Frontenac, Lennox and Addington Health Services Restructuring. Report

Transcription

1 Frontenac, Lennox and Addington Health Services Restructuring Report Restructuring Report 1

2 Table of Contents INTRODUCTION AND BACKGROUND...1 SECTION I: REGIONAL AND COMMUNITY PROFILE...12 GEOGRAPHIC PROFILE...12 REFERRAL POPULATION...17 SOCIO-ECONOMIC INDICATORS...25 HEALTH EXPENDITURES...26 SECTION II: OVERVIEW OF THE CURRENT HEALTH SYSTEM IN KINGSTON...28 OVERALL HEALTH SERVICES...28 Overview of the Hospitals...29 BED CONFIGURATION AND CAPACITY...32 ACUTE INPATIENT UTILIZATION ANALYSIS...41 SECTION III: FRONTENAC, LENNOX AND ADDINGTON DISTRICT HEALTH COUNCIL HEALTH SERVICES REVIEW...51 Key Recommendations of the KFLADHC Steering Committee...52 SECTION IV: FRAMEWORK FOR EVALUATION OF RESTRUCTURING OPTIONS...56 SECTION V: DETERMINING CAPACITY REQUIREMENTS OF THE HOSPITAL SYSTEM...60 ACUTE CARE SERVICES...60 Acute Care Services in Lennox and Addington Counties...60 DETERMINING CAPACITY OF INPATIENT SERVICES-KINGSTON AREA HOSPITALS...63 Acute Inpatient Beds For Kingston...63 Operating Room (OR) Requirements...69 Emergency Room (ER) Requirements...71 Ambulatory Care & Day/Night Visits...71 REHABILITATION SERVICES...72 DETERMINING CAPACITY OF MENTAL HEALTH SERVICES...76 Determining Capacity Requirements for Acute Mental Health Services...79 Determining Capacity Requirements for Longer-Term Mental Health Services in Kingston...80 Determining Capacity Requirements for Forensic Services...85 Determining Capacity Requirements for Adolescent Mental Health...85 DETERMINING CAPACITY OF COMPLEX CONTINUING CARE...87 SECTION VI: FACILITIES REQUIREMENTS & ASSESSMENT OF EXISTING FACILITIES..91 Excess Capacity...91 Overall Facilities Assessment...94 Restructuring Report 2

3 SECTION VII: ASSESSMENT OF SITING OPTIONS...98 CRITERIA USED TO EVALUATE SITING OPTIONS...98 Siting of Inpatient Acute Care Services-Kingston Area Siting of Rehabilitation Services Siting of Short-Term Rehabilitation Beds Siting of Acute Mental Health Services SITING OF OTHER NON-ACUTE SERVICES Siting of Complex Continuing Care Services Siting of Longer-Term Mental Health Services Siting of Non-Acute Care Beds SECTION VIII : SITING OF HOSPITAL BASED ACUTE AMBULATORY CARE SERVICES IN KINGSTON The Kingston Model Current Scope of Ambulatory Services-Kingston HSRC s Deliberations on Academic Ambulatory Care SECTION IX: LONG-TERM CARE SECTION X: GOVERNANCE AND MANAGEMENT OPTIONS Management and Governance of Mental Health Services Regional Rehabilitation Network Human Resources Impact An Integrated Health Care System SECTION XI: RESTRUCTURING IMPACT--SAVINGS, COSTS AND REINVESTMENTS Savings Human Resources Impact ESTIMATED REINVESTMENTS TO ADDRESS RESTRUCTURING Home Care Information Systems and Technology SUMMARY OF REQUIRED REINVESTMENTS CAPITAL INVESTMENT SECTION XII: SUMMARY OF RECOMMENDATIONS CLINICAL SERVICES Summary of Clinical Services Changes APPENDIX A: METHODOLOGY APPLIED TO DETERMINE SEX AND AGE ADJUSTED RATES PER 1000 RESIDENT POPULATION APPENDIX B: SUMMARY OF REVISED COST SAVINGS ESTIMATION METHODOLOGY APPENDIX C: CAPITAL ESTIMATES Restructuring Report 3

4 APPENDIX D: PLANNING FOR GROWTH Restructuring Report 4

5 INTRODUCTION AND BACKGROUND The Ontario health services system is facing its single greatest challenge since the inception of medicare. Increasing demand, changing patterns of practice, and new technologies coupled with limited resources must be addressed if we are to maintain and enhance a health care system that is among the best in the world. We must streamline administration, reduce redundant capacity, and improve clinical services delivery to ensure efficient and effective use of resources and improved linkages between sectors. These are some of the steps necessary to restructure the current system effectively. Only when they are accomplished can a true health services system emerge that will be responsive to the future needs of the population into the next millennium. In the seventies and eighties growth in the funding of health care services, hospital services in particular, exceeded both inflation or economic growth. Incentives to be innovative, particularly in addressing reduction and operating expenses, were few. This is in sharp contrast to the lower budgetary increases and reduced government funding that followed in the nineties, at a time when actual costs of providing hospital care were rising. This combination of circumstances and technological improvements provided the incentive for significant restructuring of service delivery system in order to meet increased service requirements within the resources available. There has been a long-standing tradition of cooperation between the hospitals in the Kingston area. For example, since 1975, Hotel Dieu and Kingston General hospitals have a combined emergency medical staff and an academic department of emergency medicine operating on two sites. More than a decade ago the two acute care hospitals in Kingston and the Queen s University formed the Southeastern Ontario Health Sciences Centre (SOHSC). Over time its membership expanded and now includes Hotel Dieu Hospital, Kingston General Hospital (KGH), Providence Continuing Care Centre, Kingston Psychiatric Hospital (KPH), Kingston, Frontenac, Lennox & Addington Community Care Access Centre and the Kingston, Frontenac, Lennox & Addington Public Health Unit. This Health Sciences Centre has made unique contributions to restructuring of health care delivery in Ontario. In particular, it is the first health sciences centre in Ontario to put all of its academic physicians on an alternative funding plan (AFP). Dating from 1994 this AFP arrangement has eliminated the fee-for-service funding of academic physicians. Most specialty and sub-specialty physicians clinical work within the Kingston area is now funded under this model. The AFP model has provided opportunity to explore comprehensive provision of hospital services that address clinical, educational and research needs. 1

6 Kingston hospitals facing reduced resources and changing demographics of the population in the years to come, have seen the need for further restructuring to improve patient care delivery. In spring of 1996, the boards of the Kingston General Hospital (KGH), Hotel Dieu and St. Mary s of the Lake (SMOL) hospitals along with the Faculty of Health Sciences, Queen s University, created the Remodelling Implementation Group whose mandate was to advise the boards on ways to enhance provision of health care and to prepare better health care professionals for the future. Significant realignment and consolidation of services was recommended by this group and implementation is currently under way. As of April 1, 1997, all inpatient acute care services with the exception of acute psychiatry was transferred from Hotel Dieu to the Kingston General site and all rehabilitation care was consolidated (with transfer of rehabilitation beds from KGH) at St. Mary s on the Lake. The Hotel Dieu presently provides ambulatory care services with 14 hour walk-in emergency and acute inpatient mental health beds. The Kingston Frontenac Lennox and Addington District Health Council (KFLADHC). The DHC s first consultation report, Charting the Course(July 1997) called for significant restructuring of clinical activities and roles played by various hospital sites, most of which the hospital were already implementing through their own initiatives. The Frontenac, Lennox and Addington health services system has been innovative and adaptable to the changing circumstances as dictated by the more limited availability of resources and changing population health service needs. This is a tribute to the leadership of the hospitals, university, district health council, physicians, community and other providers. This report addresses the deliberations and conclusions of the HSRC with respect to health services restructuring in Frontenac, Lennox and Addington and other southeastern Ontario communities that its serves. HSRC Mandate and Terms of Reference Bearing in mind the magnitude of the task and the limited time and funds available, the HSRC will function in accordance with the following terms of reference. 1. To discharge its mandate, the HSRC will: Make decisions on restructuring of hospitals by directing or recommending to the Ministry of Health hospital closures, amalgamations, program transfers and any other actions considered necessary to implement hospital restructuring. Make recommendations to the Minister of Health on how to improve the efficiency and effectiveness, including cost-effectiveness, of other elements of the health services system including provincially operated 2

7 psychiatric hospitals, while maintaining or enhancing the quality of services provided. Identify areas for reinvestment in communities that will lead to the development of a comprehensive, integrated community, district and regional health system. 1. The HSRC s work plan will be undertaken quickly, meeting a schedule to discharge its mandate within four years. 3. Options for change will be evaluated against three broad criteria: maintenance or enhancement of quality of services maintenance or enhancement of accessibility to service, and affordability. The current need to rationalize, consolidate and better integrate health services in Ontario means that difficult decisions must be made about how to restructure the health care system. The goal is a system that continues to provide high-quality services to patients while becoming more fully integrated. This is one of the major assumptions underlying all of the Commission s deliberations. In January 1997, the HSRC released a vision statement of what it believes the future health services system will look like. The vision statement describes a system that is characterized by improved integration and coordination, organized geographically but managed locally in concert with provincially developed policies, goals and objectives. It is a system that recognizes that constantly improving technologies and changing patterns of practice are reducing the need for institutional care even as demand increases for other levels of care, including community-based health services, because of changing demographics and consumer expectations. As a working hypothesis the vision statement is intended to provide a context for HSRC s restructuring decisions and recommendations, and to stimulate broad public discussion that will help to refine the health services system. Historically, health care has been a fragmented sector. In fact, the difficulties of the current care non-system have been well-recognized: silos of funding, structure and policy tend to build rigidity and fragment care. Government policy and funding envelopes for example, can contribute to the placement of patients in levels of care that they do not require and deny them easy access to those they do. They can also frustrate new initiatives and services that offer better alternatives to the status quo. The HSRC believes that much of this fragmentation will be reduced with the current trend toward greater vertical and horizontal integration of providers and sectors into systems (described in our vision statement as 3

8 integrated health systems -- IHSs) capable of offering the full continuum of care while shifting resources as appropriate to meet real needs. While the HSRC believes that integration is essential to system-building, it also acknowledges the importance of diversity in each sector s components. The objective is not to make all hospitals or long-term care facilities the same. Integration need not stifle diversity or distinctiveness, nor result in organizational consolidation. Integration does, however, require compromise, shared vision and values, and a willingness to pursue the common goal of improved health outcomes and health care. As integration is essential, so is diversity an element that has been carefully considered in our review of the Frontenac, Lennox and Addington health care system. A high level of commitment and a high degree of change are needed to alter the current level of organizational and provider autonomy that will allow us to advance from today s relationships to tomorrow s integrated systems. While the HSRC has not underestimated the magnitude of this challenge it is also aware that preserving the status quo is not in anyone s interest. The HSRC believes that the notices of intention to issue directions being released in Frontenac, Lennox and Addington will allow the health care partners to proceed with a plan for a sustainable service delivery model. This model is characterized by a strong hospital system and a strongly integrated health system capable of meeting the future needs of the community within the financial resources available. The HSRC is of the opinion that the changes for Frontenac, Lennox and Addington, as outlined in the accompanying notices of intention to issue directions, will continue a process of coherent, constructive change, renovation and modernization. The HSRC Process The role of the HSRC is to make decisions about health system reconfiguration and restructuring based on three prime criteria: quality of care, accessibility to care, and affordability of care. Given the current fiscal environment, quality and accessibility will suffer unless significant changes are made in the delivery of services. Sensible planning to restructure hospital and related services is the starting point. The major objectives of the HSRC are to ensure accessibility and high quality health care, to reduce expenditure on overhead and administration, to reduce duplication and redundancy, to focus resources on direct patient services, and to reinvest in those areas where needs dictate. Perhaps more fundamental to its decision-making is the organization of health services to improve the critical mass and clinical coherence of programs and services to maximize benefits to patients and providers. Organizing and sizing services to improve accessibility are also cornerstones of HSRC decision-making. 4

9 A leading objective for the HSRC is to create a hospital system in Frontenac, Lennox and Addington the components of which work cooperatively to provide the residents and the referral populations with the best services. At the same time this system must be set up to provide the foundation of an integrated health system to meet the health services needs of the region. The HSRC has addressed issues of a regional nature such as long-term inpatient mental health services and the needs for inpatient rehabilitative services in the southeast region. The lead commissioner involved in the review was Harri E. Jansson, and Rob Williams was an accompanying commissioner. At the start of its review in Frontenac, Lennox and Addington, the HSRC invited persons and organizations to provide input and, as a result, received a number of written briefs from persons and organizations in Frontenac, Lennox and Addington, both within the health care sector and outside it. In mid-november, 1997 the lead commissioners, the HSRC chief executive officer and senior staff met with the Kingston, Frontenac Lennox and Addington District Health Council, administrators, board members, physicians, professionals, labour representatives and others in an effort to better understand the issues affecting and interrelationships among the Frontenac, Lennox and Addington hospitals and other health services in the region. Using the material collected and applying up-to-date planning and efficiency benchmarks, the HSRC built on the DHC s comprehensive report and developed its recommendations for the hospital system. The HSRC is encouraged by the degree of cooperation among the various hospitals and Queen s University and commends them and other stakeholders for their commitment to restructure the hospital system to meet the needs of the community in the future. As in other centres, the HSRC has made its recommendations based on the best available data and analysis, community input and recommendations, never losing sight of its three primary criteria of quality, accessibility and affordability of health services. Updating the data, analyzing the information, and assessing the available options are major activities that the HSRC has undertaken as part of its decision-making process. The HSRC s decisions recognize and address the particular aspects of the Frontenac, Lennox and Addington health care system and its leadership role in serving the needs of the southeast Ontario community. The decisions are focused on the development of a hospital system that will serve the needs of Frontenac, Lennox and Addington for years to come. To this end the recommendations for a restructured hospital system take into account the expected population growth rate for the region to

10 Purpose and Overview of the Report The results, decisions and directions to the hospitals are detailed in the following pages. While building on the work of the KFLADHC, the HSRC has used the experience gained in other communities to strengthen the efficiency methodologies that will be applied to Frontenac, Lennox and Addington and gain additional efficiencies. To achieve the directions laid out in this report will require the dedication, commitment and hard work of all stakeholders. The recommendations balance quality, accessibility and affordability in a comprehensive approach to the future configuration of the health care delivery system in Frontenac, Lennox and Addington. The structure of the report is as follows: Section I provides a regional and community profile of Frontenac, Lennox and Addington and includes key demographic, health status and socio-economic data related to the population. Section II provides a broad overview of the current health care delivery system and an analysis of costs, clinical/utilization rates and supply requirements. Section III provides summaries of the Frontenac, Lennox and Addington District Health Council s deliberations. Section IV outlines the framework and decision criteria for assessment of options that the HSRC considered during its review process. Section V outlines beds and other resource requirements to Section VI gives an overview of facilities assessment. Section VII assesses siting options for hospital services for Section VIII outlines the academic ambulatory care centre. Section IX outlines long-term care requirements. Section X outlines governance and management changes. Section XI outlines the capital investment requirements for restructuring, and the reinvestment requirements to lessen the effects of restructuring and address gaps in current services. Section XII outlines the summary of the HSRC s decisions and intended directions. 6

11 SECTION I: REGIONAL AND COMMUNITY PROFILE Geographic Profile Frontenac, Lennox and Addington counties cover an area of 6,660 square kilometres and are located in the southeast region of Ontario. These counties are bordered by Hastings county to the west, Lanark, Leeds and Grenville counties to the east and Renfrew county to the north. Resident Population The 1996 census population of Frontenac, Lennox and Addington counties was 180,704. The greater Kingston area, located in south Frontenac, is the major urban centre in the district. The City of Kingston contains 34% of the total district population. The second largest township is Napanee with a population of 5,180. Napanee is located in southwest Lennox and Addington counties. Most of the district s population is located in the south, with northern areas being sparsely populated. Population Projection A population projection is an estimate of what the future population might be, given alternative plausible assumptions about fertility, mortality and migration. It is difficult to predict population size beyond the most recent census years. In the past, the HSRC planning framework relied on Ministry of Finance projections which were based on the 1991 census and generally overestimated growth in different areas of Ontario. The population projection reported in the next section is obtained from Statistics Canada, based on the 1996 census (adjusted estimate) it provides a more accurate growth rate for different areas of Ontario. For instance based on the new projections the growth rate for the province between 1995 and 2003 is estimated to be 10% as opposed to 12% reported previously using Ministry of Finance projections. The following graph depicts the differences in growth rates in various areas throughout the province from 1995 to Percentage Change in Population (1995 to 2003) County Ontario Frontenac/L&A Hastings/Prince Edward Waterloo GTA 905 Essex Ottawa-Carleton R.M. Middlesex 4.0% 5.6% 6.3% 8.6% 10.2% 10.7% 11.6% 19.7% 0.0% 2.0% 4.0% 6.0% 8.0% 10.0% 12.0% 14.0% 16.0% 18.0% 20.0% Percent 7

12 Based on Census Canada projections, between 1995 and 2003 (see table 1), the population of Frontenac, Lennox and Addington (FL&A) is expected to grow by 6.3% as compared to the provincial average growth forecast of 10.2 % for Table 1: Population Projections, Year Frontenac, Lennox and Addington Province ,762 11,097, , ,097 % increase 6.3% 10.2% Source:1996 Census Data The projected population growth rate in Frontenec, Lennox and Addington is less than many other counties including Essex, Ottawa-Carleton and Waterloo, and slightly higher than Middlesex (London). Table 2: Growth by Age Group for Frontenac, Lennox & Addington & Ontario AREA YEAR Total Frontenac, Lennox ,287 82,099 38,353 14,394 9, ,762 and Addington ,689 85,020 43,526 14,084 12, ,237 % increase/ decrease (-) 1.1% 3.6% 13.5% -2.1% 34.1% 6.3% Ontario ,235,708 5,196,778 2,320, , ,366 11,097, ,352,078 5,520,471 2,801, , ,088 12,233,097 % increase 5.2% 5.2% 20.7% 3.9% 34.0% 10.2% Source: Ministry of Health population projection, The population projections for Frontenac, Lennox and Addington counties to year 2003 indicate a projected decline of 2.1% in the age group when compared to an overall increase of 3.9% for the province(see table 2). For all age categories with the exception of the 75+ age group, Frontenac, Lennox and Addington counties exhibit lower growth rates than the province as illustrated in the chart on the next page. 8

13 Percentage Change in Age Groups (1995 to 2003) Total 75+ age group Ontario Fron,L&A -10.0% 0.0% 10.0% 20.0% 30.0% 40.0% Inmates in the district institutions are included in the census data and the 1991 census noted 4,500 inmates in the Kingston area. The census data does not capture many students who attend post-secondary institutions in Kingston as they are enumerated elsewhere. The KFLADHC has estimated that more than 75% of students attending Queen s University, the Royal Military College (Kingston) and St. Lawrence College are from outside of the district and account for an additional 16,586 residents who need to be added to the population that use health services. Student population is not included in census data. Referral Population The referral population is the number of persons, regardless of where they live, who receive care in Frontenac, Lennox and Addington counties. Referral population is assigned to a hospital, based on a relative share of inpatient separations (i.e., discharges, transfers, deaths, sign-outs) for a given county/region attributable to that hospital. In , the referral population of Frontenac, Lennox and Addington was 213,676 compared to the resident population of 178,762. This indicates that the region s hospitals serve a significant number of residents from surrounding communities. Inflow/Outflow Analysis The net inflow/outflow is the difference between the utilization of inpatient acute hospital services by county residents and the provision of these services by county hospitals. Table 3 shows that 54% of the separations from Kingston hospitals were from outside the region. These patients used Kingston hospitals for a range of secondary and tertiary services such as cardiovascular surgery, neonatology, trauma and major cancer procedures. 9

14 Table 3: Net Inflow to Kingston Hospitals for Inpatient Activity ( )* Separations % of Total Days % of Total Total Frontenac patients 14, % 89, % Total from other 17, % 151, % jurisdictions Total of above 31, % 240, % Source:S *(excludes newborn, acute psychiatric and non-ontario residents As table 4 shows, a majority of Frontenac county patients get their care in Kingston hospitals. Since Kingston is an academic health sciences centre, it is a regional referral source for the surrounding areas such as Lennox and Addington, Hastings, Prince Edward and Lanark counties. Table 4: Usage of Kingston Hospitals by Residents of Southeast Ontario( ) County of Residence % Separations % Days Frontenac 94% 96% Lennox and Addington 56% 54% Hastings 12% 15% Prince Edward 18% 18% Leeds & Grenville 22% 23% Lanark 5% 4% Source: S Frontenac (Kingston) County Separations By Place of Residence, Other 6% Frontenac 94% Source: S Lennox and Addington County Separations By Place of Residence

15 Other 5% Lennox & Addington 36% Frontenac 56% Hastings 3% Source: S Lennox and Addington county residents used Kingston hospitals for most of their inpatient care (56%), indicating a strong referral link to Kingston. Of all Lennox and Addington county residents hospitalized in , 36% received care in the county s only hospital located in Napanee. Health Status Profile Standardized Mortality Rates Standardized mortality rates, proportion of low birth weights and infant mortality rates are some of the health status indicators used to gauge a community s health status. Table 5: Standardized Mortality Rates For Selected Categories Frontenac County. Standardized Mortality Rates 1 Selected Categories Neoplasm Mental Disorders* All Ischemic Diseases Circulatory System Psychosis Nervous System & Sense Organs *Rates are Standardized so that the Ontario average equals one. Source: Public Health Branch, Ministry of Health 1 Standardized mortality rates (SMR) are used when comparing mortality and morbidity of a district with that of the province. This statistic is a ratio of the observed total rate in the area over the expected total rate of the province. 11

16 Table 6: Standardized Mortality Rates Year Frontenac, Lennox and Addington SMRs All Main Causes Source: MOH The mortality indicators shown in tables 5 and 6 suggest: that relative to the province as a whole, mortality due to ischemic disease is high in Frontenac Lennox and Addington counties that mortality rate for circulatory diseases is lower in the two counties relative to the province as a whole that mortality due to nervous system diseases is particularly elevated in Frontenac, counties compared to the provincial rates. that relative to the province, mortality due to mental disorders and psychosis over the five year period noted is much higher for Frontenac, Lennox and Addington than the province as a whole Frontenac, Lennox and Addington counties have a slightly higher overall Standardized mortality rate than the provincial average. Infant Mortality and Low Birth Weight The percentage of low birth weight babies is an indicator of the level of both maternal and infant health. It also reflects the level of general reproductive health in a community. In the past five years of available data ( ), the low birth weight rate for Frontenac, Lennox and Addington counties was generally similar to the provincial average. As shown in table 7, the infant mortality rate for same period from was slightly higher for Frontenac, Lennox and Addington counties than the provincial average. This elevation may not be statistically significant however, as the actual numbers of infant deaths were small (14 to 29 per year). 12

17 Table 7: Infant Mortality (per 1,000 live births) and Low Birth Weight Frontenac, Lennox and Addington Infant Mortality Rate % Low Birth Weight Ontario Infant Mortality Rate % Low Birth Weight Source: Mortality and Morbidity Reports, Ministry of Health The percent of low birth weight is generally higher than the provincial average except for 1993 year. Socio-Economic Indicators Unfortunately, census 1996 data on socio-economic indicators was not available at the time of writing this report. The socio-economic profile of Kingston residents differs from that of Ontario as a whole. There is a smaller proportion of residents with less than grade 9 education and a lower proportion of people earning low incomes. Table 8: Socio-Economic Indicators in Frontenac, Lennox and Addington Counties Indicators Kingston Ontario Unemployment Rate 5.5% 8.5% Labour Force Participation Rate 68.6% 69.6% Less than Grade 9 Education 8.8% 11.5% Prevalence of Low Income 9.7% 10.9% Mother Tongue Other than English or French 6.1% 17.7% Source: Statistics Canada., 1991 An overall review of demographic, health status, and socio-economic indicators reveals Frontenac, Lennox and Addington as having lower unemployment rates, less prevalence of low income while measures of health status such as low birth weights are less favorable than those of the province overall. These data should not be viewed as indicators of the appropriate level of resources, utilization of services or need. They are provided strictly for comparative purposes and should not be assessed in isolation from a more complete analysis of the region s health system. Health Expenditures A comparison of overall provincial health expenditures for Frontenac, Lennox and Addington counties (Kingston) versus Hamilton, Metro Toronto and the province suggests that, on a per capita basis, the level of funding is higher in Kingston than Toronto, Hamilton and the province as a whole. The per capita expenditure in mental health is almost double 13

18 the provincial average and more than double that of Toronto. This may be a reflection of a higher proportion of elderly people in Kingston, the high prison population and the presence in Frontenac, Lennox and Addington of a provincial psychiatric hospital. Table 9: Comparison of Health Expenditures (Per Capita, 1993/94) Ontario Frontenac, Lennox & Hamilton Metro Toronto Addington Health Expenditures $1,551 $2,418 $2,147 $2,157 Hospital & Related $718 $1,104 $1,118 $1,049 Facilities OHIP Expenditures $449 $646 $532 $714 Long-Term Care* $178 $235 $197 $163 Mental Health Services $65 $275 $105 $50 Drug Programs $89 $134 $108 $108 *Includes Extended Care, Home Care Assistance, and Placement Coordination Services Source: Ministry of Health 14

19 SECTION II: OVERVIEW OF THE CURRENT HEALTH SYSTEM IN KINGSTON Overall Health Services Frontenac, Lennox and Addington counties have a multitude of health services including: approximately 559 practicing physicians general practitioners and 330 specialists one community health centre (North Kingston CHC) and one health service organization (HSO) :the Sharbot Lake Family Medicine Centre a department of public health a Community Care Access Centre three homes for special care 13 mental health group homes with a total of 73 beds six nursing homes with a total of 476 beds four homes for the aged with a total of 649 beds. the Kingston Regional Cancer Centre a provincial psychiatric hospital a private 18-bed psychiatric hospital a chronic care/rehabilitation hospital, St. Mary s of the Lake two acute care teaching hospitals a community hospital : Lennox and Addington County General two walk-in clinics 13 independent health facilities all located in Kingston several other health care services. Hospital Services Overview of the Hospitals There are six hospital organizations in the district. Table 10 outlines the type of ownership and the 1997/98 budget of these hospitals. All hospitals are located in Kingston with the exception of Lennox and Addington County General Hospital (LACGH) which is located in Napanee. A map showing the locations of the hospitals is provided on the next page. 15

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21 Table 10: KFLA District Hospital System, Ownership and Budget Hospital Ownership budget (in millions) Kingston General Public Board $132.2M $96.4M Hotel Dieu Religious Hospitallers of St. Joseph of Hotel Dieu $42.2M $44.2M Kingston Psychiatric Hospital (KPH) St. Mary s of the Lake (SMOL) Institute of Psychotherapy (IP) Lennox and Addington County General Hospital (LACGH) Provincial Government $33.9M $33.9M Religious-Sisters of $24.5M $19.7M Providence Private $0.6M $0.6M Public Board $9.4M $7.9M Total $242.8M $202.7M Source: Hospital Operating Plans MOH Revenue (in millions) All five hospital sites in Kingston are located within three kilometres of each other. Kingston General and Hotel Dieu hospitals are acute care hospitals. St. Mary s of the Lake Hospital (SMOL) is a chronic and rehabilitation hospital, and Kingston Psychiatric Hospital (KPH) is a provincial psychiatric hospital. The Institute of Psychotherapy (IPH) is an 18- bed private psychiatric hospital. Bed Configuration and Capacity The current configuration of beds in Kingston hospitals, staffed and operated as of March 1996, is presented in table 11. This configuration varies slightly from the total potential bed capacity at specific sites, an issue addressed more fully in Section VII. 17

22 Table 11: Configuration of KFLA Hospitals ( ) Bed/Service Category Kingston General Hotel Dieu SMOL KPH IPH LACGH Adult Acute Paediatrics Complex Continuing Care Acute Mental Health Longer-Term Mental 256 Health Rehabilitation Forensic 30 TOTAL BEDS Weighted Cases 28,834 12,925 2,170 Operating Rooms Emergency Visits 39,184 42,022 29,666 Total Surgeries 15,519 9, Day Surgery 9,441 6, % Day Surgery 61% 67% 72% Amb. Care Visits 123,559 86,069 3,201 59,068 31,028 Day/Night Visits 24,437 2,320 2, Total Births 2, Source: Operating plan 1997/98 and CIHI data Overview of Clinical Activity Table 12: Weighted Cases by Level of Care,-Kingston Hospitals ( ) Hospital Primary % of Total Secondary % of Total Tertiary % of Total Total Inpatient Wt. Cases KGH 7,731 8,561 10,089 (29.3%) Hotel Dieu 4,973 (43.7%) Source: CIHI Inpatient Abstract, 1995/96 (32.5%) 4,484 (39.4%) (38.2%) 1,924 (16.9%) % of Total Wt. Cases 26, % 11, % The Kingston General Hospital has a higher proportion of tertiary cases largely due to its role as a regional centre for trauma, cardiovascular surgery, neonatology and cancer surgery. Current ( ) Hospital Program Configuration As noted in Section I, hospitals in the Kingston area, along with the Faculty of Health Sciences at Queen s University, have made significant headway towards integrating programs and rationalizing services. Some examples include the alternate payment plan for all academic physicians and shared clinical department heads. 18

23 In response to fiscal constraints imposed by the government and to meet the challenge of providing more relevant training to medical and health sciences students, the hospitals in Kingston initiated a major planning exercise. On July 31, 1996 the Remodelling Implementation Group released the document, Changes For A Healthy Future. This report recommended a reallocation of programs and changing roles among Hotel Dieu, Kingston General and St. Mary s of the Lake hospitals. In summary, the role and program changes entailed the following: Hotel Dieu would become the main entry point into the hospital system, operating as the Health Sciences Diagnostic Centre, as well as, providing acute ambulatory programs and acute inpatient psychiatry services. Kingston General would consolidate and enhance its existing role in providing acute inpatient care, critical care and emergency services including trauma. St. Mary s would retain its role in geriatric and continuing care and enhances its rehabilitation role by consolidating all inpatient rehabilitation to this site. The Remodelling Implementation Committee has developed a joint management process to implement the recommendations. As of April 1997, all inpatient acute care services except acute psychiatry has been consolidated at the Kingston General Hospital. Acute psychiatry has been consolidated at the Hotel Dieu site. Emergency services have been rationalized with the KGH site providing full 24-hour emergency capacity and the Hotel Dieu site with 14-hours walk-in emergency services. Ambulatory services are in the process of being consolidated to the Hotel Dieu site. In the past two years, in Lennox and Addington counties, considerable thought has been given to reorganize services between the Lennox and Addington County General Hospital (LACGH) and the adjacent Lenadco Home for the Aged managed by the county. The county council and the Hospital trustees have developed a strategy that with time would lead to full amalgamation of the two facilities under one management. LACGH has applied to the Ministry of Health to become a pilot site for primary care reform. Academic Medicine (Research and Education) Activities Education and research activities, as in other academic health sciences centres, are intertwined with the clinical activities of all of the hospitals in Frontenac county. The Queen s University Faculty of Health Sciences, St. Lawrence College, the OCTRF Kingston Regional Cancer Centre, KFLA Community Care Access Centre, KFLA Health Unit and all the hospitals in Kingston (KGH, KPH, SMOL and Hotel Dieu) have together formed the Southeastern Ontario Academic Health Sciences Centre. 19

24 The Centre has been instrumental in the introduction of initiatives to reduce costs while maintaining and enhancing patient care. Included among these initiatives are: coordination and consolidation of support services clinical utilization improvements including current work on common evidence-based clinical pathways coordination of services between members. Through affiliations with both Queen s University and St. Lawrence College, the Kingston hospitals provide clinical placements for students in a variety of health disciplines including medicine, nursing physiotherapy and occupational therapy. Current enrollment in these educational programs (as noted in the KFLADHC report): Nursing: Queen s BSc.N..(4years) St. Lawrence RN(2years) St. Lawrence RPN(1.5years) 65 students/year students/year students/year Medicine: Undergraduate (4 years) 75 students/year Postgraduate (2-5yrs) 26 programs with a total of 258 physicians Rehabilitation: Occupational Therapy Physiotherapy 40 students/year 40 students/year The availability of a critical mass of patients and facilities to engage in education activities is also a strong element of HSRC decision-making in health services restructuring. The integration of research activities with the delivery of clinical services is a common feature of academic health sciences centres. The HSRC recognizes these important linkages and strives to preserve and enhance them. Both Kingston acute care teaching hospitals, St. Mary s of the Lake and Kingston Psychiatric hospitals have research programs. Several research initiatives have competed successfully for national and international grants. Some of their major research initiatives are outlined in the following report. 20

25 Summary of Externally Funded Research Areas Primary Hospital Affiliation Research Areas Hotel Dieu Clinical Research Groups: Gasteroenterology -9 research projects Rehabilitation-2 research groups Paediatrics-1 research project Psychiatry-1 research project Nursing research-2 projects Kingston General Clinical Research Groups: Haemostasis & Thrombosis Genetics/Pathology Oncology Photodynamics Bone Cements Development Group Clinical Mechanics Group Clinical Trials for Alzheimer and Epilepsy research Health Outcomes Research Critical Care Research Group Urology Research Group Cardiology Research Group Radiation Oncology Research Unit Group on Development and Aging St. Mary s of the Lake Several research projects in rehabilitation medicine, physiotherapy, geriatrics and palliative care Kingston Psychiatric Hospital Clinical research in psychiatry, psychopharmacology Source: KFLADHC Report Charting the Course-Associated Documents, July 1997 Acute Inpatient Utilization Analysis The HSRC conducted a comparative analysis of resource utilization to examine opportunities to improve the utilization of acute care hospital services. While the HSRC has not established a target rate for utilization of hospital services, it is of interest to understand utilization of resources in comparative terms and make observations about opportunities to improve utilization. Acute inpatient utilization can be measured in terms of separation and utilization rates. The HSRC has developed a model to compare those rates across the 21

26 province and provide an indicator of the services currently being delivered. While the model describes the rates for the province, for Ontario counties and regions, it does not indicate whether those rates are appropriate or inappropriate; the HSRC makes use of the model as background information and as an indicator that further research may be necessary. Separation Rates Provincial Separations per 1000 age adjusted population 101 Frontenac County Separation rates Thunder Bay District 132 (i.e., Sudbury Regional Municipality 116 hospitalization rates) provide a Hamilton-Wentworth Peel Region measure of the admission (or York Region Ottawa-Carleton Region separation) Durham Region 104 activity of residents in various Middlesex County Toronto Metropolitan Halton Region communities. The Essex County 118 separation rates identified here are determined by the number of separations in 1995/96 per 1,000 age-adjusted population (1996 census) 2. This rate is calculated before utilization improvements are considered, and is based on the population of Frontenac, Lennox and Addington regardless of where residents receive care. This rate will therefore differ from the ESI utilization rates of the hospitals which are utilized later in this section. The methodology used to develop the age sex rates is described in further detail in Appendix A. The comparison across several counties shows Kingston s separation rate is similar to all other health sciences centres, which are lower than the provincial average number of separations per 1,000 population. Initial analysis of admission (i.e., separation) rates indicated that the rates are related to a number of variables. Much of the variation is explained by differences in the age-sex composition of the population compared to that of the province. Standardizing to the provincial age-sex distribution allows for more appropriate comparisons. The HSRC is conducting a further analysis of the remaining variation in rates. A clearer understanding of the variation will be required if the province moves towards per capita funding models. The HSRC is undertaking further analysis to determine the relationship between hospitalization rates and 92 2 The separation rates illustrated differ from those shown in previous reports as the rates have been corrected to use recently released 1996 Census Canada population. The 1996 population as per Census is more accurate than using the 1995 Ministry of Finance projected population. Separation rates reported in previous HSRC report reflected Ministry of Finance projections based on 1991 census. 22

27 factors such as health status, physician supply, socio-economic indicators and geography, all of which may help to explain why academic centres have lower admission rates than nonacademic centres. The methodology that the HSRC used in its restructuring of the health care system does not involve significant changes in separations in Frontenac, Lennox and Addington or any other community. The conservable days associated with avoidable admissions (i.e., social/primary care admissions and ambulatory care indicated admissions) amount to less than 2% of total days provincially. Utilization Rates Patient days per 1000 age adjusted population Examination of utilization rates Provincial 628 considers the total Frontenac County 572 utilization of hospital Thunder Bay District 1,000 care by residents Sudbury Regional Municipality 844 within a geographic Hamilton-Wentworth 620 area, irrespective of Peel Region 516 where services are York Region 449 accessed. This Ottawa-Carleton Region 577 measure is Durham Region 660 calculated as total Middlesex County 510 patient days for Toronto Metropolitan Halton Region residents of the county/region Essex County 734 divided by the ,000 1,200 population adjusted for age and sex. The rates were calculated using 1995/96 patient days and the1996 census population. The rates differ from those described in earlier HSRC reports; 1996 census population data was used ( since Ministry of Finance 1995 and 1996 population projections overestimated population growth) along with the age and sex adjustments to control for variation in age across communities. For 1995/96, the utilization rate for Kingston was 572, lower than both the provincial average of 628 and most of the other four communities with health sciences centres. The utilization rate is a function of two aspects of acute inpatient hospital use: the rate of hospitalization (separations) and the average length of stay. 23

28 In fact, an equation for the utilization rate 3 may be written as follows: (Acute Separations X Acute Average Length of Stay) X 1000 Population (number) 3 Since a hospital s utilization rate is driven by these two factors, hospitals need to ensure that utilization management strategies are in place that monitor and where possible improve both length of stay and appropriate admissions. The previous two charts, Acute Separations, per 1000 age-adjusted population and Patient Days per 1000 age-adjusted population are useful tools when reviewing the health care status of the counties, since they provide a proxy for the health needs, and resource consumption of the population. However, their relationship to hospital performance is indirect. Since there is no municipality that receives all hospital care exclusively from one hospital, the rates are composites of the performance of all the hospitals that provide services to residents of the regions. All hospitals in Ontario see patients from outside their regions, and in some cases the number of patients from outside the region can be a significant portion of a given hospital s case load. Thus no region is exclusively dependent on a single hospital for care and no hospital provides care exclusively for residents of one region. For those hospitals that serve as referral centres, the cases from outside the region are frequently more difficult, (high end secondary, tertiary or quaternary) requiring resources or expertise that may be unavailable in the region. Each hospital s contribution to the region s separation and patient day rates varies depending on the type of cases seen by that hospital, and the hospital s relative efficiency. Further, the hospital s contribution to the region s rate may not reflect the hospitals overall performance; therefore there is a need to look at hospital-specific rates and county rates separately. At the hospital level, the HSRC continues to use the patient days per 1000 ESI (Expected Stay Index) referral population rate. The ESI is an adjustment, specific to each hospital, that reflects the differences in the age and case mix of the patients being served. The ESI adjustment is an indexed rate that is applied to the referral population of each hospital. The referral population for each hospital represents the total Ontario population served by the hospital 4. Hospitals with a preponderance of cases that are expected to have a longer length of stay than the provincial average will have an ESI greater than one (e.g., tertiary/quaternary referral hospitals). Hospitals that have a preponderance of cases with a length of stay less than the Ontario average will have and ESI of less than one( e.g. hospitals that are focused on primary care). For further information on the ESI adjustment please refer to the JPPC document Methodological Improvements in the calculation of 3 3 The acute utilization rate can also be calculated by multiplying the hospitalisation rate (separations per 1000 population) by the Average Length of Stay. 4 The referral population for hospital A is equal to a region s population times the percentage of that regions separations treated at Hospital A, summed for all regions in Ontario. 24

29 Hospital Referral Population and Utilization Rates. This distinction between the county or region age-and sex-adjusted rates and the ESI age adjusted rates is important. In Frontenac County, the patient days per 1000 age adjusted population is lower than the patient days per 1000 ESI referral population rate for hospitals in Kingston. This difference indicates that residents receiving care outside of Frontenac county, experience relatively less days in hospital than those inside the region. This may be due to differences in acuity or practice patterns. This difference may also be influenced by variations in the way the different rates are calculated. In conclusion, it must be noted that the HSRC uses neither rates to determine the appropriate level of care required for Frontenac, Lennox and Addington counties. The methodology that the HSRC uses to size the hospital system in Frontenac, Lennox and Addington counties is based on benchmarks for each case, rather than applying an aggregate rate that would be less precise. Per Capita Acute Care Expenditures Net Acute Per Capita Expenditures by County (1995/96) (age and sex adjusted) Provincial Frontenac Thunder Bay District Sudbury Regional Hamilton-Wentworth Renfrew Brant Ottawa-Carleton Kent Middlesex Lambton Leeds & Grenville United Essex As in its Hamilton and GTA reports, the HSRC undertook further study of the per capita funding for acute care services in Frontenac, Lennox and Addington. The HSRC methodology accounts for acute care expenses attributable to county residents regardless of where the care is delivered. The methodology does not reflect total hospital expenditures 25