceto-face Assessment and triage, Completion of OCAN, Match coordination, Waitlist management, Coordination, monitoring of services. The Access 1 database includes information on the different functions of the hub. 15

16 Description of Databases Used For Quality Indicators continued Data Source Transitions Resource Matching and Referral (RM&R) Primary Care Sector Community Health Centres (CHC) Data ICES Databases CCAC Community Care Access Centres (CCAC) Data Continuing Care Reporting System (CCRS)- linked data Description RMR focuses on transitions from different sectors across the healthcare system. It includes information on: Number of referrals, types of services applied for, characteristics of the patients, length of wait before acceptance into a program, outcomes of the process e.g Requests for information, Bypasses, Denials. Provides information on client demographics and service utilization data of CHC services in Ontario. Information includes: Number of clients served, Types of services received, Demographics, socio-economic data and clinical characteristics of clients. Provides information on clients receiving home care services. Information includes: Number of clients served, Types of services received, Demographics and clinical characteristics of clients. The CCRS- contains demographic, administrative, clinical and resource utilization information on individuals who receive continuing care services long-term care homes. The information includes: Number of residents served, Types of services received, assessment information, demographics and clinical characteristics of residents. H Daily Census homes track information on residents who go to acute care/ed on a medical leave of absence (LOA) in their databases. Community Support Services (CSS) Manual data collection of CSS agencies CSS agencies are collecting information on the number of clients who are being transferred to the emergency department or being admitted to admitted. 16

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