Sub-Acute Care Capacity Plan

Transcription

1 Sub-Acute Care Capacity Plan Final Report Submitted to: Champlain LHIN Sub-Acute Capacity Planning Steering Committee Hay Group Health Care Consulting 121 King Street West Suite 700 Toronto, Ontario M5H 3X7 May, Hay Group Limited. All rights reserved

2 Contents 1.0 EXECUTIVE SUMMARY PROJECT OBJECTIVE AND APPROACH PROJECT SCOPE AND OBJECTIVE PROJECT APPROACH KEY PROJECT ACTIVITIES CURRENT STATE CURRENT SUB-ACUTE BEDDED CAPACITY APPLICATION OF THE REHABILITATIVE CARE ALLIANCE PLANNING FRAMEWORK TO CURRENT STATE CURRENT SYSTEM STATE KEY QUANTITATIVE FINDINGS CURRENT SYSTEM STATE KEY QUALITATIVE FINDINGS DESIRED FUTURE STATE AND PLANNING PRINCIPLES DESIRED SYSTEM CHARACTERISTICS WORKSHOP ADVICE - CHAMPLAIN LHIN SUBACUTE CAPACITY PLAN PROPOSED PRINCIPLES TO GUIDE DECISION MAKING PLANNING ASSUMPTIONS AND PROJECTED SYSTEM CAPACITY POTENTIAL IMPACT OF PROJECTED CHAMPLAIN LHIN POPULATION CHANGE KEY CAPACITY PROJECTION ASSUMPTIONS PROJECTED SYSTEM CAPACITY PROJECTED CHAMPLAIN SUB-ACUTE CARE SYSTEM COSTS INTERIM SURGE CAPACITY PLANNING IMPLEMENTATION CONSIDERATIONS IMPLICATIONS AND CRITICAL SUCCESS FACTORS ENABLERS AND CRITICAL SUCCESS FACTORS BEST PRACTICE LEARNINGS FOR MOVING TO THE IMPROVED SYSTEM OF SUB-ACUTE CARE GOVERNANCE OPTIONS FOR SUB-ACUTE CARE IN THE CHAMPLAIN LHIN APPENDIX A: LITERATURE REVIEW RE SUB-ACUTE SYSTEM MODELS APPENDIX B: LIST OF STAKEHOLDERS CONSULTED APPENDIX C: APPLICATION OF RCA LEVELS OF CARE APPENDIX D: QUANTITATIVE ANALYSIS RESULTS

3 1.0 Executive Summary To consider all rehab, CCC, convalescent and transitional beds, as well as any publicly funded community restorative care services Steering committee to make recommendations and ensure alignment with RCA planning framework The Champlain Local Health Integration Network (LHIN) engaged Hay Group Health Care Consulting to assist with the development of a region wide plan for sub-acute health services in an effort to establish a framework to support capacity planning for rehabilitative care. The project scope included approximately 875 rehabilitation, complex continuing care and convalescent and transitional care beds, including publicly funded community restorative care services. The plan was to be aligned with the Rehabilitative Care Alliance (RCA) Capacity Planning Framework. The goal was to develop a region-wide plan to guide the Champlain LHIN in its planning and execution of programming and services that allow timely access to sub-acute care and optimize patient outcomes. The project was led by The Champlain Sub-Acute Capacity Planning Steering Committee. The Steering Committee s role was to: 1. Provide leadership and strategic oversight for the Champlain Sub- Acute Capacity Plan; 2. Align the scope of the study with the Rehab Care Alliance Capacity Planning Framework as well as local issues which have been identified; 3. Ensure the study makes recommendations on the numbers and siting of sub-acute resources required to optimize access to these resources for those in need across the region; and 4. Optimize the utilization of these valuable resources through the development of tools and processes to improve coordinated access to these resources. The project included 41 individual interviews and focus groups, through which approximately 75 stakeholders were engaged and qualitative information was collected. These individuals were also invited to participate in a LHIN-wide sub-acute services planning workshop. Clinical service records from acute care hospitals, rehabilitation and chronic units, convalescent beds in long-term care homes, and home care services were used to describe the current patterns of population use of sub-acute care, and to identify opportunities to apply best practice guidelines and new models of care to project the future capacity of service that will be required in the Champlain LHIN in Analysis revealed that if sub-acute services continued to be provided as they are now, but to the projected larger and older Champlain population of the near future, there would need to be a $45 million Page 1

4 increase in funding and an increase of 156 sub-acute beds to respond to demand. This projected increase in beds and funding is not likely sustainable, as it is far in excess of the possible future hospital and health service funding increases that are anticipated. The projected bed need is also based on the assumption that that there are no opportunities to improve the organization or efficiency of the existing system. However, based on benchmarking standards and a review of other provincial and national sub-acute delivery systems, it appears that there are efficiencies that could be achieved in the current system to mitigate the demand pressures. Analysis revealed that these opportunities include: Improved coordination of access to, and distribution of, sub-acute care capacity. This will help ensure that bedded care is effectively and efficiently used within Champlain, and that communities across the region have more equitable access to both local and regional services. On average, patients admitted to Champlain LHIN rehabilitation units have the highest FIM scores (i.e. functional status) on admission of any LHIN in Ontario. They also have the lowest average improvement in FIM score during their rehabilitation stay, which is likely a function of the high FIM upon admission rather than the efficacy of rehabilitation therapies being provided. Thus, there are opportunities to shift some of the activation/ restoration patients out of designated rehab beds and into chronic or convalescent beds, thereby increasing the capacity for higher needs patients in rehabilitation beds. Champlain LHIN stroke and hip fracture patients have the greatest delay between ready for rehab and admission to a rehab bed. Best practice and comparisons with provincial benchmarks provides evidence that there is a need for increase inpatient rehab capacity for these patient groups, i.e. capacity over and above that generated by changes in the Champlain population. Champlain LHIN demonstrate one of the lowest rates of use of chronic beds for rehabilitation and the highest rate of use of chronic beds for long-term medically complex patients in the province. The high alternate level of care days in these beds contributes to the Champlain LHIN chronic beds having the longest average length of stay in the province. There appear to be opportunities to reduce these lengths of stay and ensure that chronic or medically complex patients are receiving care in the right care setting. Page 2

5 Very few sub-acute patients in Champlain are admitted or discharged to service on the weekend. The traditional 5 day a week operation leads to inefficiencies and extended patient stays. Expansion to a model that includes weekend admission, discharge, and service capacity will be needed in the near future to optimize use of these bedded resources. Champlain LHIN residents have had very low rates of in-home progression care, and access to in-home care has varied across the LHIN. Increased availability of in-home rehabilitation could reduce the pressures on bedded rehabilitative care in the future. A sub-acute capacity plan for 2019 is recommended based on the opportunities for optimization (listed above) revealed through careful analysis, the advice of system stakeholders and direction provided by the Sub-Acute Capacity Planning Steering Committee. The recommended plan: Increases the capacity of inpatient rehabilitation beds and consolidates the most highly specialized services at a single site in Ottawa. It also distributes higher volume, less specialized rehab capacity across the LHIN, using a regional hub model to maximize access. Suggests that most population growth and future need for sub-acute care can be accommodated within today s supply of rehabilitation and chronic care beds 1 in the LHIN if: Investments in in-home, ambulatory, and other community subacute care is made, including alternative housing and assisting living options The sub-acute system has improved access to long-term care capacity that exists, including, potentially, preferred or priority access to existing long-term beds in order to ensure flow within the sub-acute sector. Although no increase in long-term care capacity has been assumed, it is assumed that redistribution of services and investments to community based care will help patients remain longer in their homes. This will reduce the demand from the community for admission to long-term care, and result in improved access for hospital patients. There is a redistribution of capacity and redefinition of hospital sub-acute roles to more equitably provide access to bedded care across the LHIN 1 Ottawa is the exception, where the projected combined number of rehabilitation and chronic beds exceeds the current available combined supply. Page 3

6 Redistribution of roles includes greater reliance on convalescent units in LTCH for activation/restoration, and greater access to community hospices to help reduce the portion of Champlain residents who die in hospital Efforts to avoid and conserve unnecessary rehabilitation days are successful Lengths of stays are reduced to provincial averages, particularly in chronic beds, and ALC days are therefore significantly reduced. Acknowledges that efforts to reduce future demand for sub-acute services, through investments in earlier identification of at risk patients (particularly the frail elderly), broader availability of wellness and prevention strategies in the community, and prevention of decline by shifting to a restore and maintain function approach to care throughout the system is likely necessary. Increased attention must be paid to hospital acquired disability 2, and the portion of elderly patients in acute care who develop new functional limitations as a result of their acute care stay. There was agreement among stakeholders that while aggressive, these strategies are realistic and achievable with concerted, system level efforts. Redistribution of subacute resources will require careful planning over the next year. A number of enablers, such new mechanisms for accountability, investments in therapy staff capacity and capabilities, more centralized coordinating mechanisms and tools for communication and reporting, will be critical for success. Leadership and willingness to accommodate change for the benefit of the patients in Champlain will be essential. The proposed plan for distribution of sub-acute hospital beds across the LHIN is shown below: Program/Bed Type Eastern Counties Greater Ottawa Renfrew County Grand Total Regional Rehabilitation General/Geriatric Projected Rehabilitation Beds Current Designated Rehab Beds Gill TM, Allore HG, Holford TR, Guo Z. Hospitalization, restricted activity, and the development of disability among older persons. JAMA: the journal of the American Medical Association. Nov ; 292(17): Page 4

7 Program/Bed Type Eastern Counties Greater Ottawa Renfrew County Grand Total Additional Rehab Beds Required Projected Chronic Beds Current Designated Chronic Beds Additional Chronic Beds Required (16) (7) (22) (45) Required Change in Total Sub- Acute Hospital Beds (11.5) 32.6 (18.1) 3.9 The Eastern Counties and Renfrew County currently have enough combined rehabilitation/chronic beds to accommodate the projected requirement, although there will need to be a shift from chronic to rehab beds. Greater Ottawa will require additional rehabilitation beds, reflecting the greater growth projected in this region, and the proposed consolidation of specialized inpatient rehabilitation in Ottawa. The estimated increased cost of the proposed Champlain LHIN subacute care system by 2019 would be $17.3 million, with $5.6 million more for bedded care (after mitigation), and $11.3 million more for other services. This does not include a parallel increased investments in long-term care homes that will be required to meet the increased demand for long-term care resulting from population growth and aging. Long-term care capacity was not considered to be within in scope for this project, but it is a critical enablers of system flow and functioning. It is important to realize that this sub-acute capacity plan assumes that there will be sufficient (and potentially priority) access to long-term care beds for the general population (i.e. those long-term care beds that are not considered part of the sub-acute continuum of care). If general long-term care bed availability does not keep up with population growth and aging, long-term care will continue to be a bottleneck in the system, and this sub-acute capacity plan will be difficult to execute successfully. The proposed focus of the bedded capacity on the patients with the greatest needs for rehabilitative care will mean that the average intensity of care and cost per bed will increase. Implementing the new sub-acute plan will require effective coordination and system-wide oversight that doesn t exist now. It is likely that an oversight or implementation body with the following accountabilities will be needed for the next several years: Providing advice to the LHIN for the implementation of the new sub-acute capacity model Overseeing effective implementation of the new sub-acute capacity model, including: Page 5

8 Ensuring a balanced perspective and a coordinated, collaborative approach in developing and implementing the plan, including how sub-acute care fits with the broader planning and improvement/oversight structures and bodies already in place Planning the new approach at both the system and organization level Gathering information, advising on and developing new approaches, standards, processes, tools and policies that should be in place Advising on resource requirements to effectively execute the plan Overseeing implementation of the new plan, including operational and systems level changes Providing advice for more permanent structure that will be in place for continuing to plan, monitoring and evaluate the delivery of sub-acute care across the Champlain LHIN Advising on and advocating for future system changes and investments, such as a dementia care strategy and other upstream preventative approaches, that will be required to reduce the demand for sub-acute care over the longer term Terms of reference for governance and oversight of the new sub-acute model should be developed further, but likely will require: The LHIN to continue to direct and steward system level changes necessary, including changes to roles, resources, funding and accountability agreements as required. An executive committee with authority to make organization-level change across the system. This committee will be both advisory to the LHIN on the change required to implement the new plan, and will be responsible for overseeing the implementation of necessary organization and system level changes. An advisory group of sub-acute experts and stakeholders who will provide expert advice to the executive committee, and who will assist with implementing and executing operational changes required for implementation. Several specialized task groups may need to evolve within this working group. Implementation support, who will be a new resource to assist to organize and support the work of the executive committee and advisory/action groups during the transition period (at minimum). Page 6

9 The structure and authority of a more permanent sub-acute regional structure should be a recommendation of the executive committee after transition work is complete. Page 7

10 2.0 Project Objective and Approach Timely access to rehabilitative and restorative care Timely access to rehabilitation and restorative care is an important factor optimizing patient outcomes following illness, injury or functional decline, and in achieving safe, sustainable discharges for select patient populations. The Rehabilitation Care Alliance has been commissioned by the LHINs in Ontario to provide a common framework to support capacity planning for rehabilitative care. The Champlain LHIN, on the advice of the ED /ALC Steering Committee (April 27, 2015) agreed to review and develop a region-wide plan for sub-acute services. 2.1 Project Scope and Objective Develop a region-wide plan to facilitate timely access and to optimize patient outcomes To consider all rehab, CCC, convalescent and transitional beds, as well as any publicly funded community restorative care services Steering committee to make recommendations and ensure alignment with RCA planning framework The Champlain Local Health Integration Network (LHIN) engaged Hay Group Health Care Consulting to assist with the development of a region wide plan for sub-acute health services in an effort to establish a common framework to support capacity planning for rehabilitative care. The project scope included approximately 875 rehabilitation, complex continuing care and convalescent and transitional care beds, including publicly funded community restorative care services, and was to be aligned with the Rehabilitative Care Alliance (RCA) Capacity Planning Framework. The goal was to develop a region-wide plan to guide the Champlain LHIN in its planning and execution of programming and services that facilitate the achievement of the timely access to rehabilitation and restorative care and provides for the optimization of patient outcomes. The project was led by The Champlain Sub-Acute Capacity Planning Steering Committee. The Steering Committee s role was to: 1. Provide leadership and strategic oversight for the Champlain Sub- Acute Capacity Plan; 2. Align the scope of the study with the Rehab Care Alliance Capacity Planning Framework as well as local issues which have been identified; 3. Ensure the study makes recommendations on the numbers and siting of sub-acute resources required to optimize access to these resources for those in need across the region; and 4. Optimize the utilization of these valuable resources through the development of tools and processes to improve coordinated access to these resources. Page 8

11 In addition to the requirement that the project objectives be addressed, the Sub-acute Capacity Planning Steering Committee identified that a number of important principles and processes issues be investigated as part of the project approach. Principle of Right Care, Right Place, Right Time The key principle guiding the development of the plan was identified to be the Ontario Ministry of Health and Long-Term Care (MOHLTC) priority, as stated in the Premier s mandate letter to the Ministry of Health and Long-Term Care of: Putting Patients at the Centre the Right Care, Right Place, Right Time 3 Desire for stakeholder engagement and quantitative analysis Specific issues to be addressed in the plan There was also a desire to ensure that quantitative analyses and qualitative stakeholder engagement be completed to address important questions about sub-acute services in the Champlain LHIN, such as: Which populations are accessing services and why? What populations are currently not being served? What are the service use patterns (e.g. LOS, ALC, flow patterns, waits, home care use, efficiency) and how do they benchmark in comparison to other LHINs in Ontario? What can be done to optimize access, flow, waits and efficiency within existing resources? After optimization, what is the best mix and geographic distribution of (in-scope) services to meet current and future needs, assuming no significant changes in funding? Other regional issues to be considered as part of the plan were identified to be: Seasonal fluctuations in patient flow (i.e. surge capacity) Geographic access/hotspots Stroke capacity planning The unique needs of long-stay complex populations. Population with responsive behaviours Palliative care community hospice planning 3 Page 9

12 2.2 Project Approach Under the direction of the Steering Committee Hay Group Health Care Consulting developed and executed a detailed project work plan over the course of several months to meet project objectives and requirements. A four phase work plan was developed to achieve objective and meet project requirements The following exhibit shows the four project stages and key activities that were completed in order to develop the draft Regional Plan presented in this document: Exhibit 1: Project Workplan Phase Task 1 - Project Initiation Meet with Steering Committee Initial Interviews with Key Stakeholders Acquire & Review Associated Documents Identification and Acquisition of Data Literature Review 2 - Analysis of Utilization of Acute and Sub-Acute Service Epidemiology and SAVA Patient Characteristics and Service Use Resource Allocation Efficiency of Care Access to Resources SC Meeting re Analysis and Modelling Projective Modelling Formative Evaluation 3 - Stakeholder Workshops Preparing for Stakeholder Workshops Conducting Workshops Analysis & Synthesis of Workshop Results Solicitation of Feedback & Further Analysis 4 - Development of Plan and Reporting Present Analysis Results & Workshop Package Develop and Present Draft Plan Revise Plan & Develop Implementation & Evaluation Framework Prepare Project Report and Plan Present Project Report and Plan Page 10

13 2.3 Key Project Activities Literature Review Evidence and best practice for sub-acute capacity planning and service delivery A literature review was conducted for evidence with respect to the development of models of sub-acute care, sub-acute capacity planning, and governance of sub-acute care (see Appendix A). This was completed to ensure that the planning approach, and the subsequent model for the regional sub-acute system, was informed by any best practice or evidence available. Unfortunately, evidence suggests there is no gold standard for subacute capacity planning or sub-acute system structure and organization. Definitions of sub-acute care vary across health systems, and the costeffectiveness of sub-acute care is unknown. Similarly, the evidence of sub-acute care models, and subsequently sub-acute care capacity planning and governance of sub-acute care, was weak and often nonexistent. While there is no single model of sub-acute care for all systems, and no strong evidence for any model in particular, the literature review was helpful for informing around the diversity of financial and governance structures of post-acute care models in various health systems. This helped to inform the recommendation and implementation considerations included in the planning process in the Champlain LHIN Key Stakeholder Interviews Key stakeholders in subacute care planning and/or delivery in the LHIN were engaged to inform this project Key stakeholders from across the Champlain LHIN were engaged to inform this project. Stakeholders (see Appendix B) included members of the steering committee and a broad range of individuals and working groups involved in the delivery and/or planning of sub-acute rehabilitative or restorative services in the LHIN. Significant time and effort were invested working with stakeholders in order to gather information and begin the process of building consensus towards the recommendations to be developed in this project. Individual interviews and focus groups were completed with stakeholders with the objective of gathering the following information to inform the project: Clarification of current state, in terms of size, siting and use of existing sub-acute resources, patient low and organization Strengths and challenges of the existing sub-acute system in Champlain, including service gaps, opportunities for efficiencies and quality improvements Page 11

14 Desired future state and characteristics of the sub-acute system in Champlain Opportunities for system improvements in the future, including operational improvements and ways of mitigating future demand for sub-acute services Stakeholder perceptions of the principles most important for planning and decision making, particularly relating to resource utilization and systems organization in the future. Feedback from these stakeholders is summarized in this report in the following chapters, and has been used to inform the capacity model and recommendations Rehabilitative Care Alliance Planning Framework The Rehabilitative Care Alliance (RCA) was established by the 14 LHINs in Ontario in order to, among other things, provide standardized definitions of rehabilitative and restorative care in Ontario. Because one of the key objectives of this project was a capacity plan that aligned with the RCA framework, time was invested early in the project to ensure the framework was well understood and that the work completed by the RCA was used to guide the work of this LHIN. Developed approaches to categorize existing administrative data according to the new levels of care established by the RCA A key project activity was the development of algorithms that could be used to categorize historical rehabilitative care activity according to the RCA levels of care. While the RCA levels of care frameworks were finalized prior to the initiation of this capacity planning project, and the Champlain LHIN coordinated a process for health service providers to map their current services to the RCA levels of care, there had been no prior development of approaches to categorize administrative data according to the RCA levels of care. The consulting team worked with a Champlain LHIN data advisory group developed to support the project, the RCA, and representatives from other LHINs, to develop the approaches for administrative data Quantitative Analysis Quantitative Analysis was used to understand current and future population health needs for sub-acute care, and to understand current utilization and performance To support this project we have obtained via IntelliHealth NRS and CCRS records for all inpatient rehabilitation and chronic care patients discharged from Ontario hospitals in 2014/15. We also obtained DAD records for all acute care discharges from Ontario hospitals who were coded as having been discharged to either inpatient rehabilitation or inpatient chronic care. Although it was understood that the purpose of this project was to develop a sub-acute regional plan, some analyses (e.g., discharge disposition) of relevant populations within the acute care period was Page 12

15 necessary due to the inherent impact acute care has on sub-acute delivery. Furthermore, there are unique contextual factors within the Champlain LHIN that were considered throughout all of our analyses: A substantial number of patients that receive services within the LHIN but live outside of the LHIN s borders; a larger proportion of Frenchspeaking patients relative to the provincial average; and a larger proportion of First Nations patients relative to the provincial average. Data analysis consisted of: Epidemiological information about the patient populations served in the Champlain LHIN, including prevalence and incidence for relevant populations requiring sub-acute care. This was completed to provide insight into the relative burden of these populations in the Champlain LHIN compared to other LHINs (using small area variation analyses) and other health systems (found in the literature). Demographic (e.g., age, sex, or municipality) and clinical characteristics (e.g., co-morbid conditions) of relevant populations to understand which patient populations are using which rehabilitative care resources (e.g., inpatient rehabilitation vs. complex continuing care). This was completed to help determine which populations are accessing which services (e.g., mean age of patients referred to complex continuing care) and which populations are not being served. Service use patterns (e.g., length of stay, number of alternate level of care days, number of home-based rehabilitation visits) were determined for each rehabilitative care resource for each patient population. We used targets found in both the literature and from peer groups within Ontario, in order to better understand relative performance of the Champlain LHIN. The number and distribution of rehabilitative care beds amongst Champlain LHIN institutions. This was used to inform what resources are available and where they are located, as well as efficiency and access to care measures. Efficiency was understood by investigating occupancy rates within each level of rehabilitative care, number and type of allied health care visits received through home care, alternate level of care rates, and average functional independence measure (FIM) efficiency for each institution. Actual versus expected costs were also determined for each service by weighted case as an efficiency indicator. We attempted, through limited administrative data and through other stakeholder sources, to determine resource allocations, including which resources are accessible for which patient Page 13

16 populations. This included information such as the admission disposition of each patient population (i.e., what level of care patients are admitted from to rehabilitation), the average distance of a patient s residence from basic and specialized services (to help identify geographic hotspots ), referral patterns, transportation options, and number of community programs (e.g., falls prevention classes) Stakeholder Workshop In order to develop the sub-acute capacity plan and recommendations for the Champlain LHIN, a process for developing and testing the planning assumptions and modeling criteria was used. There was desire to ensure that broad stakeholder feedback (beyond that represented on the Sub-Acute Capacity Planning Committee) was used throughout the planning process, and to ensure that there was consensus among regional stakeholders regarding the recommendation being developing and presented by the Planning Committee. A regional planning workshop was help to ensure that the Planning Committee was incorporating feedback from regional stakeholders into recommendations. This was an important step for ensuring that there was consensus among regional stakeholders. To provide a forum for the Planning Committee to obtain feedback from Champlain LHIN Stakeholder in order to finalize recommendations to the LHIN, a regional planning workshop was held as part of the project approach. The stakeholders who were engaged earlier in the project came together for a full day workshop. A facilitated process was developed to allow regional stakeholder to: Consider a future state model for rehab and restorative services that has been developed based on current state, population needs, RCA guidelines and best available evidence Provide advice and guidance needed to help refine the planning assumptions and capacity model Provide a reality check of what is possible in terms of moving toward the desired future state Provide advice on the changes, investments and trade-offs that will be required in order to site and size services, and optimize systems capacity and resource use, in the future. Feedback from this workshop was used to refine the capacity planning model, and to further develop the recommendations and implementation considerations included in this report Capacity Plan Development and Reporting Projective modelling was used to understand how the various scenarios will change within the next 5 years, and to considering the optimization Page 14

17 of the capacity plan for best meeting future sub-acute needs. We refined the model based on our analysis, stakeholder feedback throughout the project, benchmarking to other LHINs in Ontario and an understanding of current best practice in rehabilitative and restorative care delivery. Particular attention was given to target areas for efficiency, which is of particular importance given fiscal constraints. The plan and recommendations presented here were created under the direction and advice of the Sub-acute Capacity Planning Committee Recommendations provided in this report represent the sum total efforts of the entire project process, including all objective and subjective advice received for planning purposes, and were made under the direction and advice of the Sub-acute Capacity Planning Committee. Page 15

18 General/ Short Term Rehab The Ottawa Hospital Queensway Carleton Cornwall Community Pembroke Regional Hôpital Montfort General/ Short Term Rehab - Total 3.0 Current State 3.1 Current Sub-Acute Bedded Capacity As of February 27, 2015, the Champlain LHIN ALC Working Group reported the following distribution of sub-acute beds by program and hospital/ltch in the Champlain LHIN. Exhibit 2: Champlain LHIN Sub-Acute Bedded Capacity by Service and Hospital Complex Specialized Rehab Continuing Care 54 Bruyère CC / Rehab Centre St. Vincent Locomotor 18 Specialized 22 The Ottawa Stream Complex Care ABI Stream 15 Restorative/ Neuroscience Care Neuromuscular /SCI Stream 21 Transitional Care Supportive Care 14 Bruyère Cont. 70 Arnprior & Care District Mem. 10 Geriatric Rehab 50 Renfrew Victoria 22 Stroke Rehab 20 St. Joseph s CC Centre 21 Glengarry 10 Hawkesbury Memorial & District Stroke Rehab 6 Glengarry Memorial Geriatric Rehab 4 Kemptville District Pembroke Regional Almonte General St. Francis Memorial Winchester District 89 Specialized Rehab - Total 134 Complex Continuing Care - Total Convalescent Care 336 Residence St Louis Perley Rideau 15 Carling View Manor 50 Kemptville District Convalesc. Care - Total Transitional Care 22 Queensway Carleton 34 St. Joe s CC Centre 12 CCC- Restorative 8 76 Transitional Care - Total Sub-Acute Beds February 27, Champlain ALC Working Group 8 Palliative Care 24 Bruyère CC 8 32 Palliative Care - Total Page 16

19 The General/Short Term Rehab and Specialized Rehab inpatient beds are all located in units formally designated as rehabilitation units by the MOHLTC. The same is true for the Complex Continuing Care inpatient beds. These are all located in unit formally designated as chronic units by the MOHLTC. The Convalescent Care beds are provided in LTC homes (including 8 beds at the Kemptville District Hospital). 24 of the inpatient rehabilitation beds at the Queensway Carleton Hospital are allocated to Transitional Care, as are 8 inpatient chronic beds at St. Joseph s Continuing Care Centre. 31 of the designated Chronic beds at Bruyère Continuing Care are used as Palliative Care beds. While the table above shows the number of sub-acute beds as of a specific point in time (i.e. February 27, 2015) there has been some variation in the bed capacity as individual hospitals make decisions regarding their financial resources and role. The following tables show the reported number of rehabilitation and chronic beds in Champlain hospitals. Exhibit 3: Number of Rehabilitation Beds in Champlain Hospitals by Time Period and Data Source Hospital ALC Working Group Feb. 27 MOHLTC Bed Census Reports /15 Avg. Q3 2015/16 Ottawa Hospital - General Ottawa Hospital - Rehab Centre Elisabeth Bruyère Hospital Queensway-Carleton Hospital Pembroke Regional Hopital Montfort Cornwall Community Hospital Glengarry Memorial Hospital Grand Total The MOHLTC bed census summary reporting guide describes the bed count as being based on the cumulative calendar days that beds were available to provide services to inpatients/residents during the reporting period. The total beds and/or cribs available each day of the month are added. Beds closed for admission are not included. Page 17

20 Exhibit 4: Number of Chronic Beds in Champlain Hospitals by Time Period and Data Source Hospital ALC Working Group Feb MOHLTC Bed Census Reports 2014/15 Avg. Q3 2015/16 St.-Vincent Hospital St. Joseph's CC, Cornwall Almonte General Hospital Renfrew Victoria Hospital Pembroke Regional Hawkesbury & District Arnprior & District Memorial Winchester District Memorial St. Francis Memorial Hospital Glengarry Memorial Hospital Kemptville District Hospital Grand Total Average of 882 Sub-Acute Beds in Champlain LHIN in Fiscal Year 2014/15 7 Fewer Rehab Beds at the Rehab Centre in 2015/16 On average, over fiscal year 2014/15 (which is the baseline year for the capacity projections), the number of sub-acute beds in the Champlain LHIN was: 246 beds in MOHLTC designated rehabilitation units 560 beds in MOHLTC designated chronic units 76 beds in Convalescent units in LTC Homes Total of 882 sub-acute beds in Champlain LHIN For the 3 rd quarter of fiscal year 2015/16 (i.e. the most current data available as of preparation of this report), there were 7 fewer rehabilitation beds, or a total of 875 sub-acute beds. The map of the Champlain LHIN below shows the counties included within the LHIN geography, and the locations of the hospitals with subacute beds. Page 18

21 Exhibit 5: Champlain LHIN Geography and Location of Hospitals with Sub-Acute Beds 3.2 Application of the Rehabilitative Care Alliance Planning Framework to current state The Rehabilitative Care Alliance ( was established by the 14 LHINs in the spring of 2013 to improve standardization across Ontario s rehab Care System and to address 4 key priorities (to April 2015): Definitions: Development of common terminology, clear definitions and standards of practice for all levels of rehabilitative care across the continuum. Capacity Planning & System Evaluation: Development of standard rehabilitative care capacity planning & evaluation toolkit to support monitoring and evaluation of system performance Frail Senior/Medically Complex: Develop a rehabilitative care approach for frail senior/medically complex populations to operationalize Assess and Restore Framework. Outpatient/Ambulatory: Development of a comprehensive and standardized minimum data set for outpatient/ambulatory rehabilitation to inform evaluation and planning. Page 19

22 The RCA published its Mandate I Final Report (April 1, 2013 to March 31, 2015) 5 in 2015, and described the report contents as: This report summarizes the work completed during the course of the RCA's first mandate. The recommendations outlined are expected to result in system-wide impacts that lead to improved long-term clinical outcomes, increased community capacity for rehabilitative care, greater clarity on the eligibility and clinical components of rehabilitative care programs, direct admissions to bedded levels of rehabilitative care to avoid ER/acute care programs, and better support for high risk older and medically complex adults with restorative potential. The report contains tools, guidelines and resources that will aid LHINs and health service providers in implementing RCA recommendations. Key highlights from the completion of the RCA s first two-year mandate include, but are not limited to: Definitions Framework for Bedded Levels of Rehabilitative Care. Capacity Planning Framework - Support LHINs and HSPs to identify opportunities for improved care, potential for cost reductions relative to current expenditure, and estimates of the need for re-investment or re-allocation of funding within local rehabilitative care systems Standardized Provincial Process to Support Direct Admissions to Bedded Levels of Rehabilitative Care from the Community/ED - Early identification/ screening of frail elderly/ medically complex patients/clients with restorative potential, assessment to determine the need for bedded rehabilitative care, and streamlined referral to support access to bedded levels of rehabilitative care directly from the community. Outpatient/Ambulatory Rehabilitative Care Minimum Data Set (MDS) PCRC Toolkit - Helps system stakeholders more fully understand the implications of HSFR on patient flow and resource allocation for rehab and CCC, and to mitigate any potential risks. 5 Page 20

23 3.2.1 RCA Levels of Care The RCA has developed a framework for bedded levels of Rehabilitative Care that applies to designated inpatient rehabilitation and chronic (CCC) beds, and convalescent beds in LTCH. 6 The definitions for the bedded levels of rehabilitative care reflect the understanding that the focus of rehabilitative care across the 4 levels may vary from where it is a primary focus in some levels (e.g. Rehabilitation and Activation/Restoration) to a more secondary focus in others where the medical complexity of the patient is higher than in other levels (e.g. Short and Long Term Complex Medical Management). Note: The framework is not inclusive of all beds within CCC or Acute Care. Palliative Care, Respite, Behavioural programs as well as programs where patients are waiting for an alternate level of care (e.g. ALC and LTC) are beyond the scope of this rehabilitative care framework as their focus is not rehabilitative care. However, there is recognition that patients within these programs may receive some rehabilitative care for maintenance during their admission. The RCA has provided guidance to support categorization of inpatient beds by level of care by describing the functional trajectory, patient characteristics, and clinical care resources for each of the 4 bedded levels of care, using the framework shown below. Exhibit 6: RCA Definitions Framework For Bedded Levels Of Rehabilitative Levels Of Care RCA Bedded Level of Rehabilitative Care: Patient Characteristics Medical/ Allied Health Resources Rehabilitation (Low to high intensity) Activation / Restoration Functional Trajectory: Progression Progression Level of Care - Goal Target Population Functional Characteristics Estimated Avg. LOS Discharge Indicator Medical Care Nursing Care Therapy Care Intensity of Therapy Reporting Tools Short Term Complex Medical Management Stabilization & Progression Long Term Complex Medical Management Maintenance 6 Framework_for_Bedded_Levels_of_Rehabilitative_Care FINAL_Dec_2014_. pdf Page 21

24 The RCA also developed a similar framework for community based services, which supports the categorization of community rehabilitative care as either progression or maintenance Applying the RCA Levels of Care to Administrative Data A key project activity was the development of algorithms that could be used to categorize historical rehabilitative care activity according to the RCA levels of care. While the RCA levels of care frameworks were finalized prior to the initiation of this capacity planning project, and the Champlain LHIN coordinated a process for health service providers to map their current services to the RCA levels of care, there had been no prior development of approaches to categorize administrative data (i.e. National Rehabilitation Reporting System [NRS], Complex Care Reporting System [CCRS], and RAI-HC) according to the RCA levels of care. The consulting team worked with a Champlain LHIN data advisory group established to support the project, the RCA, and representatives from other LHINs, to develop the approaches documented in Appendix C of this report. Using Ontario 2014/15 NRS, CCRS, and RAI-HC data, the tables below show the resulting categorization of sub-acute care activity by RCA levels of care. In 2014/15, 9% of discharges, representing 6% of total days, from Champlain LHIN designated rehabilitation beds were categorized as Activation/ Restoration, and the vast majority were categorized as Rehabilitation. The Champlain LHIN Activation/Restoration cases had the shortest average length of stay compared to all other LHINs. Exhibit 7: 2014/15 NRS Rehabilitation Bed Discharges by LHIN by RCA Level of Bedded Care Hospital LHIN % Activation/ Rehabilitation Activation Restoration Restoration Avg. Avg. Cases Days Cases Days Cases Days LOS LOS Central 1,574 34, % 3% Central East 2,796 70, , % 5% Central West 1,074 32, % 2% Champlain 3,305 81, , % 6% Erie St. Clair 1,698 39, , % 5% HNHB 2,385 74, , % 12% Miss. Halton 2,299 60, , % 6% 7 ve_care Final_March_2015_.pdf Page 22

25 Hospital LHIN % Activation/ Rehabilitation Activation Restoration Restoration Avg. Avg. Cases Days Cases Days Cases Days LOS LOS North East , , % 6% North West , % 1% Nth. Simcoe Musk , % 3% South East , % 2% South West 1,868 55, , % 4% Toronto Central 9, , , % 2% Waterloo Well , , % 9% Grand Total 29, , ,934 39, % 5% While the RCA levels of bedded care don t include all types of patients who may occupy chronic beds, it was necessary for this project to be able to assign a category for all patients in Champlain sub-acute beds. Whether new beds will be required to accommodate the projected volume of rehabilitative care patients (as defined by the RCA) will be very dependent on the extent to which sub-acute beds are used by other patients not included in the RCA framework. In the table below, showing the distribution of CCRS assessments by level of care, end of life, respite, and other (further subdivided into those assessments of patients with a diagnosis of dementia, and those without a dementia diagnosis) are shown as levels of care in addition to the 4 RCA levels of bedded care. Exhibit 8: Levels of Care for Chronic Hospital Patients Bedded Levels of Rehabilitative Care Outside RCA Rehabilitative Care Framework Rehabilitation Progression Activation/ Restoration Progression Complex Medical Management Short Term Stabilization & Progression Long Term Maintenance End of Life Respite Other - ALC? Other - Dementia - ALC? Page 23

26 Exhibit 9: 2014/15 CCRS Chronic Bed Assessments by LHIN by RCA Level of Bedded Care Patient LHIN Total Assessments Percent Distribution of Assessments of Patients in LHIN RCA Bedded Level of Care Rehabilitation Activation/ Restoration Medically Complex - ST Medically Complex - LT End of Life Not in RCA Framework Respite Care Other Other - Dementia Central 2,872 20% 2% 15% 23% 24% 0% 6% 11% Central East 2,958 14% 4% 21% 23% 18% 0% 9% 10% Central West % 1% 28% 25% 5% 0% 10% 7% Champlain 3,143 10% 4% 12% 28% 20% 0% 20% 6% Erie St. Clair 1,423 13% 3% 18% 24% 16% 0% 13% 12% HNHB 4,529 29% 3% 28% 12% 22% 0% 4% 2% Miss. Halton 1,986 25% 2% 15% 18% 24% 0% 7% 8% North Sim. Musk % 2% 30% 14% 17% 0% 11% 7% North-East 1,214 24% 4% 18% 14% 9% 0% 17% 14% North-West 1,406 19% 3% 27% 15% 11% 0% 17% 8% South East % 9% 27% 18% 16% 2% 7% 4% South West 1,673 15% 9% 25% 16% 15% 1% 12% 7% Toronto Central 4,559 31% 4% 10% 22% 15% 0% 9% 9% Waterloo Well. 1,298 19% 11% 25% 16% 17% 1% 9% 2% Grand Total 29,266 21% 4% 19% 20% 18% 0% 10% 8% Champlain Rank In 2014/15, the Champlain LHIN hospitals had the lowest % of CCRS assessments where the patient was categorized as Rehabilitation level of care, and the highest % of assessments where the patient was categorized as Medically Complex Long Term or Other. When the same algorithm was applied to the assessments of patients in Champlain LHIN convalescent beds in long-term care homes, 60% of the assessments categorized the residents as being in one of the RCA levels of bedded care. Exhibit 10: 2014/15 LTCH Convalescent Bed Assessments for Champlain LHIN by RCA Level of Bedded Care Level of Care Assessments # % Rehabilitation - 0.0% Activation/ Restoration % Medically Complex % End of Life - 0.0% Respite 7 1.4% Page 24

27 Level of Care Assessments # % Other % Other - Dementia % Grand Total % In RCA Framework % The final set of administrative data to which the RCA framework was applied was the RAI-HC home care assessment and service records. In 2014/15, 85% of Champlain CCAC in-home services were categorized as being provided to patients included within the RCA framework, but most of these services were Maintenance services, and the Champlain CCAC had the lowest percent of in-home services for patients categorized as Progression. Exhibit 11: 2014/15 Categorization of CCAC In-Home Services by Level of Care % Distribution by Level of Care Service CCAC Total In- Home Services Progression Maintenance Acute In Home End of Life Other % in RCA Framework Central 4,220,511 5% 82% 7% 5% 1% 87% Central East 4,245,052 4% 81% 7% 6% 1% 85% Central West 1,587,046 9% 71% 9% 5% 5% 80% Champlain 3,236,990 3% 82% 8% 6% 1% 85% Erie St. Clair 2,232,394 5% 74% 11% 9% 1% 80% HNHB 5,241,953 8% 78% 8% 5% 1% 86% Miss. Halton 2,480,990 8% 70% 11% 10% 1% 78% North East 1,904,438 5% 79% 9% 6% 1% 84% North West 919,885 6% 82% 7% 5% 1% 88% Nth. Simcoe Musk. 1,375,659 2% 78% 8% 9% 2% 81% South East 2,007,113 11% 78% 7% 3% 1% 89% South West 2,719,212 5% 77% 10% 6% 2% 83% Toronto Central 3,679,413 4% 86% 4% 4% 2% 90% Waterloo Well. 1,987,192 10% 74% 8% 8% 1% 83% Grand Total 37,837,848 6% 79% 8% 6% 1% 85% Champlain Rank The consistent categorization of sub-acute care services according to the RCA levels of care, for all services provided in 2014/15 in all Page 25

28 LHINs was an important step to support the benchmarking comparisons of activity and performance described later in this report. 3.3 Current System State Key quantitative findings Appendix D to this report shows the quantitative analysis prepared to support this project. The most important quantitative findings, including the key learnings used to inform the development of the planning assumptions and capacity recommendations, were as follows: There is apparent variation in utilization of sub-acute services across counties in LHIN, and this suggests barriers to access (e.g. proximity, transportation, etc.) and potential inequities for residents in Champlain. While inpatient rehabilitation providers in Champlain achieve short lengths of stays, functional status upon admission to inpatient rehabilitation (admit FIM) is highest of all LHINs in Ontario. As such, Champlain residents experience lesser gains in term of functional independence during their rehab stays. Some inpatient rehabilitation beds in Champlain are used for other purposes, such as transitional care. As such, a lower percentage of inpatient rehab patients are able to be discharged home after their inpatient stay than in other places in Ontario. The overall capacity of IP rehab per population in Champlain LHIN is above provincial average, but: Current capacity of inpatient rehabilitation for Stroke patients is below most other LHINs, and Stroke patients in Champlain experience longest delays from ready for rehab to admission Current capacity and role of inpatient rehabilitation for Hip Fracture patients doesn t reflect current evidence and practices elsewhere, and Hip Fracture patients in Champlain experience long admission delays There is very low inpatient utilization of rehab for Amputation, Lower Extremity compared to other place in Ontario Utilization patterns suggest that rehabilitation admission and discharge focused on weekdays, rather than 7 days per week. This may have a negative impact on length of stay and efficiency measures. However, length of stay for inpatient rehab in Champlain is shorter than in most other LHINs. Page 26

29 Champlain chronic hospital (i.e. CCC) patients are much less likely to be categorized as Special Rehab, but more likely to be Extensive Care compared to other chronic hospitals in Ontario. CCC patient average length of stay in Champlain is longest in province. Population-based rate of use of CCAC in-home care is among the lowest in province, and is 2nd lowest in province for in-home rehabilitation. Assisted living clients and expenditure per population for Champlain is below provincial average. There is very little assisted living activity reported for patients with Acquired Brain Injuries Champlain LHIN chronic hospitals have much greater concentration of long-stay Medically Complex patients than shortstay Medically Complex patients, compared to other LHINs in Ontario. There is a high rate of End of Life clients in CCC beds in Champlain, but the average LOS for these patients is much lower than in other LHINs. There are high rates of End of Life in-home care clients in Champlain, but lower rates of End of Life services than in other LHINs in Ontario. This suggests there may be fewer services per client provided to End of Life clients in Champlain. There is very high use of CCC beds in Champlain for Other patients (i.e. patients not receiving therapies or nursing activation, not medically complex, not palliative or respite). High ALC rates suggest that strategies required to reduce ALC in CCC are needed. 3.4 Current System State Key Qualitative Findings Stakeholder interviews and focus groups were used to inform the understanding of current state, the planning assumptions and the future model used. The majority of stakeholders in the LHIN feel that Champlain is currently a 6 or 7 out of 10 in terms of achieving Ontario s goal of right service, right provider, right place, right time for sub-acute care. Most common gaps and challenges cited by stakeholder to be addressed or considered in the model include: Page 27

30 Increasing pressures and complexity within this sector has been an ongoing challenge that the system needs to address more effectively. Bottlenecks in system most often seem to be related to long term care home and CCC capacity, as well as lack of affordable and accessible alternative living arrangements. There is limited outpatient, ambulatory and community based services for all types of care, particularly outside of the Ottawa area. There are limited homecare supports available, particularly for rehabilitative care, but also for supporting care. In addition, processes to access services that are available through CCAC generally not timely or comprehensive enough to meet the needs of patients or the inpatient system Resources and infrastructure available in CCC have not caught up to the new role of CCC now that it is part of the rehab continuum, rather than a destination. Patients are more complex and stay for a shorter time, and CCC needs more timely access to a broader range of rehab, diagnostic and supportive resources to care for these patients appropriately. Despite best efforts, multiple silo continue to exist across the different part of our system. We still silo care by setting. Transitions and continuity of care continue to be difficult, and no provider has accountability for ensuring patients get what they need for their entire care experience. Stakeholders also identified a number of service gaps within the current sub-acute system: Community based stroke services Services for people with brain injuries, particularly outpatient and chronic supports Paid community based services for people under 65 Behavioural/psychogeriatric services and supports Services for people with mental health/dual diagnosis Options for patients with dementia/delirium who still have functional potential Oncology patients who require rehab or restoration Places for people on chronic ventilation Treatment for people with chronic pain Options for people with bariatric needs Page 28

31 Services/programs for people aging with disabilities Falls prevention in the hospital and community Palliative options and hospice care Specialized rehab outpatient care (spasticity, neuro rehab, prosthetics, etc.) Options for complex long term patients Case Management for geriatric patients and those with specialized rehab needs Services in poorer and more rural populations within the LHIN Transportation to access services Page 29

32 4.0 Desired Future State and Planning Principles 4.1 Desired System Characteristics Stakeholders engaged throughout this project were clear that they feel Champlain LHIN has the potential to get to an 8/10 on right service, right provider, and right place/time for sub-acute services as a result of this planning. They indicate that a reallocation of existing resource may be required, as well as some potential process improvement to improve efficiency and potentially some investments to build capacity. In order to improve, stakeholder feel that attention to the following CAPACITY issues will be needed: More upstream care to prevent the need for sub-acute services and early identification, focusing on maintaining function and delaying the need for subacute services. There is an opportunity to for the Champlain LHIN to demonstrate leadership in adopting strategies aimed at prevention and maintenance in both the community and in acute care, in order to decrease the overall demand for downstream restorative and rehabilitative care. Increase access to care in own communities (except very specialized care) by distributing care and ensuring the right ambulatory/community services are in place (potential need to invest in home care services to achieve this). Accessible transitional and supportive housing options for those not ready to go home. Expanded team of providers responsible for delivering sub-acute care, including current primary care and new types of providers. A plan that includes strategy to deal with dementia/behavioural population, very complex populations and palliation/end of life. Use of technology to better link providers and improve access/extend our capacity for providing care across the LHIN. Capacity to address chronic, long term, life cycle needs of people with disabilities. Stakeholder also suggested that moving to better future state requires willingness to do things differently, not just to invest in more capacity, in order to optimize the assets and resources that we currently have. They advised that attention to the following PROCESS issues would be beneficial: Page 30

33 There is a need for clearer, more standardized levels of care, terminology and criteria in subacute care. Fewer and bigger buckets is desired, resulting in better flexibility and responsiveness of the system. There is a sense that the RCA framework will certainly facilitate standardization. More transparent process and decision making across the care continuum will result in more equitable access for all patients. Continued attention to reducing delays and wait times, ensuring flow and efficiency. There may be situations where priority access to certain resources should be granted in order to facilitate systems flow. Less hot potato of patients. In other words, there is a need for new processes to ensure that, as a system, we have shared accountability for getting patients to the right services at right time. We need to do what is right for patients, not what works best for each individual organization. A need to increase continuity of care, so that patients make fewer transitions/handoffs and are assisted to navigate the system more effectively. Consider improved case management and coordination approaches for our most complex/costly/at risk patients (similar to the Health Links concept being introduced in Ontario). A need to reduce silos by considering subacute as one pot of resources. Move, where possible, to an approach where money and funding follows the patient Identification and implementation of better outcomes measures to reflect system performance and client success. 4.2 Workshop Advice - Champlain LHIN Subacute Capacity Plan The regional planning workshop was used as a forum to test planning assumptions for specific populations to be served by the sub-acute system in the Champlain LHIN. The following feedback was provided and has been used to develop the capacity model and recommendations: For Specialized Rehab: Agreement that the LHIN may be underserved for stroke, but not as large of an increase in utilization needed for inpatient stroke care as projected compared to other LHINs. Current model for amputee rehabilitation works well and is aligned with best practice. There is no desire to increase utilization in this area. Page 31

34 Agreement that there is a need to increase capacity for specialized outpatient. Desire to consider a hub or day hospital model to help distribute these services across the LHIN more effectively (and consider sharing day hospital capacity with geriatric rehab). Consider consolidating specialized rehab to a single site to allow better access/more ability to flex beds to meet needs (ideally co- or closely located with acute/medicine services). Moving to a 7 day a week model (including discharges and admissions) is essential to meet LOS targets. Consider implementing a single decision making body that includes clinical expertise for access to all resources. For Geriatric/General Rehab: Geriatric rehab is a specialized service that should be provided in rehab beds, because there is a need for an inter-professional team and specialized clinical resources. Critical mass is needed, but because of high volumes but should be distributed in centres throughout the LHIN not just Ottawa. General rehab patients can be treated in multiple locations and services should be distributed throughout the LHIN. Increase day hospital and home care capacity to decrease LOS for this population. Need to increase use of a restorative care philosophy as general principle for treatment for inpatient care. Hip fracture, oncology and dementia delirium populations are definitely underserved at present. Need for greater inpatient capacity for these throughout the LHIN geography. Centres need to be equipped with nursing, SLP, dieticians to service this population. Should invest in prevention strategies (e.g. falls prevention), early identification and assessment through primary providers throughout the LHIN to mitigate future demand. This should include a dementia strategy. There will be no short term impact of these strategies that will be seen in current capacity model. Continuity, efficiency and good hands off very important for this population. There are risks of multiple assessments, duplication, and opportunity for care gaps unless case managing and wrapping care around client that create waste and do a disservice to the patient. Activation/Restoration services should be distributed and patients should definitely have direct access from community. A new Page 32

35 referral process (not through CCAC) may be needed. These services should also be distributed throughout the LHIN, and could be offered in CCC beds and in LTC (if legislative issues can be resolved). This is a relatively low cost/high impact part of the care continuum. There is agreement that investing in reactivation in acute care to prevent people from declining and help to increase functioning would be beneficial for patients and to mitigate demand. Complex Medical: Pediatric population is a gap here; also patients on chemotherapy that need rehab Opportunity for pulmonary and wound care in LT Medical (felt that pulmonary should be a 6 week in patient program) There is unused capacity for complex medical in beds in outlying regions that needs to be tapped Consolidate ventilated/respiratory patients, wound care and dialysis as integrated regional programs because they are highly specialized and lower volume. However, could deliver wound care in more distributed model with regional telehealth support Distribute short term medical throughout LHIN. Capacity building, skill boosting and investment in resources would be need for this at an organizational level Single triage/access approach is desired, and this must include clinical assessment (not just wait list management) End of Life/Palliative Care Palliative should not be a silo within our system. All parts of system need to be equipped to provide palliative support There should be much fewer than 54% dying in acute care Navigation is needed for palliative patients to ensure needs are met, to save costs, and to help people die in place (be it at home, LTC bed, wherever they happen to live) Major systems change needed in this area. Until then may not be able to make a lot of change in terms of capacity (we shouldn t need more beds in the community, but we probably do until some system changes are made) Page 33

36 Patient Flow/ALC: This is single biggest opportunity in Champlain LHIN for freeing up sub-acute capacity. Urgently need to address with new strategies Need to divert resources and providing top up funding to allow people to access assisted living/move to community in timely way Consider a single body (similar to CCO) to oversee resource allocation for all sub-acute capacity in LHIN Implement the use of a regional bed board to help understand and control flow throughout the system Upstream investment in dementia patients is critical now to reduce some demand now and more in the future. Consider using a health links model for this population. 4.3 Proposed Principles to Guide Decision Making Throughout the project, there was consensus on a number of principles that should be used to guide decision making for this project. Stakeholders and the Planning committee advised that as the capacity model and recommendations are developed consideration should be given to ensuring that it is: Evidence based: the model must consider what we know we should be doing to align with best practice Reality based: although not always ideal, the model must take into consideration the realities of the system i.e. our current capacity/starting point, expectations and incentives that exist/will exist within the system (funding approaches, QBPs, etc.), geography, etc. Client-centred: as much as possible, the model should align services around clients needs, choices and preferences. People should be able to obtain services as close to home as possible, whenever it is reasonable. Efficient: there will always be more demand that our resources can provide for, therefore the model should reflect an effort to maximize the use of the resources that we have. Connected and Accountable: there is a desire to move to a more integrated approach where everyone is responsible to one another and to the client. The model should consider how the parts of the system can work together in new ways to ensure transitions are improved and clients are getting what they need. Page 34

37 Focused on early identification and prevention: because it is recognized that maintenance of function is important, and we should look to mitigate future demand for subacute services by investing in prevention and maintenance activities (despite a lack of strong evidence for the same). Page 35

38 5.0 Planning Assumptions and Projected System Capacity 5.1 Potential Impact of Projected Champlain LHIN Population Change Demand for Sub-Acute Care Very Much Driven by Size of Seniors Population An overriding consideration in the development of the Champlain subacute care capacity plan has been the sustainability of the sub-acute care system. More so than many other health care services, the demand for sub-acute care services is driven by the size of the senior population. The graphs below show the historical annual inpatient days per 10,000 population used in Ontario by patient age and gender. Exhibit 12: Rate of Inpatient Days per 10,000 Population by Age and Gender Cohort for Rehabilitation and Complex Continue Care Patients For both inpatient rehabilitation and inpatient CCC, the population rates of use of the services increases dramatically after age 65. Majority of Population Growth in Champlain will be Seniors The table below shows the projected change in the Champlain LHIN population from 2014 (i.e. the year for which the baseline activity data is available) to 2019 and 2024 (i.e. 5 and 10 years after the baseline). Page 36

39 While the overall Champlain LHIN population is projected to increase in size by 5.8% in 5 years and 12.3% in 10 years, the respective percent increases in the senior population (i.e. those aged 65 and older) for the same periods are 21.3% and 47.0%. More than half of the overall growth in the Champlain LHIN population will be for people aged 65 and older. Exhibit 13: Projected Change in Champlain LHIN Population from 2014 to 2019 and 2024 by Age Cohort Age Cohort Change 14 to 19 Change 14 to # % # % ,585 73,535 4, % 79,813 11, % 9-May 69,426 71,793 2, % 77,217 7, % 14-Oct 69,204 72,216 3, % 74,942 5, % ,694 74,246-5, % 77,851-1, % ,671 89,223-6, % 84,320-11, % , ,856 10, % 96,783 4, % ,714 97,788 11, % 108,593 21, % ,581 90,344 6, % 101,846 18, % ,375 87, % 94,442 7, % ,649 89,257-4, % 89,295-4, % ,316 93,765-12, % 89,669-16, % , ,700 11, % 92, % ,369 91,303 12, % 102,756 24, % ,803 76,516 9, % 89,702 22, % ,145 63,442 16, % 73,269 26, % ,591 42,860 8, % 58,332 23, % ,671 29,035 3, % 36,642 10, % ,653 18,915 2, % 21,924 5, % ,480 13,478 2, % 16,188 5, % Total 1,306,238 1,382,325 76, % 1,466, , % 65 & Older 201, ,246 42, % 296,057 94, % Increased Beds and Services to Respond to Projected Population Change if No Mitigation Steps Taken If the current patterns of use of sub-acute care continued, and identified unmet needs were met, with no mitigation of demand through reducing utilization, shortening length of stay, or shifting care from institutional to non-institutional care, the projected increase in demand in only 5 years would be: 78 more rehabilitation beds, $17.6 million cost per year 67 more chronic hospital beds, $15.8 million 11 more convalescent beds, $0.7 million Significant increases in CCAC in-home care cases: Page 37

40 4,500 more Progression clients, $3.4 million 2,300 more Maintenance clients, $6.8 million 216 more End of Life clients, $0.8 million 10 Year Increase in Annual Sub-Acute Operating Costs of $99 Million if Status Quo Approach to Care Continues Announced Hospital Funding Projections will Not Support a Status Quo Approach This projected increase in sub-acute care operating costs (excluding other ambulatory and community services) from 2014 to 2019 would be approximately $45.1 million in 2014 dollars (i.e. no inflation adjustment). There would be a further increase in annual operating costs of $54.2 million from 2019 to In addition, there would be capital costs associated with increasing the supply of beds (i.e. 156 additional hospital and convalescent beds in 5 years). In the February 2016 budget 8, the Government of Ontario announced that there would be a 1% increase in base funding for Ontario hospitals, the first increase in 5 years. Given the current average inflation rate of approximately 2%, this will not provide increased funding for the hospital sector in real dollar terms. The increase in operating funding required in the Champlain LHIN to support a status quo approach to responding to population demand for sub-acute care won t be provided by the budgeted increase in hospital funding; a status quo approach will not be sustainable. In the budget, the Government of Ontario stated that: To deliver a patient-centred health care system, the government must pursue systemic change to modernize health care and maximize the value of investments Integration of the health system will improve patient care while achieving efficiencies in the overall health sector. Onus on Champlain LHIN Sub-Acute Care Providers to Modernize System and Achieve Efficiencies Sub-Acute Capacity Plan Must Incorporate All Opportunities to Mitigate Cost Impact of Projected Demographic Change If the sub-acute care providers in the Champlain LHIN cannot implement changes to modernize health care and achieve efficiencies, then the most vulnerable people in the LHIN, i.e. the socioeconomically disadvantaged elderly, will be the ones who suffer. As such, the Champlain LHIN sub-acute capacity plan must aggressively incorporate opportunities to mitigate the cost impact of demographic change through shifts in service modalities and efficiencies. The key planning assumptions to support this mitigation, and their estimated impacts on future service requirements and costs, are described in the following sections of this chapter. 8 Page 38

41 5.2 Key Capacity Projection Assumptions Unmet Needs for Inpatient Rehabilitation Low Utilization by Champlain Residents of Inpatient Stroke and Amputee Rehab Evidence of Unmet Need for Inpatient Stroke Rehab Access to IP Rehab for Champlain Hip Fracture Patients Has Been Less than Emerging Evidence would Recommend The analysis of population-based utilization of inpatient rehabilitation by the population of the Champlain LHIN showed that in 2014/15, the Champlain LHIN population had very low rates of use of inpatient stroke and lower extremity amputee rehabilitation compared to elsewhere in the province. The stroke report card, and project analysis of percent of stroke patients discharged directly to inpatient rehab from acute care, reinforced the concern raised during stakeholder engagement that the current number of stroke rehab beds had not been sufficient to ensure that the Champlain stroke patients who could benefit from inpatient rehabilitation could gain access to this service. Rates of access of Champlain LHIN acute care hip fracture patients directly to inpatient rehabilitation were slightly below the provincial average (i.e. ~25% in the Champlain LHIN, versus 30% provincially). The Toronto Central LHIN has set a target of transfer of 60% of all acute care hip fracture patients directly to inpatient rehab, and was over 50% in 2014/15. While the HQO QBP handbook for hip fracture did not specify a target percent of acute hip fracture patients to be discharged directly to inpatient rehabilitation, the Bone and Joint Canada National Hip Fracture Toolkit 9 has recommended a target of 65%. Recent work by ICES researchers has found that 1 year survival rates for hip fracture patients who are referred to inpatient rehabilitation are much better than for matched patients who don t get inpatient rehab, and have recommended that at least 40% of hip fracture patients be transferred directly to inpatient rehabilitation from acute care. 10 Low Use of Inpatient Rehab for Amputee Rehab Reflects Good Ambulatory Support Available in Champlain LHIN Although the use of inpatient rehabilitation for amputee rehabilitation was identified as being lower than in other LHINs, the Stakeholder Workshop participants confirmed that this was because support for these patients was provided on an ambulatory basis, and no increase in utilization rates were required Personal communication, Dr. Susan Jaglal, Senior Scientist, Toronto Rehabilitation Institute (TRI), Senior Scientist, Institute for Clinical Evaluative Sciences Page 39

42 Target Utilization Rate for Both Stroke and Hip Fracture Rehab Increased by One Third Increased Hip Fracture Utilization Increases Beds by 8.1 in 2019 Increased Stroke Utilization Increases Beds by 14.9 in 2019 Both hip fracture and stroke utilization rates were increased by 33% to create additional capacity for historical unmet need. At the Stakeholder Workshop, a model incorporating a 50% increase in the stroke utilization rate increase was presented, but advice of the stakeholders was that increase of that magnitude not required, given the ambulatory and community supports for stroke patients in place in the LHIN. The increase in the hip fracture utilization rate generates a further increase of 8.1 inpatient rehabilitation beds for 2019, beyond the increase required to address population change. The increase in the stroke utilization rate generates a further increase of 14.9 inpatient rehabilitation beds for 2019, beyond the increase required to address population change Geographic Distribution of Services Concentrate Specialized Services in Regional Centres, but Distribute Others to Maximize Patient Access The initial planning assumption was that inpatient (and other) services considered to be specialized should be concentrated in regional centres, and that non-specialized services should be distributed as widely as possible (subject to critical mass and efficiency considerations) to allow patient access as close to home as possible. All projected services were assigned to one of three geographic areas within the LHIN, based on the patient residence and the type of service provided. The three geographic areas were: Greater Ottawa Ottawa, Lanark, Leeds and Grenville, plus Arnprior and McNab/Braeside (i.e. from Renfrew County), and Russell and Clarence/Rockland (i.e. from Prescott Russell Counties) Eastern Counties Prescott Russell, Stormont, Dundas, Glengarry, excluding Russell Township and Clarence/Rockland Renfrew County Renfrew County excluding Arnprior and McNab/Braeside The following exhibit shows a map of the LHIN with the 3 geographic areas shown. Page 40

43 Exhibit 14: Champlain LHIN with 3 Geographic Areas Used for Sub- Acute Service Distribution Planning Differentiation between Specialized and General/Geriatric Rehabilitation Cases For inpatient rehabilitation cases, the CIHI NRS Rehabilitation Group designation was used to differentiate between specialized (i.e. regional) and general/ geriatric rehabilitation, as shown in the table below. Exhibit 15: Identification of Specialized and General/Geriatric Rehabilitation Cases by CIHI Rehabilitation Group Specialized/ Regional Rehabilitation G e n NRS Rehabilitation Group Stroke Neurological Amputation, Not Lower Extremity Amputation, Lower Extremity Non-Traumatic Spinal Cord Injury Maj Multiple Trauma w/brain or SC Injury Burns Pulmonary Traumatic Spinal Cord Injury Non-Traumatic Brain Injury Traumatic Brain Injury Multiple Trauma & Maj Multiple Fracture Fracture of Lower Extremity Page 41

44 NRS Rehabilitation Group Replacement of Lower Extremity Other Orthopedic Rheumatoid & Other Arthritis Osteoarthritis Debility (excl. Cardiac/Pulmonary) Cardiac Other Disabilities Medically Complex Pain Collocate Stroke Rehab with Acute Stroke Centres in each Region Long-Term Medically Complex Patients with Special Treatment Requirements Should be treated in Ottawa The advice of stakeholders and the project steering committee was that inpatient stroke rehabilitation should be distributed to three locations across the LHIN, in alignment with the distribution of acute stroke services, and that both inpatient stroke rehab and hospital ambulatory services for stroke should be collocated in acute stroke centres. In Ottawa, all inpatient stroke rehabilitation should be located in a specialty rehabilitation site. For Long-Term Medically Complex patients (i.e. in complex continuing care), where those patients require ventilator/respirator, tracheostomy care, chemotherapy, radiation, or renal dialysis, for planning purposes we have assumed that this inpatient care should be provided in Ottawa. Patients from outside the Champlain LHIN have been assigned to a Champlain county based on the historical patterns of reliance on specific hospitals for patients from those counties. Planning assumptions related to sub-acute care for patients from Quebec are described separately later in this chapter Unmet Need for In-Home Rehabilitative Care The initial projections of the required growth in in-home rehabilitative care services was based on the projected impact of the demographic change in the population of each county. However, the analysis of population-based utilization of in-home rehabilitative care showed some variation in the apparent use of these services across the counties outside Ottawa. Where the 2014/15 utilization rate for either Progression or Maintenance in-home care in a Champlain County was below the Ontario average, the target utilization rate for 2019 was increased to reflect the Ontario average. The counties where an increased utilization rate was applied for the projection are highlighted in yellow in the following table. Page 42

45 Exhibit 16: 2014/15 Actual and 2019 Target In-Home Clients per 10,000 Population by Client County and RCA Level of Care Actual 2014/ Target County Progression Maintenance Progression Maintenance Ontario Renfrew Lanark Stormont Dundas & Glengarry Prescott & Russell Ottawa With both the projected impact of the demographic change, and the adjustment of utilization rates, there would need to be a 19.8% increase in in-home Maintenance clients and a 64.9% increase in in-home Progression clients in the Champlain LHIN by Exhibit 17: Projected In-Home Maintenance Clients with Demographic Change and Response to Unmet Need Location 2014/15 Actual 2019 with Growth 2019 with Unmet Need % Change from 14/15 Eastern Counties 2,124 2,500 2, % Greater Ottawa 8,617 10,189 10, % Renfrew County 1,018 1,181 1, % Grand Total 11,759 13,871 14, % Exhibit 18: Projected In-Home Progression Clients with Demographic Change and Response to Unmet Need Location 2014/15 Actual 2019 with Growth 2019 with Unmet Need % Change from 14/15 Eastern Counties 1,367 1,531 1, % Greater Ottawa 4,595 5,220 8, % Renfrew County 982 1,092 1, % Grand Total 6,944 7,843 11, % Not only were the rates of home care admissions per population below the provincial average in some Champlain LHIN counties, but once admitted to home care, clients of the Champlain CCAC received, on average, fewer services during their care episode than clients in other CCACs. In 2014/15, Champlain CCAC Progression clients received an average of 8.9 services per episode of care (2 nd lowest in the province, tied with the Central East CCAC) compared to the provincial average of Page 43

46 Exhibit 19: 2014/15 MOHLTC Reported Average Services Per In-Home Client by CCAC CCAC (Service) Avg. Services per Client Progression Maintenance Central Central East Central West Champlain Erie St. Clair HNHB Miss. Halton North East Nth. Simcoe Musk North West South East South West Toronto Central Waterloo Well Ontario Average Champlain Rank Later in this report where the projected in-home care costs are calculated, the Ontario provincial average cost per Progression episode of care is used, rather than the lower actual Champlain cost per episode of care, so as to reflect the additional resources required to bring Champlain up to the provincial average services per client Increased Reliance on Residential Hospice and Palliative Care Majority of Acute Care Inpatients Coded as Palliative Care Die in Acute Care In the February budget, the Government of Ontario stated that the government plans to increase its investments in residential hospice and palliative care. In 2014/15, 54% of all acute care patients in Champlain LHIN hospitals who were coded as receiving palliative care died in the acute care hospital (i.e. the 6 th lowest rate). Exhibit 20: 2014/15 Discharge Disposition of Acute Care Palliative Care Cases by Hospital LHIN Palliative % Distribution of Acute Palliative Cases by Discharge Disposition Hospital LHIN Cases in Died in Home w/ Home no Acute Continuing Acute Acute Services Services Care Care Other Central 4,129 57% 14% 3% 1% 22% 2% Central East 5,280 64% 14% 4% 2% 15% 0% Central West 1,464 65% 15% 8% 1% 9% 2% Champlain 4,518 54% 20% 3% 3% 16% 5% Page 44

47 Palliative % Distribution of Acute Palliative Cases by Discharge Disposition Hospital LHIN Cases in Died in Home w/ Home no Acute Continuing Acute Acute Services Services Care Care Other Erie St. Clair 2,435 65% 12% 5% 1% 13% 4% HNHB 4,928 58% 15% 3% 2% 19% 4% Miss. Halton 2,648 50% 26% 3% 1% 20% 1% North East 2,511 60% 17% 5% 4% 9% 5% North West % 22% 6% 4% 7% 12% Nth. Simcoe Musk. 1,566 52% 23% 4% 0% 10% 10% South East 2,047 58% 18% 3% 3% 16% 2% South West 3,712 70% 12% 3% 2% 10% 2% Toronto Central 5,730 48% 21% 5% 3% 21% 2% Waterloo Well. 2,441 52% 23% 3% 1% 14% 6% Grand Total 44,392 57% 17% 4% 2% 16% 3% Champlain Rank (1 is low, 14 is high) The Champlain Hospice Palliative Care Action Plan ( ) produced by the Champlain Hospice Palliative Care Program in July 2014 found (through international research) that regional planning for palliative care has resulted in: Improved access to and quality of hospice palliative care services, significant reductions in acute care hospitals as the place of death for individuals with cancer, increased access to hospices and palliative home care services and significant cost-savings for their respective health care systems. The Action Plan included an analysis of Current and Projected Acute Palliative and Residential Hospice Beds in Champlain and identified a 15 bed shortfall (based on current plans to increase residential hospice beds) for the Champlain LHIN by This recommendation was based on the Gomez Batiste standard that communities have 10 hospice palliative care beds per 100,000 inhabitants (or a total of 138 beds for 2019). Assume No Increase in Hospital Inpatient Sub- Acute Palliative Care Beds Required, If Recommended Investments in Expanded Residential Hospice and Palliative Care are Made For sub-acute hospital bed capacity projections, we have assumed that the current 31 bed Bruyère palliative care unit will be sufficient to accommodate the need, if the recommended investments in expanded residential hospice and palliative care (as supported in the Ontario Budget) are implemented. Expanded capacity for residential hospice and palliative care will also help Champlain LHIN hospitals to reduce the likelihood that acute care palliative care patients will die in an acute care hospital, solely because community options are not available. Page 45

48 5.2.5 Reduction of Transfers from General Rehab to Specialty Rehab Reducing Transfer from General Rehab to Specialty Rehab Would Save 5 Beds In 2014/15, there were 43 general rehabilitation patients who were transferred from a general rehabilitation unit to a specialty rehabilitation hospital after their general rehab stay. All but 2 of these patients were transferred from either QCH or Hôpital Montfort to the Bruyère site. For modelling purposes, we have assumed that in the future these patients could be transferred directly to the specialty rehabilitation site from acute care. Eliminating these initial general rehabilitation stays would save 5 inpatient beds in Repatriation of Patients from Outside the Champlain LHIN to Providers in Their Home Communities 4 Champlain LHIN Rehab Beds Used for Quebec Residents In 2014/15, there were the equivalent of 12 inpatient rehabilitation beds in Champlain LHIN hospitals that were used for non-residents of the LHIN. The equivalent of 3.5 beds were used by Quebec residents. Exhibit 21: 2014/15 Distribution of Champlain LHIN Inpatient Rehabilitation Cases by Patient LHIN 2014/15 Actual Patient LHIN Beds Cases 95% Champlain 3,125 76, Quebec 45 1, South East North East Other Out of Province All Other LHINs Total 3,278 80, Outside Champlain 153 4, The inpatient rehab cases in Champlain LHIN hospitals for Quebec residents were distributed by program as shown below, with the highest volume of cases and days for pulmonary patients. Exhibit 22: Distribution of 2014/15 Champlain Hospital Inpatient Rehab Cases for Quebec Residents by Rehab Group Rehabilitation Group Cases Days Avg. LOS Pulmonary Stroke Traumatic Spinal Cord Injury Geriatric Rehabilitation Medically Complex Page 46

49 Rehabilitation Group Cases Days Avg. LOS Cardiac Neurological Non-Traumatic Brain Injury Fracture of Lower Extremity Grand Total 45 1, Chronic Beds Used for Quebec Residents In 2014/15, there were the equivalent of 27.5 Champlain LHIN chronic hospital beds used for non-champlain residents, 14.7 of which were used for Quebec residents. Exhibit 23: 2014/15 Estimated Distribution of Equivalent Champlain Chronic Hospital Beds by Patient Residence Patient LHIN Estimated Beds Champlain Quebec 14.7 Unknown 6.0 South East 2.2 North-West 2.0 North-East 1.2 Other Out Of Province 0.9 HNHB 0.5 Waterloo Wellington 0.0 Grand Total 516 Outside Champlain 27.5 Most of the chronic hospital patients from Quebec were categorized as Long-Term Medically Complex patients. Exhibit 24: 2014/15 Use of Champlain LHIN Chronic Hospital Beds by Quebec Patients by Program Program Estimated Beds Rehabilitation 1.2 Medically Complex - ST 2.2 Medically Complex - LT 9.8 End of Life 0.9 Other 0.5 Other - Dementia 0.1 Grand Total 14.7 Page 47

50 Actual 2014/15 Sub-Acute Capacity for Patients Living Outside Ontario Maintained in 2019 Projection The reliance of Quebec residents on hospital services in the Champlain LHIN is very dependent on the capacity and capability of the health service providers in the Outaouais. Because of the uncertainty of, and lack of influence on, health system capacity outside Ontario, for projections of future volumes, the actual 2014/15 inpatient days for patients living outside Ontario were kept constant and included in the 2019 projected capacity requirements Length of Stay in Hospital Beds Overall, the Champlain LHIN lengths of stay for rehabilitation patients are shorter than the provincial averages. There is only one rehabilitation group where QBP length of stay targets have been established for inpatient rehabilitation, i.e. stroke. Champlain IP Rehab LOS Already Below Targets Provincial Average LOS by RCA Level and Age Cohort Used as LOS Target for Chronic Day Projections In 2014/15, the Champlain LHIN inpatient lengths of stay by stroke RPG were on average almost one day shorter than the QBP length of stay target, so no targets for further LOS reduction have been applied in the projection of future beds. The average length of stay for patients in chronic hospitals beds in Champlain has been the longest in the province. We compared the average length of stay in Champlain LHIN hospitals against the Ontario average length of stay for every combination of sub-acute program and patient age cohort. Where the Ontario average length of stay was shorter than the Champlain length of stay, we applied the Ontario average length of stay and identified the Champlain days in excess of that LOS as estimated conservable days. The table below shows the five program and age cohort combinations that contributed the greatest volume of estimated conservable days. Exhibit 25: Example of Program and Age Cohort Combinations Contributing Highest Volume of Estimated Conservable Days in Champlain LHIN Chronic Units RCA Program Age Cohort Avg. Champ. LOS Tgt. LOS Champlain Cases Est. Conserv. Days Other ,224 Other ,625 Rehabilitation ,740 Medically Complex - LT ,240 Other ,211 Page 48

51 More than half of the estimated conservable days were identified in the Other program (i.e. patients not receiving significant rehabilitation therapies, nursing activation, and without complex medical conditions). Length of stay reduction targets were not applied to End of Life patients or any other patients who died in the Chronic bed. Exhibit 26: Estimated Champlain Chronic Hospital Conservable Beds from Ontario Average LOS Targets in 2014/15 by Program LOS Program Conservable Beds Rehabilitation (15.9) Activation/ Restoration (7.2) Medically Complex - ST (4.2) Medically Complex - LT (17.6) End of Life - Respite Care (0.0) Other (55.2) Other - Dementia (4.4) Grand Total (104.4) Elimination of Conservable Days Would Save 104 Beds in 2019, But Leave at Least 120 Beds Available for ALC Application of the length of stay targets reduces the projected chronic unit bed requirements in the Champlain LHIN by beds in Achievement of the LOS reduction targets will require investments in ambulatory and community based services, particularly in-home care. However, in 2019, there would still be more than 120 Chronic beds in the Champlain LHIN for patients in the Other programs (i.e. ALC patients) Alternate Level of Care Days and Cases Inpatient Rehabilitation ALC 1.1% of Champlain Rehab Days Reported as Having Discharge Delay The NRS rehabilitation records support coding of a ready for discharge day, and tracking of the time elapsed between ready for discharge and actual discharge. In 2014/15, only 1.1% of the inpatient rehabilitation days for Champlain LHIN hospital cases were documented as reflecting delays between ready for discharge and discharge. Page 49

52 Exhibit 27: 2014/15 Discharge Delay Days for Rehabilitation Discharges by Hospital LHIN Hospital LHIN IP Rehab Days Discharge Delay Days % Discharge Delay Days Central 35,162 1, % Central East 74,638 2, % Central West 33, % Champlain 86, % Erie St. Clair 41,140 2, % HNHB 84,299 4, % Miss. Halton 63,973 6, % North East 31,080 2, % North West 17,586 1, % Nth. Simcoe Musk. 9, % South East 23,838 1, % South West 57,377 3, % Toronto Central 256,161 8, % Waterloo Well. 26,375 2, % Grand Total 841,027 38, % The provincial Wait Time Information System (WTIS) also tracks alternate level of care days, and the table below shows that the Champlain LHIN hospitals reported higher rates of ALC days (and equivalent beds) via the WTIS than were reported above as discharge delays. In fiscal year 2015/16, ALC days used the equivalent of 12 Champlain LHIN inpatient rehab beds. Exhibit 28: WTIS ALC Days and Equivalent Beds for Champlain LHIN Inpatient Rehab Beds Site ALC Days 2014/ /16 Equiv. Beds ALC Days Equiv. Beds Elisabeth Bruyère Hospital Cornwall Community Hospital Hopital Montfort Ottawa Hospital - Rehab Ctr Ottawa Hospital - General Pembroke Regional Queensway-Carleton Hospital Glengarry Memorial Hospital Not Available Total 2, , Page 50

53 The evidence that some Champlain LHIN rehabilitation inpatients may not fully require intensive rehabilitation services, and the expectation of increased investment in in-home and ambulatory rehabilitation services, led to further examination of the 2014/15 NRS data to identify potential ALC cases. All of the Ontario 2014/15 NRS discharges were analyzed by revised rehabilitation group (i.e. with Geriatric Rehabilitation established as a separate group) to see if there were some cases where inpatients had exceptionally high admission FIM scores. Within each revised rehabilitation group, the average admission FIM, and the standard deviation of the admission FIM, was calculated to determine an outlier FIM score (i.e. higher than the average admission FIM plus 1.96 times the standard deviation). The table below shows that this was a very conservative approach to identifying outliers, with the outlier FIM score for many cases approaching (or exceeding) the maximum achievable functional status for a health patient of 126 FIM points. Exhibit 29: 2014/15 Outlier Admission FIM by Revised Rehabilitation Group Revised Rehab Group Ontario Cases Avg. Admit FIM Std. Dev. Outlier FIM Geriatric Rehabilitation 8, Stroke 5, Medically Complex 2, Replacement of Lower Extremity 2, Fracture of Lower Extremity 1, Amputation, Lower Extremity Non-Traumatic Brain Injury Non-Traumatic Spinal Cord Injury Traumatic Brain Injury None Pulmonary None Other Orthopedic Neurological Cardiac Multiple Trauma & Maj Multiple Fracture Debility (excl. Cardiac/Pulmonary) Traumatic Spinal Cord Injury Maj Multiple Trauma, Brain or SC Pain Burns None Rheumatoid & Other Arthritis None Amputation, Not Lower Extremity Osteoarthritis Page 51

54 For stroke patients, the QBP target that RPG 1160 patients should not be admitted to inpatient rehabilitation, was also applied. Applying the outlier identification approach to the 2019 Champlain LHIN hospital projected NRS cases identified 165 inpatient rehabilitation cases, with an overall average LOS of 13.6 days, that for capacity modelling purposes have been assumed to not require inpatient admission. Exhibit 30: Projected Inpatient Rehabilitation Cases for 2019 That Should Not Require Inpatient Admission Hospital Cases Days Hopital Montfort 94 1,091 Ottawa Hospital Pembroke Regional Queensway-Carleton Hospital St. Joseph's CC Cornwall Grand Total 165 2,240 Admission Avoidance Reduces Rehab Beds by 6.5 At 95% occupancy, these outlier cases used an average of 6.5 inpatient rehabilitation beds in 2014/15. Inpatient Chronic ALC Alternate Level of Care days are not documented on the CCRS records for patients in chronic hospital beds. Real time ALC activity is monitored via the Wait Time Information System (WTIS), and as of January 29, 2016, the Champlain Weekly ALC Dashboard showed that there were approximately 81 open ALC cases at St. Vincent, most who were waiting for LTC. Because the ALC days are documented on the CCRS data, we can t tell whether the conservable days identified based on provincial average LOS targets reflect opportunities to achieve rehabilitative goals more quickly, ALC days, or (likely) some combination of both. The majority of the conservable days were identified in those cases that were categorized as Other (with or without dementia) that have been assumed to potentially reflect ALC cases, since they don t appear to have any of the characteristics that would necessitate ongoing care in a chronic hospital bed. The initial modelling approach used the CCRS LOS targets to identify opportunities to reduce use of days in Champlain chronic hospital beds, but did not fully eliminate any cases as not requiring admission at all. Page 52

55 The WTIS wait time data for 2014/15 showed 41,146 ALC days in Champlain chronic hospital beds, and 36,369 ALC days in the same beds in 2015/ Exhibit 31: WTIS ALC Days and Equivalent Beds for Champlain LHIN Inpatient Chronic Beds 2014/ /16 Site ALC Days Equiv. Beds ALC Days Equiv. Beds Almonte General Hospital Arnprior & District Memorial Bruyère Continuing Care 35, , Hawkesbury & District Kemptville District Hospital Pembroke Regional 2, ,775 5 Renfrew Victoria Hospital ,071 3 Winchester District Memorial St. Joseph's CC, Cornwall St. Francis Memorial Hospital Not Available Glengarry Memorial Hospital Total 41, , The Champlain LHIN sub-acute capacity plan incorporates targeted investments in ambulatory and community services intended to mitigate the demand for bedded levels of care. As such, it should be expected that (with these proposed investments) the Champlain LHIN hospitals could further reduce the reliance on inpatient chronic hospital beds beyond the reduction calculated using average Ontario lengths of stay. ALC Cases Identified for Admission Avoidance Potential ALC cases were identified by examining the Champlain LHIN chronic patients in 2014/15 who were discharged home (including to a retirement home), and who were assigned to the Other level of care (i.e. not palliative, not receiving significant rehabilitation therapy or nursing activation/restoration services, and not medically complex). 11 Three Champlain LHIN chronic programs do not report ALC data via the WTIS, so the reported ALC day volumes are likely lower than the actual total numbers. Page 53

56 Exhibit 32: Champlain LHIN 2019 Beds for ALC Cases in Chronic Beds, to Be Saved Via Admission Avoidance 2019 Beds Program to Save re Admission Avoidance Rehabilitation - Activation/ Restoration - Medically Complex - LT - Medically Complex - ST - Other 15.0 Other - Dementia 3.5 Grand Total 18.5 Admission Avoidance Reduces Projected Chronic Beds by 18.5 For modelling purposes, it was assumed that these identified ALC cases, and the associated 18.5 equivalent beds should not require admission to a chronic hospital bed if enhanced ambulatory and community rehabilitative care services were available Hospital Ambulatory Care The sub-acute bed projection has assumed that there are opportunities to avoid some inpatient admissions and find efficiencies in LOS for patients in Chronic hospital beds (provincial average LOS targets by level of care and patient age). The advice from the Stakeholder Workshop was that there are opportunities to invest in ambulatory/community services to achieve LOS reduction, and to eliminate some of the ALC activity in chronic hospital beds. The health services research literature provides little concrete evidence of the relationship between expanded ambulatory/community services and the potential to reduce the reliance on sub-acute beds. Geriatric day hospital has been the most studied, but the evidence is mixed. The understanding of current ambulatory/community services available within Champlain LHIN, and identification of historical access to these services and the impact on use of hospital beds, is incomplete. The table below shows the reported Champlain hospital visit volumes for rehabilitation clinics and geriatric day hospital in 2014/15. It is unlikely that these volumes reflect the total rehabilitation ambulatory clinic activity in the Champlain LHIN hospitals, but in some hospitals ambulatory clinic activity focused on rehabilitation may not be separately identified from clinic visits for other types of care. Page 54

57 Exhibit 33: Champlain LHIN Hospital 2014/15 Ambulatory Rehabilitation and Geriatric Day Hospital Visits Hospital Rehab Clinic Day Hospital Total Visits Ottawa Hospital 6,216 2,518 8,734 Bruyère Continuing Care 968 4,601 5,569 Almonte General Hospital - 3,570 3,570 Queensway-Carleton Hospital - 3,105 3,105 Pembroke Regional 1,315-1,315 CHEO 1,140 1,140 Grand Total 9,639 6,675 16,314 In spite of the lack of strong evidence (primarily because of the absence of the data systems and measurement capability that would facilitate high quality research), the participants at the Stakeholder Workshop expressed the belief that investment in ambulatory services is an important strategy that can mitigate the demand for sub-acute bedded care. The capacity plan should ensure that ambulatory rehabilitation services (including day hospital) are available in a lead hospital in each geographic cluster. An initial attempt to develop ambulatory visit capacity benchmarks based on actual Ontario data from academic health science centres and freestanding rehab/chronic hospitals was unsuccessful, because of lack of confidence in the reported activity data. Some very large facilities, with many inpatient rehabilitation and chronic beds reported no ambulatory clinic or day hospital activity at all. The Ontario Rehabilitative Care Alliance was tasked to: Develop a comprehensive and standardized minimum dataset for Ministry-funded outpatient/ambulatory rehabilitative care programs. The data set will enable standardized data collection and the development of comparable performance metrics, evaluation and planning at the provincial, regional, local and organizational levels as well as an understanding of the role of outpatient rehab in optimizing patient outcomes and supporting other aspects of hospital and community-based services. The RCA surveyed health service providers to assess the status of ambulatory rehabilitative care data collection and to validate the Page 55

58 proposal to introduce a new minimum dataset. 12 The RCA has recently initiated a pilot study of the minimum dataset 13 and once the system is mandated across the province (likely a few years from now) it will be more possible to accurately assess the impact of access to ambulatory sub-acute on use of bedded levels of care. In the absence of both a comprehensive inventory of ambulatory and community sub-acute services in the Champlain LHIN, and evidence or benchmarks to support ambulatory services capacity planning, the projections of hospital ambulatory capacity have been based on application of ambulatory visit planning standards developed by the Toronto Central LHIN for the highest volume rehabilitation groups. While these planning standards don t cover all sub-acute patients, they may provide an estimate of the order of magnitude of ambulatory capacity required by the highest volume rehabilitation patients. The Toronto Central LHIN ambulatory rehabilitation planning assumptions for joint replacements, hip fracture, and stroke, are listed in the table below. Exhibit 34: Toronto Central LHIN Ambulatory Rehabilitation Planning Assumptions for Highest Volume Rehabilitation Groups Sub population group TJR Hip Fracture Stroke Standard 90% of TKR discharges home get a 1 hour assessment visit, follow by 2 hour class (run by PT/PTA), twice per week, for 6 weeks 10% of TKR discharges home get 1 hour assessment, followed by 1:1 treatment with average of 15 treatment visits of 30 minutes each, with additional 15 minutes of documentation time 80% of THR discharges home get 45 minute class session (run by PT/PTA), followed by 45 minutes 1:1 treatment, for 2 hours total including documentation time 20% of THR discharges home get 45 minute class session (run by PT/PTA), followed by up to 8 individual treatment visits OP rehab provided by PT or PTA with access to other professionals (e.g., OT, social worker) as needed Average 8 week OP program (range 6-12 weeks, based on clinical needs of patients) Intensity of program: 1-2 sessions per week, most with home exercise program provided Mixture of both 1:1 intervention and group therapy mode OP rehab intensity of 1 hour therapy by each of PT/OT/SLP two to three times per week, for 8 to 12 weeks Page 56

59 The ambulatory visit targets in the above table were developed to be applicable to all live discharges from acute care in the three patient categories, with the expectation that some patients will receive these services immediately after discharge home from acute care, and others will receive the services following their inpatient rehabilitation stay. 2014/15 Champlain LHIN acute care discharge data was used to estimate the volume of outpatient visits that would have been required based on these targets in 2014/15, and the growth in required visits by 2019 based on the projected demographic changes. The estimated number of outpatient visits for just the selected patient groups greatly exceeds the reported outpatient rehabilitation clinic visit volumes reported by the Champlain LHIN hospitals in 2014/15. This may reflect significant under-reporting of outpatient rehabilitation visits, a shortfall in outpatient rehabilitation capacity in the Champlain LHIN, or most likely, a combination of these factors. Exhibit 35: Estimated Champlain LHIN Hospital Outpatient Rehabilitation Clinic Visits Based on TC LHIN Planning Standards Acute Care Group 2014/15 Discharges* Avg. OP Visits per Discharge 2014/15 OP Visits % Growth 2019 OP Visits Stroke 1, ,625 16% 36,685 Knee Replacement 2, ,928 18% 36,495 Hip Replacement 1, ,721 18% 5,571 Hip Fracture 1, ,500 22% 16,470 Total of Above 6, ,774 18% 95,221 * Does not include deaths or discharges to LTCH. TC LHIN Visit Standards Developed for Urban LHIN with Emphasis on Group Clinics; Champlain LHIN Rural Communities May Rely More on In-Home Care The TC LHIN outpatient visit standards were premised on the assumption that much of the post-discharge ambulatory/community rehabilitation can be provided most efficiently via group therapy. While this may be feasible in a purely urban LHIN with comprehensive public transportation, in the Champlain LHIN, with its rural communities, it may not be as feasible to rely on hospital outpatient services, and a greater portion of post-acute care may be provided via in-home care Mitigation of Demand and Avoidance of Need for Bedded Care The modelling presented above uses targets for length of stay reduction and admission avoidance to mitigate the projected requirements for bedded sub-acute care. The magnitude of the pressures anticipated due Page 57

60 to the aging and growth of the population, and the limited increases in health care funding, will require continued emphasis on strategies that will reduce admissions and decrease reliance on subacute services, get people back to lowest level of support ASAP. The modelling has included projections of increased in-home care and some hospital ambulatory services. Other strategies identified and supported by stakeholders include: Geriatric prevention strategies such as falls prevention Geriatric Emergency Management (GEM) nurses Supportive housing options Direct admits from community to rehab New models of provincial of in-home care (e.g. Central West CCAC Home Independence Program) Most opportunities appear to be around using right type/level of resource at the right time, and supporting better integration across parts of the system. Rehab Patients Discharged on Monday Have LOS More than 4 Days Longer than Average; 7 Day per Week Admission and Discharge will Be Important Mitigation Strategy An example of a potential care process change that could lead to efficiencies is supporting admission and discharge of patients on weekends. In 2014/15, only 4% of Champlain LHIN hospital rehabilitation inpatients were admitted on the weekend, and 6% were discharged on the weekend. Lengths of stay for the small number of patients admitted or discharged on the weekends were much shorter than for patients admitted or discharged on weekdays. The longest average length of stay was for patients discharged on Monday (i.e. immediately after the weekend), more than 4 days longer than the average LOS of 23.8 days. Supporting 7 day per week admission and discharge (in addition to 7 day per week therapy service availability) will be important to ensure efficient use of rehabilitation beds. Exhibit 36: Champlain LHIN Hospital Average LOS for Rehabilitation Discharges by Day of Week for Admission and Discharge Average LOS by DOW Day of Week Admission Discharge Day Day Monday Tuesday Wednesday Thursday Friday Saturday Sunday Page 58

61 Average LOS by DOW Day of Week Admission Discharge Day Day Total Importance of Acute Care Initiatives to Reduce Hospital Acquired Disability The modeling of the projected sub-acute care capacity has been focused on how the Champlain LHIN can best respond to the projected need for post-acute care, but has not explicitly considered how changes in practices in acute care could reduce the requirements for sub-acute care. There is growing attention being paid to hospital acquired disability 14, and the large portion of elderly patients in acute care who develop newly acquired disability in activities of daily living, instrumental activities of daily living, and mobility activities, as a result of their acute care stay. In parallel with the proposed sub-acute care system changes, there should be greater focus on initiatives in acute care to identify and reduce the incidence of hospital acquired disability, such as: Mobilization tactics Physiotherapy 7 days a week Reviewing findings and benefits of Move ON study Delirium prevention, detection and early treatment Reviewing findings of Geriatric Medicine Ortho delirium screening project Hospital Elder Life Program (HELP) see Earlier consultation with Geriatric Medicine for seniors whose profile (to be developed) indicates that they are at high risk for Hospital Acquired Disability 5.3 Projected System Capacity The estimates of projected system capacity, showing growth in demand due to population change and responding to unmet need, and then after application of proposed mitigation targets, are shown separately for each RCA level of bedded care, and for selected ambulatory/ community services in the sections below. 14 Gill TM, Allore HG, Holford TR, Guo Z. Hospitalization, restricted activity, and the development of disability among older persons. JAMA: the journal of the American Medical Association. Nov ; 292(17): Page 59

62 Program Inpatient Rehabilitation In 2014/15, there were on average 246 designated inpatient rehabilitation beds in Champlain LHIN hospitals, 14 of which were used for Activation/Restoration, 232 used for Rehabilitation. The projected Regional and General/Geriatric rehabilitation beds required for 2019 are 289, 57 more beds than were actually used. An additional 55 beds in chronic hospitals will be required to accommodate rehab patients with longer lengths of stay. Exhibit 37: Projected Inpatient Rehabilitation Bed Capacity Required for 2019 by Program Program 2014/15 Beds 2019 Beds w/ Growth & Unmet Need 2019 Beds w/ Mitigation Change from 2014/15 % Change from 2014/15 Regional % General/Geriatric % Rehabilitation in Chronic (8.6) -14.6% Total IP Rehabilitation % For those patients in designated rehabilitation beds, where NRS data is collected, the projected capacity by revised rehabilitation group is shown below. Exhibit 38: Projected Inpatient Bed Capacity in Designated Rehab Beds Required for 2019 by Rehabilitation Group 2014/15 Beds 2019 Beds w/ Growth & Unmet 2019 Beds w/o Xfer to 2nd Rehab Final 2019 Beds w/o Outlier Cases Change from 14/15 % Change from 14/15 Regional % Amputation, Lower Extremity % Amputation, Not Lower Extremity % Burns % Maj Multiple Trauma, Brain or SC % Mult Trauma & Maj Mult Fracture % Neurological % Non-Traumatic Brain Injury % Non-Traumatic Spinal Cord Injury % Pulmonary % Stroke % Traumatic Brain Injury % Traumatic Spinal Cord Injury % General/Geriatric % Cardiac % Debility (excl. Cardiac/Pulmonary) % Page 60

63 Program 2014/15 Beds 2019 Beds w/ Growth & Unmet 2019 Beds w/o Xfer to 2nd Rehab Final 2019 Beds w/o Outlier Cases Change from 14/15 % Change from 14/15 Fracture of Lower Extremity % Geriatric Rehabilitation % Medically Complex % Osteoarthritis % Other Orthopedic % Pain % Replacement of Lower Extremity % Rheumatoid & Other Arthritis % Activation/Restoration % Grand Total % Rehabilitation Sub-Total % Inpatient Activation/ Restoration In 2014/15, there were the equivalent of 13.8 designated rehabilitation beds used for Activation/Restoration. The need for this service is projected to increase to 16.9 beds by 2019, and 15.7 after mitigation, but rehabilitation beds should not be used for these patients. All of the hospital based Activation/Restoration beds should be accommodated in designated chronic beds. Current Bed Location Exhibit 39: Projected Inpatient Activation/Restoration Bed Capacity Required for 2019 by Program 2014/15 Beds 2019 Beds w/ Growth & Unmet Need 2019 Beds w/ Mitigation Change from 2014/15 % Change from 2014/15 In Rehab Bed % In Chronic Bed (5.4) -25% Hospital Subtotal (3.5) -11% In Convalescent Bed % Total % Inpatient Medically Complex Most of the Medically Complex sub-acute bedded care is provided in designated chronic hospital beds. The 2019 projection is that with mitigation (i.e. achievement of Ontario average LOS) there will be 13.8 or 5% more beds required for Medically Complex patients. Page 61

64 Exhibit 40: Projected Medically Complex Bed Capacity Required for 2019 by Program and Designated Bed Type Current Bed Location 2014/15 Beds 2019 Beds w/ Growth & Unmet Need 2019 Beds w/ Mitigation Change from 2014/15 % Change from 2014/15 Medically Complex - ST % Medically Complex - LT % Chronic Bed Subtotal % Medically Complex - Conv. Bed % Total Medically Complex % Hospital Based Inpatient End of Life Care Currently, 31 beds designated by the MOHLTC as chronic at Bruyère Continuing Care are used for palliative care. The projection of future requirements has assumed that this capacity of sub-acute hospital beds will be sufficient to accommodate future needs if the planned increase in community hospice beds is implemented Other Inpatient Hospital Sub-Acute Care Reduction of 57 Beds Would Still Leave 124 Chronic Beds in 2019 for ALC Patients With the proposed mitigation strategies, the number of other chronic beds (i.e. beds for patients who aren t palliative, aren t receiving rehabilitation therapies or nursing activation/restoration, and don t have significant medical care requirements) could be decreased by 57.1 beds, even with the projected demographic changes. This would still leave the equivalent of beds available for patients who could be considered to be ALC patients. Exhibit 41: Projected Other Bed Capacity in Designated Chronic Beds Required for 2019 Program 2014/15 Beds 2019 Beds w/ Growth & Unmet Need 2019 Beds w/ Mitigation Change from 2014/15 % Change from 2014/15 Other (54.3) -36% Other - Dementia (2.9) -9% Total (57.1) -31% Page 62

65 5.3.6 In-Home Care Because of the current low rates of use of in-home Progression care in some counties, an increase of 65% is projected for in-home Progression clients by RCA Category Exhibit 42: Projected In Home Care Clients for /15 Actual 2019 Growth & Unmet Need 2019 w/ Mitigation Change from 2014/15 % Change from 2014/15 Progression 6,944 11,448 11,448 4,504 65% Maintenance 11,759 14,090 14,090 2,331 20% End of Life 1,272 1,488 1, % Total 19,975 27,025 27,025 7,050 35% Hospital Ambulatory Care The advice from the Stakeholder Workshop was that outpatient services should be protected and increased. As explained above, there is no comprehensive and accurate inventory of sub-acute ambulatory care services provided in Champlain LHIN hospitals. In addition, there are no accepted planning standards for hospital based ambulatory subacute care. The application of Toronto Central LHIN ambulatory rehabilitation planning standards to Champlain LHIN projected acute care stroke, joint replacement, and hip fracture patients suggests a requirement in 2019 for 95,221 visits (many of which could be group therapy visits). This projection is based on planning in a densely populated urban centre, where transportation to hospital-based clinics is widely available. As such, it may not be applicable outside the city of Ottawa Summary of Projected Sub-Acute Service 2019 Projection is for 49 More Rehab and 46 Fewer Chronic Beds than Currently (Q3 2015/16) in Use in Champlain LHIN The total projected sub-acute service requirements, by sector and program are shown below. The projected requirement of 288 designated rehabilitation beds is 49 more than the 239 currently (i.e. Q3 2015/16) in use in Champlain LHIN hospitals. The projected requirement of 514 designated chronic beds is 46 fewer than the 560 currently (i.e. Q3 2015/16) in use in Champlain LHIN hospitals. Page 63

66 Exhibit 43: Summary of Projected Service by Sector and Program Sector IP Rehab Inpatient Chronic Conv. In LTCH In-Home Care Program 2014/15 Beds 2019 Beds w/ Growth & Unmet Need 2019 Beds w/ Mitigation Change from 2014/15 % Change from 2014/15 Mitigation Impact Regional % (5.7) General/Geriatric % (4.6) Activation Restoration (13.8) -100% (16.9) Total IP Rehabilitation % (27.2) Rehabilitation (8.6) -15% (15.8) Activation Restoration % 8.7 Medically Complex - ST % (4.2) Medically Complex - LT % (17.6) End of Life % (5.4) Other (54.3) -36% (70.2) Other - Dementia (2.8) -9% (7.9) Total IP Chronic (44.9) -8% (112.4) Activation Restoration % - Medically Complex - Conv. Bed % - Total RCA in Convalescent % - Progression Clients 6,944 11,448 11,448 4,504 65% - Maintenance Clients 11,759 14,090 14,090 2,331 20% - End of Life Clients 1,272 1,488 1, % - Total RCA In-Home 19,975 27,026 27,026 7,051 35% - The impact of the proposed inpatient bed mitigation initiatives by 2019 would be to reduce the need for inpatient rehabilitation beds by 27.2, and inpatient chronic beds by The table below summarizes the estimated impact of each mitigation initiative. Exhibit 44: Estimated Impact on 2019 Inpatient Bed Requirements by Mitigation Initiative MOHLTC Bed Designation: Current Funding Model: Designated Rehab. HBAM - Case Weight Designated Chronic HBAM - RUG Wtd. Day RCA Activity in LTCH Conval. RUG CMI 2014/15 Average Beds: /16 Q3 Average Beds: Projected Beds with Growth, Pre-Mitigation Estimated Impact (Bed Reduction) of Proposed Mitigation* Assumption Rehab/Chronic beds as reported on MOHLTC Bed Census Summary reports. Includes impact of projected 2019 demographic change and increase in utilization of inpatient rehab for stroke Page 64

67 and hip fracture 95% target LOS Direct Access to Specialty Rehab Avoid Admission to Rehab Investment in Community Hospice Services Avoid Admission to IP Chronic Reduce Chronic LOS to Ontario Average Move Activation/ Restoration in Rehab Beds to Chronic Bed (5.0) (6.6) (5.4) (18.5) (104.4) Eliminate transfers from general rehab unit to specialty rehab unit Assume rehab cases with exceptionally high admission FIM will go home and receive in home rehabilitation Keep Bruyère palliative unit at 31 beds and avoid need to grow to 37 beds via expanded community hospice Assume Chronic ALC cases (i.e. in "Other" category) who were discharged home from Chronic can go home right away if enhanced in-home progression and maintenance services are available Use targets based on actual Ontario chronic hospital average LOS by RCA program by 5 year age cohort. Not applied to deaths. No change in net beds, but A/R can be provided in Chronic beds at lower cost and free capacity for Rehab growth (15.7 A/R beds to Chronic). Final Projected Beds Change in Beds from 2015/16 Q (45.6) Projected 2019 Service Requirements by Region within Champlain LHIN The projected 2019 service requirements were allocated to the three planning regions previously described. The table below shows the results for designated rehabilitation beds. Exhibit 45: Projected 2019 Designated Rehabilitation Bed Requirement by Planning Region Rehabilitation Program Eastern Counties Greater Ottawa Renfrew County Grand Total Regional Stroke Non-Traumatic Brain Injury Neurological Pulmonary Page 65

68 Rehabilitation Program Eastern Counties Greater Ottawa Renfrew County Grand Total Traumatic Brain Injury Non-Traumatic Spinal Cord Injury Traumatic Spinal Cord Injury Mult Trauma & Maj Mult Fract Amputation, Lower Extremity Maj Mult Trauma, Brain or SC Burns Amputation, Not Lower Extremity General/Geriatric Geriatric Rehabilitation Medically Complex Fracture of Lower Extremity Replacement of Lower Extremity Other Orthopedic Debility (excl. Cardiac/Pulm.) Cardiac Pain Rheumatoid & Other Arthritis Osteoarthritis Grand Total Current Designated Rehab Beds Difference (5.5) (39.6) (3.9) (48.9) Each of the three regions would have a shortfall in inpatient rehabilitation beds in 2019 if there was no change in the number of designated rehabilitation beds from the currently operated number. However, some of this shortfall could be eliminating by re-designating some of the projected excess chronic bed capacity outside Ottawa to rehabilitation. The projections for Chronic beds for 2019 by planning area shows that the projected number of beds in each planning region (assuming 95% average occupancy) are lower than the current number of Chronic beds in use. Exhibit 46: Projected 2019 Designated Chronic Bed Requirement by Planning Region Program in Designated Chronic Bed - 95% Eastern Counties Greater Ottawa Renfrew County Grand Total Rehabilitation Activation/ Restoration Page 66

69 Medically Complex - ST Medically Complex - LT End of Life Respite Care Other Other - Dementia Grand Total A/R from Rehab Total in Chronic Beds /16 Chronic Beds Change from 15/16 Actual (16) (7) (22) (45) Historically, very little rehabilitation (as defined by the RCA) has been provided in Renfrew County chronic beds, whereas the chronic beds in the Eastern Counties have been used to provide rehabilitation. The proposed distribution of chronic beds by region incorporates a shift of capacity from the Eastern Counties to Renfrew County to reflect the relative size of the target populations for sub-acute services. In 2014/15, the Eastern Counties population used the equivalent of 15.1 chronic beds per 10,000 population, while the Renfrew population used only 10.4 chronic beds per 10,000 population. The proposed distribution would equalize the capacity of chronic beds per population across these two regions. In total, there would be enough to accommodate the projected demand for hospital-based sub-acute care in the Eastern Counties and Renfrew County, but not in Greater Ottawa. 5.4 Projected Champlain Sub-Acute Care System Costs The projected Champlain sub-acute care system operating costs have been calculated using 2014/15 unit costs and the projected change in volumes for the activity in each sector. All costs are shown in 2014/15 dollars (i.e. projected costs do not include adjustments for inflation) Change in Operating Costs 2014/15 to 2019 $17.3 million net Increase in Sub-Acute Operating Costs (not including hospital ambulatory visits) The projected changes in operating costs by sector are shown below. The total increase in sub-acute operating costs of $17.3 million do not include any additional investments in hospital ambulatory care capacity. Page 67

70 Exhibit 47: Projected Change in Operating Costs from 2014/15 to 2019 with Growth, Unmet Needs, and Mitigation Sector Inpatient Rehabilitation Inpatient Chronic Activity Measure 2014/15 Actual Volumes 2019 Projected Volumes Projected Change in Cost Activity Total Cost Unit Cost Activity Total Cost $ % RCW 4,128 $ 66,254,225 $16,050 5,032 $ 80,763,387 $ 14,509,162 22% RWPD 199,599 $ 108,795,839 $ ,289 $ 99,905,713 $ (8,890,125) -8% All Hospital IP Sub-Acute $ 175,050,064 $ 180,669,100 $ 5,619,036 3% LTCH Convalesc. (RCA) In-Home Progression In-Home Maintenance In-Home End of Life RWPD 19,094 $ 3,799,706 $ ,578 $ 4,493,022 $ 693,316 18% Client 6,944 $ 4,659,424 $ ,448 $ 8,059,229 $ 3,399,805 73% Client 11,759 $ 34,559,701 $ 2,939 14,090 $ 41,409,409 $ 6,849,708 20% Client 1,272 $ 4,483,800 $ 3,525 1,488 $ 5,244,723 $ 760,923 17% All In-Home Sub-Acute 19,975 $ 43,702,925 $ 2,188 27,025 $ 54,713,362 $ 11,010,437 25% Total Cost $ 222,552,695 $ 239,875,484 $ 17,322, % Hospital Ambulatory Clinic* Visit?? $ ,221 $ 9,998,205?? Day Hospital* Visit?? $ 162???? Hospital ambulatory clinic and day hospital unit costs derived from provincial Healthcare Indicator Tool data, and reflect direct (i.e. not overhead) costs only. Costing Assumes Least Costly Inpatient Cases and Days are shifted to LTCH, Ambulatory, and Community; Complexity and Cost of Residual Inpatient Activity will Be Higher Although the proposed mitigation strategies have a significant impact on the growth in hospital sub-acute beds, they have less of an impact on hospital inpatient sub-acute costs. This is because the modeling has assumed that the inpatient days avoided (via LOS reduction or admission avoidance) are the lowest cost days, and the residual inpatient activity will be more complex (than average) cases, requiring more care per day, and higher costs per day. While the projection is for a small reduction in the total number of sub-acute hospital beds, the associated costs of operating these beds would increase by $5.6 million. The hospital unit costs in the model are based on Ontario Cost Distribution Methodology (OCDM) unit costs, and include both direct costs and allocated overhead costs. As such they may over-estimate Page 68

71 the cost impact of marginal changes in activity, if service volumes could be changed without having a significant impact in overhead costs (i.e. direct cost impact only). Mitigation Strategies Reduce Projected Hospital Inpatient Costs by $27.7 million Some of Estimated $69 million Champlain Hospital ALC Cost could be avoided via Enhancement of Sub- Acute System The proposed mitigation strategies have been estimated to generate a total of $27.7 million savings in 2019 hospital operating costs ($3.0 million for inpatient rehabilitation, and $24.7 million for inpatient chronic). While not formally included in the costing analysis, it should be noted that ALC days in Champlain LHIN hospitals were conservatively estimated to cost $69 million in 2014/15, and that some of these ALC days were for patients waiting for access to sub-acute care. The investment in sub-acute care (particularly the portion to address historical unmet need) should reduce ALC days in acute care and mitigate the projected increases in acute care costs associated with population growth and aging. Exhibit 48: Estimated 2014/15 Cost of ALC Days in Champlain Acute Care Hospital by Discharge Disposition Discharge Disposition IP Wtd. Cases Est. Cost IP Days Cost per Day Marginal Cost per Day (60%) ALC Days ALC Day Cost Acute 12,692 $77,082,111 45,679 $1,687 $1,012 1,980 $2,004,719 CCC 6,415 $38,958,653 35,501 $1,097 $658 7,521 $4,952,109 Died 12,870 $78,163,340 47,471 $1,647 $988 6,868 $6,785,100 Home 74,301 $451,251, ,460 $1,656 $994 2,449 $2,433,638 Home Care 35,311 $214,454, ,169 $1,224 $735 20,748 $15,240,742 LTC 11,738 $71,287,595 74,482 $957 $574 30,312 $17,407,182 Other 1,250 $7,593,477 6,677 $1,137 $ $583,414 Psych 542 $3,294,131 2,922 $1,127 $676 1,002 $677,766 Rehab 10,370 $62,982,765 50,696 $1,242 $745 9,785 $7,293,905 Grand Total 165,489 $1,005,068, ,057 $1,413 $848 81,520 $69,136, Potential Capital Costs The comparison of projected 2019 beds and current beds is based on the reported number of rehabilitation, chronic, and LTCH convalescent beds in use in Champlain HSPs in 2015/16. This comparison suggests that the projected total number of sub-acute beds required in hospitals would not be substantially different from the total beds in use for subacute care now. However, because of the greater growth in demand in the Greater Ottawa area, and the proposed consolidation of all specialty rehabilitation in a single site, additional capacity for rehabilitation service may be required in Ottawa itself. The location and amount of Page 69

72 construction of new inpatient rehabilitation capacity will be dependent on subsequent siting decisions, and the number (and quality) of bed spaces not currently in use but which could be returned to operation without significant capital costs. With the proposed shift in capacity from inpatient chronic to inpatient rehabilitation programming, outside Ottawa there may also be the need to modify current sub-acute units to reflect this change, and to add associated sub-acute ambulatory capacity HSFR and HBAM Implications The RCA has emphasized that the distinction between designated rehabilitation and chronic beds in Ontario is increasingly diminishing, as many hospitals re-categorize their chronic beds to rehabilitation, and as the continuum of rehabilitative care is emphasized, rather than a black and white differentiation between rehabilitation and chronic patients. But for now, there are differences in both data collection and funding models between the two types of beds: Patients in designated rehabilitation beds have their admission and discharge FIM documented and reported via the CIHI NRS system. CIHI determines a Rehabilitation Case Weight (RCW) intended to reflect the total cost of an inpatient episode. The HBAM unit cost model for inpatient rehabilitation measures the ratio of a hospital s actual costs of care to their total RCWs. The lower this ratio, the more likely that a hospital s average cost per RCW will be less than expected, and the hospital may be entitled to additional funds. Because (for the most part) the RCW value assigned to a case is independent of the LOS, there is an incentive to reduce patient lengths of stay and costs, so as to bring down the average cost per RCW. Patients in designated chronic beds don t have a FIM score measured, but are periodically assessed using the RAI MDS tool, and based on the assessment data will have a Case Mix Index (CMI) assigned, driven primarily by the categorization of the patient into Resource Utilization Groups (RUGs). The CMI measure is used to weight each inpatient day, so that a total number of RUG Weighted Patient Days (RWPD) can be calculated for a hospital. The HBAM unit cost model for inpatient chronic measures the ratio of a hospital s actual costs of care to their total RWPDs. The lower this ratio, the more likely that a hospital s average cost per RWPD will be less than expected, and the hospital may be entitled to additional funding. Because each actual day of Page 70

73 stay gets a weight based on the CMI, there is no funding incentive to reduce LOS for patients in chronic beds. To best benefit from the current HBAM funding model, patients for whom the expected course of care is relatively predictable, and for whom there is a well-defined care path, with a short length of stay, should be placed in a designated rehabilitation bed. Patients where the expected length of stay is less certain, and where they may stay more than 45 to 60 days (e.g. slow stream rehab) should instead be placed in a designated chronic unit. The current assignment of RCWs to inpatient rehabilitation patients is not sensitive to geriatric or slow stream rehabilitation patients, and there is a risk that the assigned RCW might not reflect the true cost of providing care, thus causing a higher than expected cost per RCW for a hospital with many of these patients in their inpatient rehabilitation unit. Currently, there are a small number of patients in inpatient rehabilitation beds in the Champlain LHIN who have very high admission FIMs, short lengths of stay, and who are sometimes transferred for additional inpatient care, rather than being discharged home. These patients get assigned RCW values far in excess of their actual cost of care, and the hospitals with these patients perform better on the HBAM unit cost funding model. Because these are the very patients identified as patients for whom admission to inpatient rehabilitation should avoided in the future, any Champlain hospitals with a substantial number of these patients will find that their HBAM rehabilitation unit cost performance will deteriorate if they implement the proposed admission avoidance mitigation strategy. This is an unfortunate example of where the current HSFR and HBAM methodologies create disincentives to practice more appropriate care, and this issue has been identified and will likely be resolved in future refinements of the funding system. An additional limitation of the HSFR and HBAM funding formulae is that they don t specifically address hospital investments in ambulatory services (treated as non-modelled costs). There is the risk that ambulatory investments will allow diversion of lowest cost (i.e. shortest LOS) cases from inpatient care, and hurt the HBAM unit cost performance, with no balancing increase in credit for increased ambulatory service. 5.5 Interim Surge Capacity Planning An additional project activity was the examination of interim strategies that could be considered to reduce the impact on Champlain LHIN providers and patients of seasonal variation in demand for sub-acute Page 71

74 Steering Committee Considerations re Interim Surge Capacity Planning care, which exceeds the available system capacity. The Steering Committee members collectively discussed what an Interim Surge Capacity Plan should look like and what options would be most effective. Their considerations included: How to effectively deal with a regional or site-specific escalation process that could potentially prevent the surge from happening altogether; Important to strategically consider all unused or under-utilized capacity in the system specifically for the purpose of surge management (i.e. sites that aren t at 100% capacity, temporary displacement of patients); Seasonality of specific injuries (i.e. spine and head injuries during the winter); Need for regional resource management, all we currently have now are long-term care beds, are there other beds that could be used? (i.e. STR or CCC), could respond to patient needs for surge in the short term; Collaboration with the 4 Public Health Units in our region; Important to look at lateral transfers not just horizontal (acute sector should be in play); Factor logistical challenges associated with patient transfers in our analysis/strategy; Components: data piece (how many beds would we need), capacity piece (where could and should they go); Approach to Developing Champlain LHIN Surge Capacity Strategy The approach to developing the Champlain LHIN surge capacity strategy included: Identify magnitude of challenge Assess opportunity to reduce surge via admission avoidance Outside scope of this project, but ED admission analysis suggests Champlain acute care hospitals already performing well with respect to ED admission avoidance Assess opportunity to redistribute acute care activity to share surge impact Assess opportunity to reallocate activity to take advantage of unused sub-acute bed capacity (including LTCH convalescent beds) Page 72

75 Consider opportunity to temporarily increase effective sub-acute bed capacity Consider opportunity to temporarily increase sub-acute community and outpatient service capacity Measuring the Size of the Seasonal Surge In 2014/15, the average January inpatient acute care census in Champlain hospitals was 1,951 patients (including birthing) vs. the annual average of 1,855 patients (96 beds above the annual average). Exhibit 49: 14/15 Champlain LHIN Avg. Acute Care Census by Month 15 In 2014/15, the average January inpatient rehab/chronic census in Champlain hospitals was 753 patients vs. an annual average of 739 patients (14 beds above the annual average). There is a much smaller seasonal variation in rehab/chronic census, but the census peak in rehab/chronic corresponds with the acute census peak. 15 MOHLTC Bed Census Summary Reports. Page 73

76 Exhibit 50: 2014/15 Champlain LHIN Average Rehab/Chronic Census by Month 16 CIHI discharge abstract (DAD) identifies a similar surge in January (84 beds). The surge is seen most in medicine patients (who are most often admitted via the ED, and particularly Pulmonary). Most surgical programs (with some elective activity) have lower reported census during the medical surge period, which suggests there may be restrictions in surgical activity (either in response to high medical occupancy, or because of scheduled holiday operating room closures) to help address the surge in non-elective cases. Exhibit 51: CIHI DAD Data 2014/15 Estimate of Average Daily Census by Program (Excluding Birthing) by Month Program Cluster Annual Avg. Census Jan. Avg. Census Jan. Excess Census Other Internal Medicine Pulmonary Orthopaedics General Surgery (29) Cardiology Non-Acute Gastro/Hepatobiliary (12) Neurology Urology (4) Other Reasons (1) 16 Ibid. Page 74

77 Program Cluster Annual Avg. Census Jan. Avg. Census Jan. Excess Census Haematology Neurosurgery Endocrinology Nephrology (3) Vascular Surgery (5) Psychiatry (2) Gynaecology (2) Otolaryngology Thoracic Surgery 11 7 (4) Plastic Surgery 8 2 (6) All Other PCCs 4 2 (2) Grand Total 1,487 1, Identifying Vacant Beds That Could Be Used For Surge At the individual hospital site level, not all Champlain LHIN acute care hospital sites face the same surge pressures. In many of the smaller hospitals outside Ottawa, there are vacant beds in January while other Champlain LHIN hospitals are over 100% occupancy. Exhibit 52: Comparison of Annual Average and January Acute Care Census and Occupancy Annual Average January Average Hospital Empty % % Empty Census Beds Census Beds Occup. Occup. Beds Ottawa Hospital - General (18) 104% % (34) Ottawa Hospital - Civic (23) 106% % (32) Queensway-Carleton Hospital % % (3) Hopital Montfort % % 0 Cornwall Community Hospital (0) 100% % (15) Pembroke Regional % 69 80% 18 Hawkesbury & District % % (5) Renfrew Victoria Hospital (10) 134% % (17) Winchester District Memorial % 30 80% 8 Arnprior & District Memorial % 27 87% 4 Carleton Place And District % 17 78% 5 Kemptville District Hospital % 16 67% 8 Almonte General Hospital % 18 70% 8 Glengarry Memorial Hospital % 17 79% 5 Deep River And District % 12 76% 4 St. Francis Memorial Hospital % 9 88% 1 Champlain LHIN Total 1,607 1, % 1, % (47) Page 75

78 Champlain Hospital Site The availability of vacant beds in some of the smaller hospitals during the seasonal surge led to the question about how much rebalancing of acute care capacity could be achieved via repatriation of care to a closer hospital. There was a perception among Steering Committee members that many of the beds in Ottawa were occupied by patients living outside Ottawa, and that repatriation of their inpatient care to a hospital closer to home could greatly reduce the surge pressures on the Ottawa hospitals. The following table shows the estimated equivalent Medicine beds in each Champlain LHIN acute care hospital that were used for non- Ottawa residents in January Based on the entire length of stay of each case, 74% of the Ottawa General Medicine beds were used for Ottawa residents, and 26% for non-ottawa residents. Approximately 52 of the Ottawa General Medicine beds were used for patients who lived elsewhere in the Champlain LHIN. Exhibit 53: January 2014 Medicine Cases Only Use of Beds by Patient Residence by Hospital Site Full LOS Medicine Days Full Cases (i.e. Entire LOS) % for Ottawa Residents 100% for Ottawa Res. Equiv. Beds for Patients from Outside Ottawa Renfrew Stormont Dundas & Glengarry Prescott & Russell Out Of Province Ottawa General 9,877 74% Ottawa Hospital - Civic 6,578 90% Queensway-Carleton 4,110 93% Hopital Montfort 3,798 76% Heart Institute 2,101 59% CHEO 1,989 54% Grand Total 28,453 78% However, most of the patients from elsewhere in the Champlain LHIN who were hospitalized in an Ottawa hospital (and particularly at The Ottawa Hospital) were tertiary/quaternary care patients who could not have received equivalent care at their local community hospital. If instead, the potential repatriation opportunity is confined to only ALC days (i.e. have the patients return to their home community to wait until the appropriate post-acute resources are available), the estimate of equivalent ALC beds in Ottawa hospitals used for non-residents is very small, and repatriation of ALC stays would not significantly impact the over census occupancy in Ottawa. Other Page 76

79 Exhibit 54: January 2014 Medicine Cases Only Use of Beds by Patient Residence by Hospital Site ALC Days Only Champlain Hospital Site Alternate Level of Care Days Only ALC Days for Medicine Patients % for Ottawa Residents ALC 100% for Ottawa Res. Equiv. ALC Beds for Patients from Outside Ottawa Renfrew Stormont Dundas & Glengarry Lanark Prescott & Russell Other Ottawa - General 2,097 93% Ottawa - Civic 1,711 98% Queensway-Carleton 1,044 98% Hopital Montfort % Heart Institute % Grand Total 5,266 91% For Champlain LHIN rehab beds, there was much less variation between the average number of empty beds throughout the year (i.e. 10 beds), and the empty beds in January (i.e. 4.5 beds). Exhibit 55: Variation in Average Daily Census by Month for Champlain LHIN Hospitals Rehab Beds Annual Average January Average Hospital Empty Empty Census Beds % Occ. Census % Occ. Beds Beds Elisabeth Bruyère Hospital % 69 99% 0.9 Ottawa Hospital - Rehab Ctre % % (1.2) Queensway-Carleton Hospital % % 0.0 Ottawa Hospital - General % % (1.0) Pembroke Regional % 21 94% 1.4 Hopital Montfort % 20 94% 1.3 Cornwall Community Hospital % 9 92% 0.8 Glengarry Memorial Hospital % 8 77% 2.3 Champlain LHIN Total % % 4.5 For chronic beds, the average annual number of vacant beds was 40, with a drop to 28.3 vacant beds in January. Exhibit 56: Variation in Average Daily Census by Month for Champlain LHIN Hospitals Chronic Beds Annual Average January Average Hospital Empty % Census Beds Beds Occup. Census % Empty Occup. Beds St.-Vincent Hospital % % 12.4 St. Joseph's CC, Cornwall % % 0.1 Almonte General Hospital % 24 93% 1.9 Renfrew Victoria Hospital % 24 99% 0.3 Page 77

80 Annual Average January Average Hospital Empty % Census Beds Beds Occup. Census % Empty Occup. Beds Pembroke Regional % 20 96% 0.8 Hawkesbury & District % % 0.1 St. Francis Memorial Hospital % 9 94% 0.6 Winchester District Memorial % 8 70% 3.6 Arnprior & District Memorial % 8 57% 6.0 Glengarry Memorial Hospital % 5 100% - Kemptville District Hospital % 2 48% 2.6 Champlain LHIN Total % % 28.3 The final examination of seasonal capacity looked at convalescent beds in LTCH. There were 76 convalescent beds in Champlain LHIN LTCHs, with an average annual occupancy of 92%. In January and February 2015, there were 7 to 8 beds available, but only 1 in March. Exhibit 57: Occupancy by Month of Champlain LTCH Convalescent Beds Champlain LHIN Convalescent Care Beds Month Total Conval. Beds Occupied Not Occupied % Occup. 14-Nov % 14-Dec % 15-Jan % 15-Feb % 15-Mar % 15-Apr % 15-May % 15-Jun % 15-Jul % 15-Aug % 15-Sep % 15-Oct % Average % For most LTCH beds, there is an expectation that the average occupancy will be over 98%, and this is reinforced by the funding approach. However, this doesn t apply to convalescent beds in LTCH, for which the target average occupancy is only 75% Conclusions from Analysis of Surge Data After review of the analysis of historical utilization of Champlain acute and sub-acute care beds, the Steering Committee reached the following conclusions: Page 78

81 A surge in inpatient medical census of ~90 additional daily patients, particularly for Pulmonary patients, in January (and all of Q4) should be anticipated There are no obvious opportunities to reduce the surge via admission avoidance in ED There may be opportunity to rebalance acute care via use of some smaller facilities outside Ottawa, but this is likely applicable to post-acute convalescence and ALC days, rather than avoiding admission in an Ottawa hospital completely There is little opportunity to rebalance rehab, but some opportunity to take advantage of unused capacity in chronic beds LTCH beds are effectively full, except for funded convalescent care beds (and possibly respite beds) Requiring full occupancy of convalescent care beds (i.e. instead of the current 75% target occupancy) could accommodate 5 to 6 more patients A centralized mechanism is likely required to coordinate identification of available capacity, and coordinate transfer of patients between hospitals Additional interim solutions must focus on temporary expansion of bedded sub-acute capacity, or expansion of community and ambulatory sub-acute capacity Proposed Short Term Surge Management Strategies The potential short term surge management strategies considered by the Steering Committee were: 1. LHIN-wide bed management plan, with coordinated assessment of occupancy of funded beds and redistribution of patients between hospitals (primarily repatriation of non-ottawa residents to hospitals outside Ottawa) First priority in acute care beds, second in chronic beds (little apparent opportunity in rehab beds) Expectation that when occupancy in a hospital exceeds 100%, responsibility of other hospitals in the LHIN to be prepared to help by allowing their occupancy increase (to maximum of 100%) Apply to funded convalescent (and possibly respite) beds in LTCH (full utilization expected) 2. Providing priority access to LTCH beds for ALC patients in chronic beds during surge periods Page 79

82 3. Consider self-directed funding for ALC patients unable to enter LTCH (due to either lack of available beds, or financial impediments) to temporarily live in retirement facility 4. Provide temporary funding to support expansion of supportive housing and assisted living by approximately 20 beds 5. Identify opportunities to expand day hospital and ambulatory clinics to facilitate discharge of ALC patients to home (may require transportation subsidy?) 6. Consider potential for marginal increase in funded service hours for home care to allow ALC patients to return home Strategies 1, 2, and 4 above (i.e. coordinated bed management, priority access of chronic ALC patients to LTCH, and temporary expansion of supportive housing/assisted living) were identified as the most feasible options, and a LHIN working group was established to develop an implementation plan. Strategy 4 (temporary expansion of supportive housing/assisted living) was determined not to be financially feasible. A daily bed management teleconference call with hospital Flow Coordinators was initiated in support of Strategy 1, as well as enhanced planning between the Ottawa Hospital and Bruyère to provide additional capacity to TOH as well as to other hospitals in Champlain. The daily bed management calls found approximately 81 vacant beds in the system (in both the acute and sub-acute sectors) in December. The new provincial repatriation policy, process, and tools should provide a vehicle to support the transfer of patients to maximize the use of available capacity Projected Sub-Acute Surge in 2019 The strategies described above have been considered and used to address recent seasonal surges in demand for bedded care. Because there has been variation in percent occupancy of sub-acute beds across the LHIN, there has been some opportunity to re-distribute patients from over-census facilities to facilities with some vacant beds. The projections of bed requirements for 2019 are based on achievement of a consistent, and relatively high (compared to historical averages) annual target of 95% occupancy for hospital sub-acute beds. Increasing the average occupancy of Champlain LHIN rehab and chronic beds to 95% will allow the region to accommodate more patients in the current stock of beds, and defer investment in building new bed capacity. However, it will also reduce the flexibility of the LHIN to take advantage of low occupancy sites during seasonal surges, Page 80

83 requiring greater reliance on health promotion and illness prevention strategies to reduce the surge, and on priority access for hospital patients to LTCH beds. The analyses of historical Champlain LHIN data found that the January occupancy of sub-acute hospital beds was approximately 33 more patients than the annual average (i.e. 5 more rehab beds, and 28 more chronic beds). With the projected growth in the size of the overall, and specifically the elderly, population in the Champlain LHIN, we project that the January surge in daily sub-acute hospital patients could increase to 48 beds (8 rehab, 40 chronic). Page 81

84 6.0 Implementation Considerations 6.1 Implications and Critical Success Factors If no change in approach, 156 additional beds will be needed by 2019 With mitigation, many of these additional beds can be avoided Reduction in chronic LOS and reductions in ALC will be the primary strategies that allow needs to be met within existing bedded capacity Redistribution, changes in how capacity is used, and investments in home and community based care will be critical enablers The capacity planning process has suggested that, based on projected population growth, 156 additional sub-acute beds will be required in the Champlain LHIN by This assumes that, with the exception of growth for unmet need primarily in hip fracture and stroke rehabilitation, services continue to be delivered as they currently are. A significant increase in home care will also be needed to address population growth. However, it may be possible to avoid adding these additional beds to the system. Informed projections show that, with the right efforts, subacute needs can be accommodated within the current system. In fact, only 4 more beds may be needed by 2019, than were actually in use at the end of the 2015/16 fiscal year. This assumes that the addition of rehabilitation beds and chronic beds to accommodate population growth can be avoided through several key mitigation strategies: Moving patients directly to specialized rehab (rather than first to generalized rehab), which will save 5 beds Expanding capacity of community hospice to allow the current 31 Bruyère palliative care beds to meet the demand for sub-acute hospital-based palliative care Reducing length of stays in chronic beds to provincial averages, which can save up to 104 beds by 2019 Reducing Alternative Level of Care Days, primarily by avoiding inappropriate admissions and reducing lengths of stay, which will save 6.6 rehab beds and 18.5 chronic beds Accommodating future need with today s capacity will require the following happens successfully: Redistribution of beds types within the system, so that beds currently used for chronic care are used for rehabilitation Geographic redistribution, so that projected excess capacity in the eastern and western counties becomes available in the Ottawa area A new paradigm that commits to providing care in the least costly setting possible, including using hospital beds as part of the continuum of rehabilitative or restorative care and not a final destination for patients. This may require that some settings, such Page 82

85 No increase in LTC beds, but anticipate that more LTC capacity will be accessible for sub-acute Costs will increase, even though number of beds will not increase In addition, there is a need to consider strategies that may reduce longer-term demand for sub-acute services now as long term care, may need to change the type and amount of care they provide. Significant investments in home care and in community based rehabilitation services. This investment is of the magnitude of 35% in homecare (primarily in progression services) as well as increased investments in hospital ambulatory care and community bases services. It is noted that this plan is not predicated on an increase in the number of long-term care beds. It does presume improved access, and more available capacity, in long-term care than current because new investments in home and community based services will ensure that more people avoid using long-term care by either staying in their homes longer and by returning to home or alternative living situations rather than relying on long-term care placement as part of the sub-acute continuum. Patient flow resulting from timely access to long-term care beds will be critical to the success of this plan, and may require that preferred or priority access to long-term care beds be considered. This plan is also predicated on investments in community based hospice and palliative services. It should also be noted that while this plan suggests that future subacute needs can be accommodated without adding beds, costs of the system will increase. Investments are needed, and the care that will be provided in existing beds will be more costly than current. Finally, while this plan will address capacity issues for the more immediate and short term future, the sub-acute planning committee advises that it is necessary to consider the longer term future. The committee strongly advises that investments in strategies and tactics that may address avoidable causes of future sub-acute demand be considered now. There is growing evidence around approaches to lessen the impact of: Acute hospital acquired disability (delirium, deconditioning, etc.) Community acquired disability (functional decline, mobility decline, social isolation, falls risks) Dementia (difficulties managing in both home and community based institutional settings). Planning to address these important upstream issues should occur concurrent to, and in coordination with, the implementation of this plan. Page 83

86 Changes from current system state, and at the organization level, will be required to actualize the recommended sub-acute capacity plan Implication of the recommended plan 6.2 Enablers and Critical Success Factors In order to actualize the sub-acute capacity plan recommendations, changes from current state will be required. Throughout the course of this project it become clear that system stakeholders recognize that there is room for improvement in the current system in terms of ensuring optimization of resources and patient access to the right care at the right time and place. It was presumed that some changes to both capacity and systems process would be required to drive improved clinical outcomes for patients, to realize efficiencies, and to mitigate future demand based on population growth. Stakeholders agreed that principles of being evidence based but anchored in reality, client centred, efficient, connected and accountable, and focused on early identification and prevention should guide the planning assumptions used for the new model. They also identified desired characteristics of the improved system. With modeling complete, it is clear that movement toward this desired state will be required if the recommended plan is to be implemented effectively. In order to operationalize the plan, some key changes will need to be considered: Achievement of reductions in ALC and LOS/convertible days in chronic bed used throughout the region will be required to avoid adding a substantial number of beds in the future. This will be achieved, in part, through the redistribution of capacity, which will reduce some of the bottlenecks resulting in ALC that the system is currently experiencing. Investments in community based services and alternative levels of care, such as home and community based services, particularly for seniors, people with dementia or behavioural needs, will also be required. This will result in more accessible capacity in long-term care homes. Additional efficiencies can likely be achieved through process improvements in patient flow through the system. Movement towards a seven day a week model for therapy, admissions and discharges in inpatient settings will also be required in order to gain efficiencies, including reductions in lengths of stay and ALC days. To be effective, all organizations will need to be enabled to both accept and discharge patients any day of the week. This will require significant operational change and redistribution of internal resources, including potentially physician availability, at the organizational level. Page 84

87 Across the region there will be a redistribution of services and bed types in order to accommodate future needs. The region will need to plan for these adjustments, transition to them over time, and develop the capabilities and programming needed across the system. The most significant redistribution considerations: Growth in bedded rehab and restorative capacity in Ottawa region, with some slight reductions in current capacity elsewhere, primarily in Renfrew County. The trend is to more specialized rehabilitation beds and fewer chronic beds. Highly specialized inpatient and ambulatory rehabilitation services will continue to be consolidated in the Ottawa geography. Further, consolidating specialized rehab services in Ottawa from two sites to a single site (with one administration) would be beneficial. This site could be co-located with acute care services, and should have the ability to flex beds as needed to deal with changes in volumes and/or surges for various diagnoses that they would service Inpatient stroke rehabilitation should continue to be provided at three sites throughout the region, as there is sufficient volume and critical mass of skill to do so. Continued attention to meeting Ontario Stroke Guidelines is required. The plan suggests that the stroke centres in the region will also need to plan for enhanced capacity to provide ambulatory stroke services in order to ensure continuity of care. This will likely require capital, staffing and operational changes. Very specialized complex medical patients with rehab or restorative needs (such as ventilated patients, patients with tracheostomies, those receiving renal dialysis) should be consolidated in Ottawa at a single site. Planning for siting and the capacity to care for and support the medical needs of these patients will need to be considered Transferring assess and restore programming to chronic beds rather than specialized rehab beds across the region. Developing program plans that are aligned with assess and restore philosophy will be necessary for the organization that begin to deliver this type of service. Recognizing that geriatric rehabilitation is a specialized service that should be provided in specialized beds, with access to specialized geriatric expertise, across the region. This contrasts with general rehabilitation services for seniors that should be available as close to home as possible. The region will need to continue to focus on ensuring that specialized geriatric services Page 85

88 and supports are available as needed, and that the capacity to identify, assess and treat at risk seniors as early as possible (ideally in the community) continues to grow. Ensuring that convalescent care, which is a cost effective approach as patients gain the strength, skills and confidence needed to return to home, is available in long-term care settings throughout the region. A new program model will be required to allow long-term care homes to offer this restorative approach to care effectively. Investments in community based care will be required to enable the new model and reduce the number of rehabilitative and restorative beds needed in the future. Modeling assumes that: In home progression and maintenance services will be increased to at least provincial averages. This represents a substantial cost, particularly for progressive services, as well as operational challenge for home care providers to ensure they have the volume of staff and range of skills needed to provide the required services. There will be increased availability of ambulatory services, such as day hospitals and outpatient care across the region in select locations. These services will ideally be co-located, and perhaps co-provided, by the organizations that deliver stroke and other more specialized rehab in each geographic area, creating a rehab hub model. Again, this represents a change in cost to the system, as well as operations for the organizations that will deliver these services. Consideration be given, despite a lack of strong evidence, to investing in similar type of prevention and maintenance supports as are available elsewhere in Ontario, with the goal of reducing or delaying the need for subacute services. This includes continued investment in programming such as local exercise classes, falls prevention, chronic disease management education, caregiver education and supports, etc. Adjustments to staffing will be required in organizations throughout the region in order to accommodate the new model. In many cases, organizations will need to be able to offer more therapy, nursing and physician services, a higher intensity of rehab or restoration, or to manage more complex patients. Similarly, throughout the system, staffing models are designed to accommodate the relatively high ALC rates that currently exist. Thus, organization do not staff their units to full capacity, as not every bedded patient requires the intensity of treatment that would Page 86

89 normally be provided in that level of care. As ALC rates are reduced, organizations will need to staff up to provide for the number of therapy and nursing hours required. This represents increased cost for each organization. Access to French language services must be planned. Decisions will need to be made on how and where French speaking residents who require highly specialized care typically consolidated and available in only one location will access services in French. Consideration should be given to providing novel approaches to offering alternatives to care when it is beneficial to both the patient and the system. For example, exploring the option of providing self-directed funding for seniors to enable them to purchase the services they need to stay at home or return home more expediently, or as a top up to access private-pay retirement settings as an alternative to long-term care where appropriate, should be considered. Systems coordination and increased integration Systems coordination will be a primary enabler to the new model. Stakeholders agree, and evidence supports that, a more coordinated or integrated approach to managing sub-acute patients, both short term and those with chronic needs, allows for improved patient outcomes and optimized the use of resources. In order to implement the proposed capacity model effectively, consideration should be given to: Moving to more coordinated or centralized approach to intake, assessment and alignment of patients with existing beds and resources. Determination of how resources will be allocated to patients, who will have this authority and how it will be operationalized across the region will be required Potentially moving to a new model of case management that spans the continuum of care for rehabilitative and restorative care and coordinates care for patients, or for a subset of these patients (such as highly complex/frail seniors, people with long term disabilities, people with high levels of complexity or multiple risks or comorbidities, people with addiction, mental health or behavioural issues) should be considered. Models similar to Health Links, where providers are mandated and incented to work together across organizations, and tools and processes to facilitate coordinated care planning and community have been developed, could be considered. The need for increased sharing of specialized knowledge and expertise throughout the region should be anticipated with the new model. It will be essential to ensure that technology and incentives that facilitate knowledge transfer, consultation, and information sharing are in place across all levels of the system, from hospital to Page 87

90 the community, and including primary care. This will be particularly true for physician (physiatry, geriatrics, care of the elderly) knowledge and expertise. Moving to a more coordinated or centralized approach to managing subacute resources throughout the region. This would include things such as flexing beds or reassigning regional resources based on needs and demand. Again, it will be important to determine who would have decision making authority and the policies, procedures and operational enablers that will need to be in place to manage and share resources in this way in Champlain. Opportunity to Better Support Chronic Ventilator Patients through Integrated Approach An example of a patient population for whom a coordinated and integrated approach to care could both enhance quality and reduce demand on institutional beds are the chronic ventilator patients. Changes in ventilator technology and home support have created greater opportunities for patients to return home or live in long-term care. In 2014/15, there were 47 ventilated patients in chronic hospital beds in Ontario who were discharged home. While the Champlain LHIN hospitals had the 2 nd highest total number of ventilated patients in a chronic hospital bed, only 1 Champlain patient was discharged home. Increasing this number will require the joint efforts of both acute and sub-acute care providers. Hospital LHIN Exhibit 58: 2014/15 Discharge Placement for Chronic Ventilated Patients in Chronic Hospital Beds Total Chronic Patients Distribution of Ventilated Patients by Discharge Disposition Home Xfer to Not (incl. LTC Acute Died Other Disch. Retire. Home IP Home) Toronto Central % 20.0% 5.7% 22.9% 1.9% 1.9% Champlain % 27.0% 40.5% 2.7% 0.0% 0.0% All Other LHINs % 23.4% 10.9% 14.1% 4.7% 3.1% Ontario Total % 22.6% 13.0% 15.9% 3.0% 2.2% 6.3 Best Practice Learnings for Moving To the Improved System of Sub-Acute Care The capacity plan necessitates significant changes to how sub-acute services are governed, planned, organized and delivered in Champlain The new capacity plan creates an opportunity, or arguably even the necessity, to create transformative changes to the organization of subacute services in the Champlain LHIN. As the desired, or necessary, systems operating characteristics are considered it becomes evident that a different approach to planning, operating and governing subacute resources may be required. Page 88

91 While there has been relatively little research in the organization of sub-acute care, we can draw on research, principals and best practices identified in related fields, such as care of the elderly, to inform the Champlain approach to implementation. A systematic review of integrated systems approaches for the care of the elderly by Margaret MacAdam (2008) finds evidence that it is possible to design programs that minimize the use of institutions (hospitals, long-term care) and achieve improved patient outcomes and satisfaction, including improved quality of life and reduced caregiver burden. The specific features of successful models may vary, but typically include the use of case management and access to a wide range of social and health supportive services. However, while client outcomes improve, cost savings are not immediate. Investments have to be made to realize the potential of integrated care. Elements to consider for implementation MacAdam s review suggests that there are four types of interventions that must be structured in ways that are supportive of each other to support well integrated system of care. These include: umbrella organizational structures to guide integration of strategic, managerial and service delivery levels; encourage and support effective joint/collaborative working; ensure efficient operations, and maintain overall accountability for service, quality and cost outcomes multidisciplinary case management for effective evaluation and planning of client needs, providing a single entry point into the health care system, and packaging and coordinating services organized provider networks joined together by standardized procedures, service agreements, joint training, shared information systems and even common ownership of resources to enhance access to services, provide seamless care and maintain quality, and financial incentives to promote prevention, rehabilitation and the downward substitution of services, as well as to enable service integration and efficiency No single element of integrated models of care has been shown to be effective in and of itself. However, at a minimum, all successful programs of integrated care for seniors use multidisciplinary care/case management supported by access to a range of health and social services. The strongest programs also include active involvement of physicians. Decision tools, common assessment and care planning instruments and integrated data systems are commonly listed infrastructure supports for integrated care. The Champlain LHIN will need to consider all of these elements when planning for the implementation of the new sub-acute capacity plan. Page 89

92 A continuum of options for integration of services When considering systems design, Leutz (1999) makes important distinctions among a continuum of integration options that should be considered: Linkage allows individuals with mild to moderate health care needs to be cared for in systems that serve the whole population without requiring any special arrangements. Coordination requires that explicit structures be put in place to coordinate care across acute and other health care sectors. While coordination is a more structured form of integration than linkage, it still operates through separate structures of current systems. Full integration creates new programs or entities where resources from multiple systems are pooled. Leutz points out that not all models require full integration to be effective. For example, he argues that seniors requiring continuing care across various care settings and providers can be provided that care through a well-coordinated care systems. It could be argued that the Champlain LHIN currently has a sub-acute system that has both linkages and coordination in place at present. The challenge for implementation of the new sub-acute capacity plan in Champlain will be to move toward greater integration only where necessary, leveraging coordination and linkages where ever possible. Levels of integration to be considered when planning Another layer within the concept of integrated care or consideration concerns levels of integrative activity: System integration includes activities such as strategic planning, financing, and purchasing systems, program eligibility and service coverage, within a geographical area or across a country or province. Organizational integration refers to the coordination and management of activities among acute, rehabilitation, community care and primary care provider agencies or individuals. Clinical integration concerns the direct care and support provided to people by their direct caregivers (Edwards and Miller, 2003). Lack of integration at any one level typically impedes integration across the levels (Banks, 2004; Kodner and Kyriacou, 2000). For example, system decisions about the range of services, their availability, eligibility requirements, funding mechanisms and desired quality affect the ability of organizations to collaborate (especially across the health and social services sectors). Also, within and across organizations, clinicians can either be encouraged or restricted from Page 90

93 participating in more integrated care programs. Again, Champlain LHIN will need to carefully consider the level of integration most necessary to facilitate implementation of the new sub-acute capacity model. Administrative and clinical best practices for system organization and design Finally, Hollander and Prince (2008) suggest best practices for integrated care models. They argue that administrative best practices for systems organization include: A clear statement of program philosophy, enshrined in policy A single, or highly coordinated, administrative structure A single funding envelope Integrated information systems Incentive systems that promote evidence based management Clinical best practices for a well-integrated system include: A single, or coordinated entry system Standardized, system-level assessment and care authorization A single, systems level client classification system Ongoing systems level case management Involvement of clients and families Hollander and Prince s best practices are well aligned with the desired future state and implementation needs suggested throughout this project. Champlain LHIN will need to determine the degree to which these best practices are adopted when moving towards the new capacity approach. 6.4 Governance Options for Sub-Acute Care in the Champlain LHIN The government proposes to expand the mandate of Local Health Integration Networks (LHINs) so they are accountable for the planning and performance of primary care and the delivery of home and community care. This proposed change will create an integrated system that works efficiently to support patients and caregivers with better access to the care they need no matter where they live and smoother transitions between health services Ontario Budget, Chapter I: Building Prosperity and Creating Jobs, Section D: Transforming Health Care Page 91

94 The degree of integration needed, and the authority and process for developing the more integrated subacute system must be determined While it is clear that the LHIN has a mandate to ensure integration occurs, the necessary degree of integration, and the authority and process for developing and designing a more integrated sub-acute system needs to be determined. Currently, organizations function primarily independently when delivering sub-acute care, although there is cooperation and collaboration in place, and a number of pan-system planning and advisory bodies exist (such as the LHIN ALC working group, the Stroke network, etc.). A new governance approach for sub-acute care in the LHIN may be required to both effectively transition to this new capacity plan and to manage the system under the new parameters required for its success. It is clear, that at minimum: A redistribution of bed types is required Siting of the various types of beds and resources needs to be determined Operational changes to support siting and sizing will need to occur Investments and/or planning for new resources will need to be considered Efficiencies and mitigation strategies (length of stay reductions, conservable days) must be realized to successfully achieve the new plan It is likely that there also need to be: Movement towards a more centralized process for patient assessment and placement Movement towards more centralized resource utilisation planning and controls across the LHIN Development of new policies, processes, tools and protocols to ensure linkages, coordination and integration occurs as needed to optimize sub-acute services Planning for changes in upstream care and a dementia care strategy, in order to mitigate future demand for sub-acute services over the longer term (i.e. beyond the timeline of this subacute plan) Development of new governing structure(s), umbrella organization or provider networks for the delivery of sub-acute services in Champlain after the transition to the new model is complete. Page 92

95 New governing structure recommended for implementation and ongoing system management Key accountabilities Governance options A structure to guide implementation at the systems level is required to complete these tasks necessary to transition to the new model for subacute care in Champlain. Champlain LHIN has had experience with many different approaches for implementing various initiatives in the LHIN, and the Sub-acute planning committee examined learnings from these experiences to make a recommendation on the best approach for implementing the new sub-acute capacity plan. Key functions to be provided by the governing structure should include: Providing advice to the LHIN for the implementation of the new sub-acute capacity model Overseeing effective implementation of the new sub-acute capacity model in the Champlain LHIN. This will include: Ensuring a balanced perspective and a coordinated, collaborative approach in developing and implementing the sub-acute plan is in place within the LHIN, including how subacute care fits with the broader planning and improvement/oversight structures and bodies already in place Planning the new approach at both the system and organization level Gathering information and advising on new approaches, standards, processes, tools and policies that should be in place Advising on resource requirements to effectively execute the plan Overseeing implementation of the new plan, including operational and systems level changes Providing advice for more permanent structure that will be in place post-transition in order to continue to plan, monitoring and evaluate the delivery of sub-acute care across the Champlain LHIN Providing advice and advocacy for investments that should be considered (such as a dementia care strategy and hospital/community acquired disability avoidance approaches) that will reduce the need for sub-acute care in the longer term. Individual organization will continue to be accountable to the LHIN through accountability agreements, which should be adjusted to over time to reflect the directions of the new sub-acute model in Champlain. It is recommended that a Champlain LHIN Sub-Acute System Implementation structure with the following attributes be considered: Page 93

96 The LHIN will remain the primary decision maker and will direct activity. The LHIN has authority for decision making, but it takes both takes advice and provides direction to an executive-level steering committee for systems and organization level change in sub-acute care service delivery. An executive steering committee could be responsible for ensuring the new capacity plan is implemented. This committee could be comprised of a sub-set or representative group of CEO/leaders from each of the key organizations who deliver subacute care (hospitals and CCAC). This group should have the insight to understand the system level changes required for subacute care, will understand how sub-acute care fits into the broader planning picture within the LHIN, and will have the authority to support the organization level changes that will be required to make the necessary sub-acute systems changes. This group will be responsible for both making implementation recommendation to the LHIN, and for ensuring recommendations/directions from the LHIN are executed within their organization. An advisory body to the executive steering committee should be put in place. The purpose of this body would be to provide detailed expert advice to the steering committee, but also to complete systems level tasks that will be necessary to execute the work required for successful implementation (for example, developing new processes and tools for central assessment and intake). The membership of the advisory body could be similar to the current Sub-acute Capacity Planning Committee, with representation from clinical experts, administrative experts, and other regional stakeholders (hospital, sub-acute programs, and regional committees). Consideration will need to be given to aligning the work of existing LHIN and regional groups and networks with the work of this advisory body, as well as how to best leverage existing knowledge, work and expertise. The advisory body may be structured into task groups as needed to complete their work most effectively, and should have accountability to the Executive Committee. Sub-Acute System Implementation Support will likely be required to help manage the work of the governing structure and act as an implementation resource. At minimum, a director with administrative support could be provided to both project manage and provide support for implementing the new sub-acute plan. Responsibilities will include such things as supporting the Executive Steering committee, supporting the advisory body, supporting the action teams by providing arms and legs resources Page 94

97 across involved organizations to develop new tools, processes and resources required for implementation. It is suggested that a process to oversee implementation will be required for 3 to 5 years as the system transitions to the new capacity model. One of the recommendations of the structure overseeing implementation should be the accountabilities and composition of a more permanent governing structure that will then exist to manage, direct and evaluate the delivery sub-acute care in the LHIN on an ongoing basis. Page 95

98 Appendix A: Literature Review re Sub- Acute System Models Page 96

99 A literature review was conducted for evidence with respect to the development of models of sub-acute care, sub-acute capacity planning, and governance of sub-acute care. Databases included Ovid s Medline and Embase and NLM s Pubmed for peer-reviewed publications, and Google Scholar for grey literature. MeSH headings for peer-reviewed publications included: subacute care, after care, rehabilitation, palliative care, discharge planning, patient discharge, intermediate care facilities, capacity planning, and governance. Google Scholar search terms included post-acute rehabilitation, subacute care, and governance. To ensure results were relevant to the Ontario health care context, studies were included if the study was conducted between January 1 st 2000 to November 21 st 2013 in one of the following regions: Europe, Australia, New Zealand, Canada, and the United States. Only English or French language articles or reports were included. The search yielded 2,398 articles and reports. After title and abstract screening, only 63 articles and reports were deemed potentially relevant. After full-text review, 58 articles were included in the review. Evidence suggests there is no gold standard for sub-acute capacity planning. In fact, there are 32 definitions of sub-acute currently in use. For the purposes of our review, we accepted a broad definition of sub-acute care as any service that links hospital care with a patient s home. Sub-acute care may therefore include, for example, rapid response nursing programs, hospital at home programs, or rehabilitation within residential care facilities. A 2014 Australian report by Dawda and Russell concluded that the cost-effectiveness of sub-acute care is unknown, and that there is no single model of subacute care for all systems [1]. Similarly, we found that the evidence of sub-acute care models, and subsequently sub-acute care capacity planning and governance of subacute care, to be weak and often non-existent. It is difficult to draw conclusions with respect to structures and models of sub-acute care when there is a lack of comparability both within and between health systems with respect to the most basic concepts, such as the definition of sub-acute care. For example, a 2008 Cochrane review of hospital at home programs found that there is insufficient evidence to determine if hospital at home is a cheaper alternative to in-patient care, or if it results in improved health outcomes [2]. This lack of comparability also leads to difficulties with respect to funding mechanisms to promote quality of post-acute care delivery. The most common financial model of sub-acute care is pay for performance (P4P), which was implemented in 2004 in the United Kingdom [4]. P4P is also used in the United States, Australia, and Page 97

100 Germany. The general concept of P4P is tying financial reward to patient health outcomes, however there are multiple barriers in practice, including the time between final outcome and provision of service, supportive information technology infrastructures, appropriate use of health human resources, and navigating geographical concerns (e.g., urban versus rural areas). Of the countries included in this study, the United States has the most diverse funding mechanisms and financial incentives. Accountable care organizations (ACOs) in the United States have bundled payment strategies that have led to various post-acute care governance models: Steering (hospital has preferred post-acute partner); Bundling (services are bundled across the entire continuum of care); integration joint ventures (collaborative agreements between acute and post-acute providers); and integration full ownership (agreements between acute and post-acute providers with acute providers full management control) [3]. The use of these models is dependent on the local health care market [3]. It is therefore difficult to determine which models would be most appropriate (i.e., cost-effective) within the context of Ontario. Also, systems with a large publically funded component (such as Ontario) are slower to integrate change than systems with a large privately funded component. The diversity of financial and governance structures of post-acute care models in various health systems, coupled with the lack of costeffectiveness (or even just costs, and effectiveness separately) information, results in a lack of gold standard post-acute care model that can be recommended for implementation in the Champlain LHIN. References 1. Dawda P and Russell L Sub-acute care: an international literature review. Australian Primary Health Care Research Institute, Australian National University. Pg Shepperd S, Doll H, Angus RM, Clarke MJ, Lliffe S, Kalra L, Ricauda NA, Wilson AD Hospital at home admission avoidance. Intervention Review, Cochrane Effective Practice and Organization of Care Group. 3. McHugh JP, Trivedi AN, Zinn JS, Mor V Post-acute integration strategies in an era of accountability. Journal of Hospital Administration, 3(6): Hall P Designing the structure for Australia s Health System. Occasional Paper, The Academy of the Social Sciences in Australia, Canberra. Pg1-29. Page 98

101 Appendix B: List of Stakeholders Consulted Participant Simon Akinsulie Andrea Andrecyk Therese Antoun Heather Arthur Fred Beauchemin Maryse Bouvette Kelly Bradley Helen Brezynskie Beth Brownlee Julie Budd Sean Burnett Cathy Burke Wendy Charbonneau Jean Chouinard Sherry Daigle Alan Davitt Sue Dojeiji Organization ED, Long Term Care, Bruyère Continuing Care Rehab Consumer Advisory Committee Clinical Director, Montfort Hospital & Rehabilitative Network of Champlain VP Patient Services and CNO Cornwall Community Hospital & Champlain Sub-Acute Capacity Planning Steering Committee Clinical Director, The Ottawa Hospital & Chair, Rehabilitative Network of Champlain & Champlain Sub-Acute Capacity Planning Steering Committee Regional Palliative Care Network Integration Specialist, Champlain LHIN Clinical Manager, The Ottawa Hospital Clinical Director, The Pembroke Regional Hospital & Rehabilitative Network of Champlain Clinical Manager, Montfort Hospital Winchester District Memorial Hospital Champlain Alliance of Small Hospitals & Champlain Sub-Acute Capacity Planning Steering Committee Rehab Consumer Advisory Committee Medical Director, St. Vincent s Hospital Clinical Manager, The Ottawa Hospital Rehab Consumer Advisory Committee Physiatrist in Chief, The Ottawa Hospital & Rehabilitative Network of Champlain & Champlain Sub-Acute Capacity Planning Steering Committee Page 99

102 Anne Elliot Participant Sean Gehring Guy Frappier Veronique French Merkley Debbie Gravelle Kathy Greene Paulette Guitard Lynn Hall Anne Harley Cheryl Homuth Patrick Hurteau Jean Joanisse Collinda Joseph Daniel Levac Leah Levesque Organization Clinical Manager, Winchester District Memorial Hospital Clinical Manager, The Ottawa Hospital Deep River District Hospital Geriatric Medicine, Montfort Hospital SVP Hospital Programs and CNO, Bruyère Continuing Care & Champlain Sub-Acute Capacity Planning Steering Committee Director, Decision Support and Clinical Admissions, Bruyère Continuing Care & Rehabilitative Network of Champlain & Chair, ALC Working Group & Champlain Sub-Acute Capacity Planning Steering Committee Dean, School of Rehabilitation, Ottawa University & Rehabilitative Network of Champlain VP, Clinical Services and CNO, Winchester District Memorial Hospital & Rehabilitative Network of Champlain Chief, Care of the Elderly, Bruyère Continuing Care Director of Community Outreach, Perley-Rideau Veteran s Health Centre Professional Practice, Bruyère Continuing Care Chief of Geriatrics, Perley-Rideau Veteran s Health Centre Rehab Consumer Advisory Committee EVP and COO, Bruyère Continuing Care & Champlain Sub-Acute Capacity Planning Steering Committee Champlain Alliance of Small Hospitals & Champlain Sub-Acute Capacity Planning Steering Committee Page 100

103 Participant Cameron Love Anne MacDonald Chantal Mageau-Pinard Anne Mantha Shawn Marshall Cal Martell Ted Masters Claire McCabe Shaun McGuire Heather McKenna Patsy McNamara Sabine Mersmann Kelly Milne Andrea Miville Frank Molnar Lynda Muckleston Carol Elaine Murphy Organization EVP and COO, The Ottawa Hospital & Champlain Sub-Acute Capacity Planning Steering Committee Clinical Director, Queensway Carleton Hospital & Rehabilitative Care Network of Champlain& Chair, Champlain Stroke Rehab Capacity Planning Work Group & Champlain Sub-Acute Capacity Planning Steering Committee Rehabilitation Manager, Glengarry Memorial Hospital Hospice Care Ottawa & Rehabilitative Network of Champlain Physiatrist in Chief, The Ottawa Hospital Senior Director, Health Systems Integration, Champlain LHIN & Champlain Sub-Acute Capacity Planning Steering Committee Rehab Consumer Advisory Committee Champlain CCAC Chief of Staff, Bruyère Continuing Care & Champlain Sub-Acute Capacity Planning Steering Committee Rehabilitative Network of Champlain Clinical Manager, The Ottawa Hospital VP, Pembroke Regional Hospital & Champlain Sub-Acute Capacity Planning Steering Committee Regional Geriatric Program of Eastern Ontario Regional Geriatric Program of Eastern Ontario Medical Director, Regional Geriatric Program of Eastern Ontario & Champlain Sub-Acute Capacity Planning Steering Committee Rehab Consumer Advisory Committee Manager, Subacute Transitions, The Ottawa Hospital Page 101

104 Participant To Nhu Hguyen Beth Nugent Melanie Parnell Sophie Parisien Jose Pereira Lucille Perrault Marice Prior Jill Rice Sherry Roberts Jacqueline Rousseau Richard Ruest Penny Sands Brian Schnarch Laurie Scissons Dionne Sinclair Paula Sleeman Brian Smith Lisa Sullivan Toni Surko Brian Tardif Page 102 Organization Director, Patient Care, The Royal Ottawa Health Care Group Champlain Regional Stroke Network Manager, Discharge Services Queensway Carleton Hospital Director, Clinical Care, Champlain CCAC & Rehabilitative Network of Champlain Medial Director, Palliative Care, Bruyère Continuing Care and The Ottawa Hospital VP Clinical Programs and CNO, Montfort Hospital & Champlain Sub-Acute Capacity Planning Steering Committee Rehabilitation Manager, The Ottawa Hospital Regional Palliative Care Network Flow Coordinator, Winchester District Memorial Hospital The Ottawa Hospital & ALC Working Group Rehab Consumer Advisory Committee Senior Director, Care Coordination, Champlain CCAC & Champlain Sub-Acute Capacity Planning Steering Committee Director, System Performance and Analysis, Champlain LHIN & Champlain Sub-Acute Capacity Planning Steering Committee Nurse Manager, Carleton Place and District Hospital Director, Complex Continuing Care, Bruyère Continuing Care Director, Patient Access and Community Liaison, Cornwall Community Hospital Rehabilitative Network of Champlain Executive Director, Hospice Care Ottawa CEO, Carleton Place and District Memorial Hospital & Rehabilitative Network of Champlain Rehab Consumer Advisory Committee

105 Participant Debbie Timpson Catherine Van Vliet Peter Walker Christine Yang Organization Physician Lead, Stroke Prevention, Pembroke Regional Hospital & Rehabilitative Network of Champlain Director of Patient Services and Integration, Kemptville District Hospital & Rehabilitative Network of Champlain CEO, Elisabeth Bruyère Research Institute Medical Director, Champlain Regional Stroke Network Page 103

106 Appendix C: Application of RCA Levels of Care Page 104

107 Algorithms to Support Assignment of Administrative Records to the RCA Rehabilitative Care Framework for Levels of Care CHRIS HELYAR TORONTO HEALTHCARE, 21 MARCH, 2016 CONTENTS RCA Bedded Levels of Care Application to Inpatient Rehabilitation data (NRS) Application to Inpatient CCC data (CCRS) RCA Community Levels of Care Application to RAI-HC data Specialized Rehabilitation vs. General/Geriatric Rehabilitation 2 Page 105

108 01 REHABILITATIVE CARE ALLIANCE BEDDED LEVELS OF REHABILITATIVE CARE 3 ELIGIBILITY CRITERIA FOR BEDDED LEVELS OF REHABILITATIVE CARE The patient has restorative potential*, (i.e. there is reason to believe, based on clinical assessment and expertise and evidence in the literature where available, that the patient's condition is likely to undergo functional improvement and benefit from rehabilitative care); AND While some patients being considered for Long Term Complex Medical Management may not be expected to undergo functional improvement, the restorative potential of patients can be considered from their ability to benefit from rehabilitative care (i.e. maintaining, slowing the rate of or avoiding further loss of function) The patient is medically stable such that s/he can be safely managed with the resources that are available within the level of rehabilitative care being considered. There is a clear diagnosis for acute issues; comorbidities have been established; there are no undetermined acute medical issues (e.g. excessive shortness of breath, congestive heart failure); vital signs are stable; medication needs have been determined; and there is an established plan of care. Some patients (particularly those in the Short and Long Term Complex Medical Management levels of rehabilitative care) may experience temporary fluctuations in their medical status, which may require changes to the plan of care, AND The patient/client has identified goals that are specific, measurable, realistic and timely ; AND The patient/client is able to participate in and benefit from rehabilitative care (i.e., carry-over for learning) within the context of his/her specific functional goals; AND Patients being considered for short term complex medical management may not demonstrate carryover for learning at the time of admission, but are expected to develop carry-over through the course of treatment in this level of care. The patient s/client s goals/care needs cannot otherwise be met in the community 4 Page 106

109 Page 107

110 CONCEPTUAL FRAMEWORK BEDDED LEVELS OF REHABILITATIVE CARE 5 02 APPLICATION OF RCA FRAMEWORK TO NRS DATA 6 Page 108

111 APPROACH Central West approach assumed all NRS patients are Rehabilitation, but some LHINs have used designated Rehab beds to accommodate other services, and some acute care hospitals have used Rehab beds for ALC patients Assume NRS patients are Rehabilitation within RCA framework, except for some in Other Disabilities RG (which is the fastest growing category, and now has a higher volume of cases than any other group (including Stroke and Hip Fracture) Separate the Other Disabilities RG into 3 groups Medically Complex, Debility, and Other Disabilities (based on RCGs) Medically Complex is Rehabilitation within the NRS framework (slightly older than average, with shorter LOS, admit FIM the same as the overall average, and average 16 point improvement during stay) Debility and residual Other Disabilities are older patients, particularly for Debility, very short LOS, very high admit FIM, but with lowest FIM change during their stay, more likely to be discharged to LTCH Categorize Debility and Other Disabilities combined as Activation/Restoration except for 7 SEPARATION OF OTHER DISABILITIES RG Other disabilities rehabilitation group contains many RCGs - split into 3 groups: Debility (16.1), Medically Complex (17), Other Disability (all others) Rehabilitation Client Group Ont. Cases Avg. LOS Avg. Age Avg. Admit FIM Avg. Disch. FIM (12.1) Congenital Anomalies - Spina Bifida (12.9) Congenital Anomalies - Other (13.1) Other Disabling Impairments (15.1) Developmental Disabilities (16.1) Debility-Include Only Subjects Who Are Debilitated For Reasons Other Than Cardiac (09) Or Pulmonary (10) Condns 2, (17.1) Medically Complex - Infections (17.2) Medically Complex - Neoplasms (17.31) Medically Complex - Nutrition (Endocrine/Metabolic) With Intubation/Parenteral Nutrition (17.32) Medically Complex - Nutrition (Endocrine/Metabolic) Without Intubation/Parenteral Nutrition (17.4) Medically Complex - Circulatory Disorders (17.52) Medically Complex - Respiratory Disorders Non-Ventilator Dependent (17.6) Medically Complex - Terminal Care (17.7) Medically Complex - Skin Disorders (17.8) Medically Complex - Medical/Surgical Complications (17.9) Medically Complex - Other 2, Grand Total 7, Page 109

112 Page 110

113 RPG DISTRIBUTION OF DEBILITY CASES BY RPG Cases Avg. RPG RCW Avg. FIM Total Avg. FIM Total Avg. LOS FIM Change FIM Effic. Admit Disch , (blank) Total 2, RPG Cases RPG 3100 cases discharged from Ontario inpatient rehab beds in 2014/15 Represent just over half of all Debility cases % Distribution by Disch. Disposition Hospital IP LTC Home Home w/hc Other , % 10.1% 54.1% 20.4% % 6.5% 50.2% 35.6% % 4.9% 36.6% 48.8% % 10.7% 30.6% 54.4% % 7.1% 37.5% 48.2% (blank) % 0.0% 0.0% 100.0% Grand Total 2, % 8.8% 48.7% 31.3% Have the lowest average FIM at admission (more than 20 points lower than other debility RPGs), and lowest average discharge FIM Have the longest average LOS and highest FIM change during the stay Are most likely to be transferred to an inpatient hospital bed from rehab, and most likely to receive home care if they are discharged home Categorize the Debility RPG 3100 cases as Rehabilitation, but assign remaining Debility cases to Activation/Restoration 9 APPLICATION OF APPROACH IDENTIFIES 6% OF NRS CASES AND 5% OF DAYS ASSOCIATED WITH THESE CASES AS FALLING INTO ACTIVATION/RESTORATION LEVEL OF CARE Hospital LHIN % Activation/ Rehabilitation Activation Restoration Restoration Avg. Avg. Cases Days Cases Days Cases Days LOS LOS Central 1,574 34, % 3% Central East 2,796 70, , % 5% Central West 1,074 32, % 2% Champlain 3,305 81, , % 6% Erie St. Clair 1,698 39, , % 5% HNHB 2,385 74, , % 12% Miss. Halton 2,299 60, , % 6% North East , , % 6% North West , % 1% Nth. Simcoe Musk , % 3% South East , % 2% South West 1,868 55, , % 4% Toronto Central 9, , , % 2% Waterloo Well , , % 9% Grand Total 29, , ,934 39, % 5% % Use of designated Rehab beds for Activation/Restoration varies from low of 1% in North West, to high of 16% in HNHB. 10 Page 111

114 03 APPLICATION OF RCA FRAMEWORK TO CCRS DATA 11 CW ASSIGNMENT OF PATIENTS TO BEDDED LEVEL OF CARE USING CCRS DATA Central West Approach All special rehab RUGs (except LOW): Rehabilitation Reduced Physical Function RUGs, Blanks: Activation/Restoration Remaining cases,<90 days stay: Short Term Complex Medical Remaining cases, >90 days stay: Long Stay Complex Medical Cautions applying CW approach to other populations: There are patients in Chronic beds that are not part of RCA Bedded Levels of Care Palliative, Respite, Behavioural shouldn t they be separately identified? If actual LOS is used to assign Levels, then can only apply Framework to discharged cases Is there a way to assign Level prospectively? 12 Page 112

115 PROPOSED APPROACH Pull out End of Life and Respite cases as explicitly excluded from RCA bedded levels of care Use identification of specific treatments, diseases, conditions, as evidence of need for complex medical care (i.e. assign to Complex Medical Management RCA level of bedded care) Assume that Special Rehabilitation RUG categories (except for Low) are assigned to Rehabilitation RCA level of bedded care Identify patients with significant recent medical interventions (i.e. ED visits, acute hospital admissions, frequent physician visits, frequent changes in medical orders) as Complex Medical Management Remaining Special Rehabilitation Medium cases assigned to Rehabilitation Remaining cases in Special Rehabilitation Low, daily single service therapy or nursing rehab/restorative care assigned to Activation/ Restoration Any remaining cases assigned to Other, but cases with Dementia separately identified; Other assumed to be ALC proxy 13 ALGORITHM ALL ONTARIO DATA PAGE 1 OF 2 Patient Description # of Assessments RCA Level Assignment Unassigned Initial assessments for discharged patients, with LOS <= 1 year Level # 16,787 Hospice care flag End of Life 2,791 13,996 End stage disease (< 6 months) End of Life 1,206 12,790 Respite care flag Respite 65 12,725 High+ Rehabilitation RUGS: Special Rehab - Ultra-High ,573 Special Rehab - Very-High Rehabilitation ,292 Special Rehab - High ,347 "Special Care" Treatments in past 14 days: Ventilator or Respirator Tracheostomy Care Chemotherapy ,551 Medically Complex Radiation Renal Dialysis 5 or more other 72 10,479 Specific Disease/Condition: Comatose Amyotropic Lateral Sclerosis Huntingtons Chorea Multiple Sclerosis Quadriplegia Clostridium Difficile Septicemia Recurrent Lung Aspirations (Last 90 days) Parenteral IV Medically Complex 2,099 8, Page 113

116 ALGORITHM ALL ONTARIO DATA PAGE 2 OF 2 Patient Description # of Assessments RCA Level Assignment Unassigned Recent Significant Use of Medical Care: 2 or more ED Visits, past 90 days 539 7,841 3 or more Hosp Stays, past 90 days 348 7, or more Dr. visits, past 2 weeks Medically Complex 667 6,826 Orders changed, 7 or more times, past 2 weeks 937 5,889 CHESS score 3 or higher 791 5,098 Special Rehab - Medium Rehabilitation 2,618 2,480 Therapy 5 or more days, 3 or more therapies, 3 or more hours per week Rehabilitation 68 2,412 Single Service or Nursing Rehab/ Restorative Care, Unless Discharge Not Expected within 90 Days Special Rehab - Low RUG 417 1,995 Daily Nursing Rehab/Restorative Care (@ least 15 minutes per day) Activation/ Restoration 386 1,609 More than 100 minutes single service therapy per week 37 1,572 For Medically Complex, if the actual LOS for discharged patients was 90 days or less, or if not discharged, the expected discharge is 90 days or less, assign as Medical Complex Short Term (ST). All others assigned to Long Term (LT) assessments left unassigned (not part of RCA bedded levels of care) 15 RESULTING ALLOCATION OF BEDS (APPROXIMATE, BASED ON DISCHARGE RECORDS ONLY) FOR ONTARIO Bed Category Cases Days Avg. Admit Age Beds % Bed Dist. Avg. LOS Respite Care 63 2, % 33 End of Life 3, , % 52 Rehabilitation 4, , ,101 21% 79 Activation/ Restoration , % 67 Medically Complex - ST 5, , % 38 Medically Complex - LT 1, , ,412 27% 279 Other , % 217 Other - Dementia , % 295 Grand Total 17,058 1,547, , % 91 In RCA Framework 8, ,471 % In RCA Framework 49% 56% 49% of discharges from CCC beds in 2014/15, accounting for 56% of days, were categorized in the 4 RCA levels of bedded rehabilitative care 23% of CCC beds in 2014/15 were used by patients categorized as Other (with and without dementia), a proxy for ALC Page 114

117 DISTRIBUTION OF 2014/15 CCRS ASSESSMENT RECORDS BY BEDDED LEVEL OF CARE Patient LHIN Total Assessments Rehabilitation Percent Distribution of Assessments of Patients in LHIN RCA Bedded Level of Care Not in RCA Framework Activation/ Restoration Medically Complex - ST Central 2,872 20% 2% 15% 23% 24% 0% 6% 11% Central East 2,958 14% 4% 21% 23% 18% 0% 9% 10% Central West % 1% 28% 25% 5% 0% 10% 7% Champlain 3,143 10% 4% 12% 28% 20% 0% 20% 6% Erie St. Clair 1,423 13% 3% 18% 24% 16% 0% 13% 12% HNHB 4,529 29% 3% 28% 12% 22% 0% 4% 2% Miss. Halton 1,986 25% 2% 15% 18% 24% 0% 7% 8% North Sim. Musk % 2% 30% 14% 17% 0% 11% 7% North-East 1,214 24% 4% 18% 14% 9% 0% 17% 14% North-West 1,406 19% 3% 27% 15% 11% 0% 17% 8% South East % 9% 27% 18% 16% 2% 7% 4% South West 1,673 15% 9% 25% 16% 15% 1% 12% 7% Toronto Central 4,559 31% 4% 10% 22% 15% 0% 9% 9% Waterloo Well. 1,298 19% 11% 25% 16% 17% 1% 9% 2% Grand Total 29,266 21% 4% 19% 20% 18% 0% 10% 8% Medically Complex - LT End of Life Respite Care Other Other - Dementia 17 DISCHARGE PLACEMENT BY RCA LEVEL 2014/15 ONTARIO Percent Distribution of Discharged Patients by Disposition RCA Level Patients Home, Home Care, Retirement Fac. Long Term Care Home Died IP Acute Care IP Rehab IP Chronic Other End of Life 3, % 3.2% 83.5% 2.8% 0.5% 0.7% 0.5% Respite Care % 3.2% 1.6% 11.3% 1.6% 0.0% 0.0% Rehabilitation 4, % 9.4% 2.5% 10.5% 3.9% 0.4% 1.3% Activation/ Restoration % 20.5% 8.3% 9.8% 4.3% 0.4% 1.0% Medically Complex - ST 5, % 11.7% 8.7% 16.0% 4.2% 0.9% 0.8% Medically Complex - LT 1, % 23.4% 15.6% 25.4% 3.1% 1.4% 1.4% Other % 23.7% 9.4% 19.7% 3.7% 1.7% 1.1% Other - Dementia % 40.2% 18.3% 15.0% 1.1% 3.6% 0.8% Grand Total 16, % 11.5% 26.0% 12.0% 3.1% 0.8% 0.9% High % of Rehabilitation patients go home Majority of Medically Complex ST and Activation /Restoration patients go home High % of Other Dementia patients discharged to LTCH 18 Page 115

118 04 REHABILITATIVE CARE ALLIANCE COMMUNITY LEVELS OF REHABILITATIVE CARE 19 ELIGIBILITY CRITERIA FOR COMMUNITY-BASED REHABILITATIVE CARE Eligibility criteria: The patient/client has: Restorative potential*, (i.e. There is reason to believe, that the patient's condition is likely to undergo functional improvement and benefit from rehabilitative care) or requires rehabilitative care to prevent functional decline and Medically stability enough to be able to participate in and benefit from rehabilitative care (i.e., carry-over for learning) w/in the context of specific functional goals; and Identified goals that are specific, measurable, realistic and timely. *Restorative Potential Restorative Potential means that there is reason to believe (based on clinical assessment and expertise and evidence in the literature where available) that the patient's condition is likely to undergo functional improvement and benefit from rehabilitative care. The degree of restorative potential and benefit from the rehabilitative care should take into consideration the patient s: Premorbid level of functioning Medical diagnosis/prognosis and co-morbidities (i.e., is there a maximum level of functioning that can be expected owing to the medical diagnosis /prognosis?) Ability to participate in and benefit from rehabilitative care within the context of the patient s/client s specific functional goals and direction of care needs Note: Determination of whether a patient/client has restorative potential includes consideration of all three of the above factors. Cognitive impairment, depression and delirium should not be used in isolation to influence a determination of restorative potential. 20 Page 116

119 DEFINITIONS FRAMEWORK FOR COMMUNITY BASED LEVELS OF REHABILITATIVE CARE APPLICATION OF RCA FRAMEWORK TO RAI-HC DATA 22 Page 117

120 CCAC HOME CARE DATA SERVICE RECIPIENT CATEGORY (SRC) Rehabilitative Care Alliance framework identifies community based levels of rehabilitative care as: Progression Maintenance 91 Acute and 95 End of Life are out of scope 92 Rehabilitation reflect RCA progression level 93 Maintenance and 94 LT Supportive reflect RCA maintenance level Category Service Goal To address the client's need for short 91 - Acute term education, care and/or support as a result of illness, disability or injury To optimize the client's functional status within limits of their disability 92- Rehabilitation and to facilitate social integration and independence To maintain the client s independence by preventing/minimizing the 93 - Maintenance premature decline in health and/or functional status. To delay institutionalization by 94 - LT providing supportive care and relief of Supportive symptoms to preserve the client's level of function and autonomy. To alleviate distressing symptoms to 95 - End of Life achieve the best quality of life /15 DISTRIBUTION OF ONTARIO CCAC ADMISSIONS BY INITIAL SERVICE GOAL In addition to client service recipient category, CCAC admission records also track initial service goal Progression could include: Rehabilitation/Rehab Complex Care Restorative Assess and Restore Maintenance could include: Maintenance Long-Term Supportive Complex Care Medically Complex Complex Care Behavioural Initial Service Goal - Clients with Completed Service Plan Only # of Admissions Avg. HC LOS Acute (In-Home) 128, Rehabilitation (In-Home) 60, Maintenance (In-Home) 19, Referred In - No Recovery 13, Long-Term Supportive (In-Home) 7, Complex Care Restorative 2, Complex Care End Of Life 2, Rehab 1, Complex Care Medically Complex Referred In End Of Life (In-Home) Complex Care Behavioral Historically Unavailable Assess And Restore CSS Services (CCAC Reimbursed) Grand Total 237, RCA Progression Level 64, RCA Maintenance Level 28, Page 118

121 2014/15 HOME CARE ADMISSIONS PER 10,000 AGE/GENDER STANDARDIZED POPULATION BY INITIAL SERVICE GOAL AND CLIENT LHIN Rates of admission to in-home care per 10,000 population, age/gender standardized to account for differences in demographics of LHIN populations Overall provincial rates of admission to in-home care are virtually identical for Progression and Maintenance, but the balance between the two varies by LHIN Central West and Waterloo Wellington CCACs serve almost twice as many Progression clients as Maintenance clients In NSM, more than twice as much Maintenance compared to Progression Client LHIN Acute In Home End of Life Progression Maintenance LTC Placement Central Central East Central West Champlain Erie St. Clair HNHB Miss. Halton Nth. Sim. Musk North East North West South East South West Toronto Central Waterloo Well Ontario Other Grand Total SPECIALIZED REHABILITATION VS. GENERAL/GERIATRIC REHABILITATION 26 Page 119

122 RCA FRAMEWORK AND BEDDED SUB-ACUTE ACTIVITY OUTSIDE RCA FRAMEWORK Some CCC patients don t fall in to the RCA bedded levels of care, and aren t either respite or palliative I.e. not significant rehabilitation or nursing activation/restoration, and no identified medical complexity Should these patients be considered to be potential alternate level of care (ALC patients)? Rehabilitation Progression Bedded Levels of Rehabilitative Care Activation/ Progression Progression Complex Medical Management Short Term Stabilization & Progression Long Term Maintenance Outside RCA Rehabilitative Care Framework Palliative Respite Other - ALC? Other - Dementia - ALC? Sector? I.e. Rehabilitation Beds (as designated by MOHLTC), CCC Beds, LTCH? General vs. Specialized? Critical Mass? 27 DISTINCTION BETWEEN SPECIALIZED AND GENERAL/ GERIATRIC REHABILITATION Does the proposed designation of specialized vs. general and geriatric rehabilitation make sense? i.e. concentrate specialized, but widely distribute general and geriatric CIHI Rehabilitation Groups don t explicitly identify Geriatric Rehabilitation Can patients 80+ in General Rehab groups (i.e. bottom part of table) be used as a proxy for Geriatric Rehab? Specialized Rehabilitation? General and Geriatric Rehabilitation? NRS Rehabilitation Group Ontario % 85+ Cases % 80+ Stroke 5,561 19% 34% Neurological % 22% Amputation, Not Lower Extremity 45 7% 20% Amputation, Lower Extremity 987 7% 17% Non-Traumatic Spinal Cord Injury 906 4% 14% Maj Mult Trauma w/brain or SC Injury 153 6% 11% Burns 54 9% 11% 28% Pulmonary % 41% Traumatic Spinal Cord Injury 299 4% 9% Non-Traumatic Brain Injury % 26% Traumatic Brain Injury % 25% Mult Trauma & Maj Mult Fracture % 23% Fracture of Lower Extremity 5,251 43% 63% Replacement of Lower Extremity 3,297 14% 33% Other Orthopedic 1,613 32% 51% Rheumatoid & Other Arthritis 76 20% 38% Osteoarthritis 70 40% 57% Debility (excl. Cardiac/Pulm.) 2,217 36% 58% 51% Cardiac 1,297 32% 52% Other Disabilities % 51% Medically Complex 5,354 28% 47% Pain % 62% 28 Page 120

123 AGE/GENDER STANDARDIZED INPATIENT DAYS IN DESIGNATED REHAB BEDS PER 10,000 LHIN POPULATION Patient LHIN Specialized General/ Geriatric Activation/ Restoration Total Nth. Simcoe Musk South East Waterloo Well HNHB South West North East Grand Total Erie St. Clair Champlain Central Central West North West Miss. Halton Central East Toronto Central Page 121

124 Appendix D: Quantitative Analysis Results Page 122

125 DESIGNATED REHAB AND CHRONIC BEDS AS REPORTED VIA MOHLTC BED CENSUS SUMMARY FOR FY 2014/15 BY LHIN Designated Rehabilitation Beds Hospital LHIN Avg. % Occup. Beds Occup. Rank Central % 1 Central East % 7 Central West % 3 Champlain % 6 Erie St. Clair % 13 HNHB % 5 Miss. Halton % 2 North East % 9 North West % 8 Nth. Simcoe Musk % 14 South East % 11 South West % 12 Toronto Central % 10 Waterloo Well % 4 Grand Total 2, % Designated Chronic Beds Hospital LHIN Avg. % Occup. Beds Occup. Rank Central % 2 Central East % 1 Central West % 9 Champlain % 6 Erie St. Clair % 12 HNHB % 5 Miss. Halton % 3 North East % 10 North West % 8 Nth. Simcoe Musk % 14 South East % 11 South West % 13 Toronto Central 1, % 7 Waterloo Well % 4 Grand Total 5, % Reported occupancy of 95.6% for designated Rehabilitation beds and 92.7% for designated Chronic Beds Unusual to have lower occupancy in Chronic beds 1 MOHLTC BED CENSUS REPORT CHAMPLAIN LHIN REHAB AND CHRONIC BED NUMBERS AND 2014/15 AVERAGE OCCUPANCY Hospital Avg. % Occup Beds Occup.. Rank Elisabeth Bruyere Hospital % 3 Ottawa Hospital - Rehab Ctre % 2 Queensway-Carleton Hospital % 1 Pembroke Regional % 6 Ottawa Hospital - General % 5 Hopital Montfort % 4 Cornwall Community Hospital % 7 Glengarry Memorial Hospital % 8 Grand Total % Hospital Avg. % Occup. Beds Occup. Rank St.-Vincent Hospital % 2 St. Joseph's CC, Cornwall % 1 Almonte General Hospital % 4 Renfrew Victoria Hospital % 6 Pembroke Regional % 8 Hawkesbury & District % 3 Arnprior & District Memorial % 10 Winchester District Memorial % 9 St. Francis Memorial Hospital % 7 Glengarry Memorial Hospital % 5 Kemptville District Hospital % 11 Grand Total % Very low occupancy of designated Chronic beds in FY 2014/15 in many sites. MOHLTC bed designation does not necessarily reflect actual use of beds. Beds may be used by patients for other programs (e.g. convalescent, assess and restore, etc.) 2 Page 123

126 2014/15 CHAMPLAIN LHIN HOSPITAL REPORTED COSTS FOR REHABILITATION SERVICES Facility Name Functional Centre # Functional Centre Name Functional Centre Expense % of Total CHEO AC Clinic Rehabilitation $221, % Hopital Montfort IP Rehabilitation - Combined $2,562, % Pembroke Regional IP Rehabilitation - Combined $3,023, AC Clinic Rehabilitation $98, % Queensway-Carleton Hospital IP Rehabilitation - Combined $4,527, % Glengarry Memorial Hospital IP Medical Rehabilitation $884, % Bruyere Continuing Care IP Rehabilitation - Combined $6,798, % AC Clinic Rehabilitation $175, IP Medical Rehabilitation $2,437,048 Ottawa Hospital IP Surgical Rehabilitation $3,891, % IP Rehabilitation - Combined $4,921, AC Clinic Rehabilitation $1,429,185 Cornwall Community Hospital IP Rehabilitation - Combined $1,245, % Total $32,216, % 3 CHAMPLAIN LHIN HOSPITAL 2014/15 AMBULATORY REHABILITATION AND GERIATRIC DAY HOSPITAL EXPENSES AND VISITS AC Clinic Rehabilitation Hospital Direct Expense Visits Expense per Visit Ottawa Hospital $1,429,185 6,216 $230 Pembroke Regional $98,348 1,315 $75 CHEO $221,842 1,140 $195 Bruyere Continuing Care $175, $182 Grand Total $1,925,366 9,639 $ 200 AC Day/Night Care - Geriatric Hospital Direct Expense Visits Expense per Visit Bruyere Continuing Care $78,169 4,601 $17 Almonte General Hospital $132,551 3,570 $37 Queensway-Carleton Hospital $235,838 3,105 $76 Ottawa Hospital $337,604 2,518 $134 Grand Total $784,162 13,794 $ 57 4 Page 124

127 CHAMPLAIN LHIN HOSPITAL 2014/15 COMPLEX CONTINUING CARE EXPENSES Facility Name Functional Centre Name Functional Centre Expense % of Total Almonte General Hospital IP LTC - CCC $2,363, % Arnprior & District Memorial IP LTC - CCC $1,103, % Hotel Dieu - Cornwall IP LTC - CCC $5,189, % Kemptville District Hospital IP LTC - CCC $83, % Pembroke Regional IP LTC - All Inclusive CCC $2,519, % St. Francis Memorial Hospital IP LTC - CCC $1,187, % Renfrew Victoria Hospital IP LTC - CCC $2,630, % Hawkesbury & District IP LTC - CCC $2,160, % Glengarry Memorial Hospital IP LTC - CCC $718, % Winchester District Memorial IP LTC - CCC $1,185, % Bruyere Continuing Care IP LTC - CCC $39,911, % Total $59,053,029 5 POPULATION-BASED ANALYSIS OF ADMINISTRATIVE DATA 2014/15 fiscal year administrative data has been used to support comparisons of utilization per population for the residents of each LHIN and for the counties within a LHIN Activity is assigned to a LHIN or county on the basis of where the patient lives, which is not necessarily where they received care All utilization rates are expressed per 10,000 population, and are age/gender standardized to take into account differences in the demographic composition of each population High utilization rates may reflect over-utilization of a service, or an appropriate response to the needs of the community that can t be explained just on the basis of population age or gender Low utilization rates may reflect barriers to access, such as lack of local capacity, socio-economic, linguistic, or cultural challenges 6 Page 125

128 RATE OF INPATIENT DAYS PER 10,000 POPULATION BY AGE AND GENDER COHORT FOR REHABILITATION AND COMPLEX CONTINUE CARE PATIENTS 7 PROJECTED CHANGE IN POPULATION BY AGE COHORT, 2014 TO 2019 CHAMPLAIN LHIN AND ONTARIO OVERALL Projected increase in total Champlain LHIN population of 5.8% is slightly higher than provincial average Double digit percent increase in Champlain population projected for each age cohort over 55 years of age, i.e. the age cohorts most likely to require rehab and CCC services Age Cohort Champlain Ontario % 6.0% % 1.6% % 3.2% % -7.0% % -3.0% % 8.4% % 7.0% % 7.3% % -1.2% % -5.2% % -8.6% % 12.0% % 16.9% % 14.4% % 32.2% % 19.3% % 10.8% % 14.3% % 36.8% Total 5.8% 5.3% 8 Page 126

129 A-2 USE OF DESIGNATED REHABILITATION BEDS 9 DATA SOURCE Records were obtained from the MOHLTC IntelliHealth system for every patient discharged from a designated rehabilitation bed in Ontario during fiscal year 2014/15 Each record contained the mandatory data elements required to be reported by the Canadian Institute for Health Information (CIHI) using the National Rehabilitation System (NRS) In some facilities, beds that are formally designated as rehabilitation (and funded via the HBAM rehabilitation performance measurement methodology) are used for other purposes, such as assess and restore or transitional care The NRS records do not contain information about this alternate use of the beds, i.e. all are considered to be rehabilitation beds NRS records are categorized by rehabilitation group depending on the clinical characteristics of the patient Each record contains an admission Functional Independence Measure (FIM) score, and a discharge FIM score, which can be used to measure the change in patient functional capabilities over the hospital stay 10 Page 127

130 2014/15 NRS DISCHARGE ACTIVITY BY HOSPITAL LHIN Hospital LHIN IP Cases All Discharges Avg. LOS Avg. RCW/ Case Avg. RCW/ Day Cases IP Days Cases w/ FIM Info. Avg. Avg. Admit Disch. FIM FIM Avg. FIM Chg. Champlain LHIN rehab patients have 3 rd lowest average LOS, highest average admission FIM, and lowest FIM change over course of inpatient stay FIM Effic. Central 1, ,517 34, Central East 2, ,825 72, Central West 1, , Champlain 3, ,421 83, Erie St. Clair 1, ,693 39, HNHB 2, ,692 80, Miss. Halton 2, ,391 62, North East , North West , Nth. Sim. Musk , South East , South West 1, ,880 55, Toronto Central 9, , , Waterloo Well. 1, , Grand Total 31, , , Champlain Rank CHAMPLAIN LHIN IP REHAB ACTIVITY BY CIHI RG Rehab Group Cases Avg. LOS Avg. Age Avg. Admit FIM Avg. Disch. FIM Avg FIM FIM Effic. Change Medically Complex Fracture of Lower Extremity Stroke Replacement of Lower Extremity Debility (excl. Cardiac/Pulm.) Non-Traumatic Brain Injury Other Orthopedic Pulmonary Neurological Cardiac Mult Trauma & Maj Mult Fracture Traumatic Brain Injury Other Disabilities Non-Traumatic Spinal Cord Injury Amputation, Lower Extremity Pain Traumatic Spinal Cord Injury Maj Mult Trauma w/brain or SC Injury Rheumatoid & Other Arthritis Osteoarthritis Burns Amputation, Not Lower Extremity Grand Total 3, Medically Complex, Fracture of Lower Extremity (Hip Fracture), and Stroke groups account for 48% of Champlain LHIN hospital inpatient rehab cases 12 Page 128

131 MOST CHAMPLAIN LHIN INPATIENT REHAB CASES ARE ADMITTED DIRECTLY FROM INPATIENT ACUTE CARE Peer Hospital IP Disch. Acute IP Other Rehab % Distribution by Source Chronic IP Ambul. Care Home/ Unknow n Other Glengarry Memorial Hospital % 0.0% 2.2% 0.0% 9.0% 1.1% Hopital Montfort % 0.2% 0.0% 0.0% 1.1% 0.5% Ottawa Hospital - General % 0.0% 0.0% 0.0% 0.0% 0.0% Ottawa Hospital - Rehab Ctre % 31.2% 0.0% 0.0% 0.0% 0.2% Pembroke Regional % 0.0% 0.0% 22.0% 3.1% 2.1% Queensway-Carleton Hospital % 0.2% 0.0% 0.3% 0.0% 0.0% St. Joseph's CC Cornwall % 0.0% 0.0% 0.0% 2.1% 0.0% Elisabeth Bruyere Hospital % 0.2% 4.0% 0.8% 3.6% 0.5% Grand Total 3, % 4.1% 1.0% 2.0% 1.6% 0.4% 13 OTTAWA HOSPITAL DISCHARGES TO INPATIENT REHABILITATION Elisabeth Bruyere Hospital Ottawa Hospital - General Ottawa Hospital - Rehab Ctre Pembroke Regional Glengarry Memorial Hospital St. Joseph's HC, Parkwood Providence - St. Mary's Hotel Dieu, St. Catharines Hamilton HSC - General Brockville - St. Vincent de Paul All Other Hospitals Grand Total ,739 Hip fracture, Stroke, and Non-Traumatic Brain Injury patients most often discharged to Bruyere Medically Complex and Joint Replacement patients go to General site rehab Pulmonary and other low volume, specialized cases to Rehab Ctre 14 Rehabilitation Hospital Medically Complex Fracture of Lower Extremity Replacement of Lower Extremity Non-Traumatic Brain Injury Stroke Other Orthopedic Neurological Pulmonary All Other Rehab Groups Total Page 129

132 REPORTED ADMISSION DELAYS FOR IP REHAB PATIENTS Hospital Site Discharges Cases w/ Rehab Ready Date % w/ Rehab Ready Date Cases w/ Admit Delay % with Delay Total Delay Days Avg. Delay for Delayed Cases Glengarry Memorial Hospital % 17 85% Hopital Montfort % 6 1% Ottawa Hospital 1,026 1,012 99% % 11, Pembroke Regional % 64 22% Queensway-Carleton Hospital % 5 3% Bruyere Continuing Care % % 8, St. Joseph's CC Cornwall % % Grand Total 3,625 3,050 84% 1,600 52% 19, Delay between ready for rehab and admission reported for 52% of Champlain LHIN patients; Average delay of 12.5 days 98% of admissions to Bruyere IP rehab report delay averaging 10 days 15 63% OF CHAMPLAIN STROKE PATIENTS HAVE DELAY BETWEEN READY FOR REHAB AND ADMISSION TO REHAB; AVERAGE DELAY OF 8.4 DAYS IN LONGEST OF ALL LHINS Hospital LHIN Total IP Cases Rehabilitation Group: Stroke # w/ Ready for Rehab % w/ready for Rehab # w/ Delay % w/ Delay Avg. Delay Central % 15 8% 4.3 Central East % 16 4% 4.9 Central West % % 4.7 Champlain % % 8.4 Erie St. Clair % % 4.2 HNHB % % 4.3 Miss. Halton % % 2.9 North East % % 2.7 North West % % 3.4 Nth. Simcoe Musk % 77 62% 7.3 South East % 90 46% 3.2 South West % % 3.1 Toronto Central 1, % % 3.6 Waterloo Well % % 1.4 Grand Total 5,561 4,703 85% 2,507 53% Page 130

133 56% OF CHAMPLAIN HIP FRACTURE PATIENTS HAVE DELAY BETWEEN READY FOR REHAB AND ADMISSION TO REHAB; AVERAGE DELAY OF 8.8 DAYS IN LONGEST OF ALL LHINS Rehabilitation Group: Fracture of Lower Extremity Hospital LHIN Total IP # w/ Ready % w/ready Cases for Rehab for Rehab # w/ Delay % w/ Avg. Delay Delay Central % 26 7% 3.5 Central East % 21 4% 4.2 Central West % % 3.7 Champlain % % 8.8 Erie St. Clair % % 4.8 HNHB % % 4.4 Miss. Halton % % 2.7 North East % 13 23% 4.0 North West % 86 82% 3.2 Nth. Simcoe Musk % 46 73% 5.7 South East % % 2.9 South West % % 3.1 Toronto Central 1,351 1,166 86% % 3.8 Waterloo Well % 49 39% 1.2 Grand Total 5,251 4,494 86% 1,945 43% DISCHARGE DISPOSITION OF CHAMPLAIN LHIN IP REHAB CASES BY RG 79.2% OF PATIENTS GO HOME % Distribution of IP Rehab Cases by Discharge Disposition Rehabilitation Group Cases CCC or Home IP Rehab IP Acute Died Other LTCH Medically Complex % 8.1% 1.0% 10.9% 0.5% 1.6% Stroke % 10.8% 8.1% 6.8% 0.9% 0.4% Fracture of Lower Extremity % 9.3% 1.4% 7.0% 0.2% 0.2% Replacement of Lower Extremity % 4.2% 0.0% 4.8% 0.0% 0.0% Debility (excl. Cardiac/Pulm.) % 19.5% 0.7% 7.5% 0.4% 1.9% Non-Traumatic Brain Injury % 7.0% 2.6% 13.7% 0.0% 0.0% Other Orthopedic % 9.3% 2.0% 8.8% 0.5% 0.0% Pulmonary % 4.6% 1.2% 5.8% 1.7% 2.3% Neurological % 6.7% 0.0% 11.2% 0.7% 0.0% Cardiac % 18.6% 1.0% 7.2% 1.0% 1.0% Mult Trauma & Maj Mult Fracture % 1.1% 1.1% 4.6% 0.0% 0.0% Traumatic Brain Injury % 8.4% 6.0% 8.4% 0.0% 0.0% Other Disabilities % 30.0% 2.5% 5.0% 0.0% 2.5% Non-Traumatic Spinal Cord Injury % 6.9% 1.7% 3.4% 0.0% 0.0% Amputation, Lower Extremity % 0.0% 1.8% 7.1% 0.0% 0.0% Traumatic Spinal Cord Injury % 2.3% 0.0% 6.8% 0.0% 0.0% Pain % 5.0% 2.5% 5.0% 0.0% 0.0% Maj Mult Trauma w/brain or SC Injury % 7.1% 7.1% 7.1% 0.0% 0.0% Rheumatoid & Other Arthritis % 10.0% 0.0% 10.0% 0.0% 0.0% Osteoarthritis % 0.0% 0.0% 0.0% 0.0% 0.0% Burns % 0.0% 0.0% 0.0% 0.0% 0.0% Amputation, Not Lower Extremity % 0.0% 0.0% 0.0% 0.0% 0.0% Grand Total 3, % 9.2% 2.2% 8.2% 0.4% 0.8% 18 Page 131

134 COMPARISON OF DISCHARGE DISPOSITION FOR CHAMPLAIN LHIN IP REHAB CASES WITH PROVINCIAL PATTERNS # of Cases % of Cases Transfer to Type Ontario Champ. Ontario (All) Champ. (All) LHIN LHIN Acute IP 2, % 8.2% Ambulatory Care % 0.6% Chronic IP 1, % 1.2% Community Services 1, % 12.8% Deceased % 0.4% Home Care Program 13,148 1, % 35.2% LTC Home 1, % 8.0% Mental Health % 0.7% Other % 0.0% Private Practice 4, % 13.5% Rehab Ambul 4, % 10.4% Rehab IP % 2.2% Unknown 2, % 6.8% Grand Total 31,599 3, % 100% Lower % of Champlain LHIN rehab patients sent home with home care, but higher % referred to community services 19 DISCHARGE DISPOSITION OF CHAMPLAIN LHIN IP REHAB CASES BY HOSPITAL 79.2% OF PATIENTS GO HOME % Distribution of Discharges by Disposition IP Hospital Site Rehab, Home IP Psych Acute CCC, IP Other LTCH Elisabeth Bruyere Hospital % 7.3% 0.0% 8.1% 0.1% Queensway-Carleton Hospital % 14.3% 0.2% 8.6% 1.9% Ottawa Hospital - General % 2.7% 0.2% 8.0% 0.0% Hopital Montfort % 29.9% 4.6% 4.2% 0.0% Ottawa Hospital - Rehab Ctre % 4.9% 0.0% 8.0% 0.0% Pembroke Regional % 2.1% 0.0% 16.1% 1.0% St. Joseph's CC Cornwall % 12.3% 0.0% 8.6% 0.5% Glengarry Memorial Hospital % 31.5% 0.0% 6.7% 0.0% Grand Total 3, % 11.4% 0.7% 8.2% 0.5% Discharges High % of Montfort and Glengarry rehab patients transferred to further institutional care 20 Page 132

135 DISCHARGE DELAYS BY HOSPITAL Hospital Site Discharges Cases w/ Discharge Ready Date % w/ Discharge Ready Date Cases w/ Discharge Delay % with Delay Total Delay Days Delay Days as % of Total Days Avg. Delay for Delayed Cases Glengarry Memorial Hospital % 1 1% 3 0% 3.0 Hopital Montfort % 6 1% 13 0% 2.2 Ottawa Hospital - General % 9 2% 38 0% 4.2 Ottawa Hospital - Rehab Ctre % 13 3% 139 1% 10.7 Pembroke Regional % 7 2% 62 1% 8.9 Queensway-Carleton Hospital % 12 2% 76 1% 6.3 Elisabeth Bruyere Hospital % 44 5% 481 2% 10.9 St. Joseph's CC Cornwall % 21 12% 132 4% 6.3 Grand Total 3,625 3,505 97% 113 3% 944 1% 8.4 Only 3% of Champlain LHIN IP rehab patients have reported delay between ready for discharge and discharge; Delay days represent only 1% of total days in IP rehab 21 ADMISSIONS AND DISCHARGES FOR IP REHAB BY DAY OF WEEK BY LHIN LHIN Total % Admissions by Day of Week % Discharges by Day of Week Cases Mon Tues Wed Thu Fri Sat Sun Mon Tues Wed Thu Fri Sat Sun Central 1,620 17% 17% 20% 18% 24% 3% 1% 15% 15% 18% 19% 26% 5% 3% Central East 2,972 14% 18% 22% 20% 20% 3% 2% 10% 18% 22% 23% 22% 4% 2% Central West 1,103 11% 15% 20% 21% 23% 9% 1% 7% 15% 22% 23% 21% 10% 3% Champlain 3,625 17% 19% 21% 21% 19% 2% 2% 15% 18% 21% 20% 19% 5% 2% Erie St. Clair 1,830 13% 18% 20% 21% 21% 4% 2% 11% 16% 21% 22% 25% 4% 2% HNHB 2,827 15% 20% 20% 25% 18% 1% 1% 12% 19% 21% 25% 20% 2% 1% Miss. Halton 2,512 13% 17% 20% 22% 22% 4% 2% 11% 18% 20% 23% 22% 5% 1% North East % 19% 20% 22% 21% 1% 1% 11% 14% 17% 26% 27% 4% 2% North West % 15% 17% 22% 24% 4% 5% 10% 19% 14% 31% 20% 4% 1% Nth. Simcoe Musk % 18% 21% 27% 18% 1% 0% 12% 19% 23% 25% 18% 2% 2% South East % 21% 20% 18% 18% 2% 1% 9% 15% 22% 25% 26% 3% 1% South West 1,956 18% 21% 20% 20% 19% 1% 1% 12% 17% 19% 23% 24% 4% 1% Toronto Central 9,561 18% 19% 18% 20% 19% 5% 2% 13% 17% 19% 21% 22% 6% 3% Very few weekend admissions or discharges (similar to other LHINs). Some other LHINs have identified 7 day per week (or at least 6 day) as a best practice target any similar discussion in Champlain? 22 Page 133

136 IP REHAB ADMISSION AND DISCHARGE VOLUMES BY DAY OF WEEK Hospital Total Cases % Admissions by Day of Week % Discharges by Day of Week Weekend Mon Tues Wed Thu Fri Mon Tues Wed Thu Fri Weekend Elisabeth Bruyere Hospital % 21% 20% 23% 19% 0% 14% 19% 21% 23% 19% 2% Glengarry Memorial Hospital 89 21% 19% 19% 26% 12% 2% 16% 22% 19% 24% 17% 2% Hopital Montfort % 19% 20% 21% 20% 3% 15% 19% 19% 23% 21% 3% Ottawa Hospital - General % 18% 20% 18% 18% 12% 7% 16% 16% 16% 20% 25% Ottawa Hospital - Rehab Ctre % 21% 30% 13% 8% 0% 33% 14% 29% 9% 11% 3% Pembroke Regional % 17% 17% 24% 18% 8% 11% 21% 25% 24% 14% 5% Queensway-Carleton Hosp % 19% 18% 23% 24% 4% 12% 18% 20% 24% 23% 3% St. Joseph's CC Cornwall % 12% 21% 20% 26% 6% 14% 12% 20% 22% 28% 3% Grand Total 3,625 17% 19% 21% 21% 19% 4% 15% 18% 21% 20% 19% 6% Virtually no patients admitted to Bruyere or Ottawa Rehab Centre on Weekend Only TOH General site has significant number of discharges on Weekend One third of Rehab Centre discharges were on Monday 23 LENGTH OF STAY COMPARISON FOR CHAMPLAIN LHIN PATIENTS AND ONTARIO AVERAGE BY REHAB GROUP Rehabilitation Group Champlain LHIN Activity IP Cases IP Days Avg. LOS Ontario Avg. LOS Ont. Avg. LOS Days Over/ (Under) Ont. LOS Stroke , ,715 (996) Fracture of Lower Extremity 439 9, ,029 (1,555) Medically Complex , ,850 (3,310) Replacement of Lower Extremity 311 4, ,713 (227) Debility (excl. Cardiac/Pulm.) 266 4, ,852 (1,511) Other Orthopedic 203 3, ,105 (1,186) Non-Traumatic Brain Injury 227 7, ,683 (796) Non-Traumatic Spinal Cord Injury 58 2, , Traumatic Brain Injury 83 2, ,168 (197) Amputation, Lower Extremity 56 1, ,829 (236) Cardiac 96 1, ,812 (27) Neurological 133 4, , Pulmonary 170 3, ,094 (370) Mult Trauma & Maj Mult Fracture 87 2, ,616 (346) Traumatic Spinal Cord Injury 44 2, , All Other Rehab Groups , ,459 2,014 Total ,891 (9,920) Average Rehab LOS for Champlain LHIN rehab patients is lower than Ontario average for most Rehab Groups May reflect some use of rehab beds for ALC buffer and/or transition to care 24 Page 134

137 AGE/GENDER STANDARDIZED IP REHAB CASES PER 10,000 POPULATION BY REHABILITATION GROUP Patient LHIN Stroke Medically Complex Fracture of Lower Extremity Replacement of Lower Extremity Debility (excl. Cardiac/Pulm.) Other Orthopedic Cardiac Amputation, Lower Extremity Non-Traumatic Brain Injury Non-Traumatic Spinal Cord Injury Traumatic Brain Injury Central Central East Central West Champlain Erie St. Clair HNHB Miss. Halton North East North West Nth. Sim. Musk South East South West Toronto Central Waterloo Well Grand Total Champlain Rank Champlain residents have 4 th highest rate of IP rehab cases per population, but 3 rd lowest rate for Stroke, and 2 nd lowest for Amputee Very high rates for Medically Complex, Non-Traumatic BI, and Pulmonary Pulmonary All Other RGs Grand Total 25 IP REHAB CASES PER 10,000 AGE/GENDER STANDARDIZED POPULATION BY LHIN Champlain LHIN rehab cases per population above provincial average, similar to rates for Greater Toronto Area 26 Page 135

138 INPATIENT REHAB CASES PER 10,000 AGE/GENDER STANDARDIZED POPULATION FOR COUNTIES WITHIN THE LHIN AND FOR ONTARIO OVERALL In 2014/15, only residents of Lanark county (part of which is in the South East LHIN) had rates of inpatient admissions per population to rehab beds below the provincial average 27 AGE/GENDER STANDARDIZED IP REHAB DAYS PER 10,000 POPULATION BY REHABILITATION GROUP Patient LHIN Stroke Fracture of Lower Extremity Medically Complex Replacement of Lower Extremity Debility (excl. Cardiac/Pulm.) Other Orthopedic Non-Traumatic Brain Injury Non-Traumatic Spinal Cord Injury Traumatic Brain Injury Amputation, Lower Extremity Central Central East Central West Champlain Erie St. Clair HNHB Miss. Halton North East North West Nth. Simcoe Musk South East South West Toronto Central Waterloo Well Grand Total Champlain Rank Champlain LHIN residents have 7 th highest rate of IP rehab days per 10,000 population; Lowest rate for Amputation Lower Extremity, 2 nd lowest rate for Stroke Cardiac Neurological All Other RGs Grand Total 28 Page 136

139 IP REHAB DAYS PER 10,000 AGE/GENDER STANDARDIZED POPULATION BY LHIN When utilization is measured in terms of days, rather than cases, residents of the Champlain LHIN have a utilization rate just above the Ontario average 29 AGE/GENDER STANDARDIZED IP REHAB RCW PER 10,000 POPULATION BY REHABILITATION GROUP Patient LHIN Stroke Medically Complex Fracture of Lower Extremity Debility (excl. Cardiac/Pulm.) Traumatic Brain Injury Non-Traumatic Brain Injury Central Central East Central West Champlain Erie St. Clair HNHB Miss. Halton North East North West Nth. Sim. Musk South East South West Toronto Central Waterloo Well Grand Total Champlain Rank Replacement of Lower Extremity Non-Traumatic Spinal Cord Injury Amputation, Lower Extremity Champlain LHIN residents have 5th highest rate of IP rehab rehabilitation case weight (RCW) per 10,000 population, a proxy measure of the cost of providing care 30 Other Orthopedic Neurological Traumatic Spinal Cord Injury All Other RGs Grand Total Page 137

140 AGE/GENDER STANDARDIZED IP REHAB DAYS PER 10,000 POPULATION BY REHABILITATION GROUP CHAMPLAIN LHIN COUNTIES Patient County Stroke Fracture of Lower Extremity Medically Complex Replacement of Lower Extremity Debility (excl. Cardiac/Pulm.) Other Orthopedic Non-Traumatic Brain Injury Non-Traumatic Spinal Cord Injury Lanark Ottawa Prescott & Russell Renfrew Stormont Dundas & Glen Ontario Traumatic Brain Injury Amputation, Lower Extremity Cardiac Neurological All Other RGs Grand Total Highest overall utilization of IP rehab days for residents of Renfrew and Ottawa, Lowest for residents of Lanark Ottawa and Lanark very low for Stroke All Champlain counties below Ontario average for Hip Fracture Very high rate in Ottawa for Medically Complex 31 MODIFIED CIHI NRS REHABILITATION GROUP (RG) The CIHI RGs don t have a Geriatric Rehabilitation category For comparative analysis purposes, all patients in the General and Geriatric rehab groups (i.e. bottom part of table) who were 80 years or older have been re-categorized as Geriatric Rehab Proxy only; not suggesting all patients older than 80, or no patients under 80, are Geriatric Rehab Specialized Rehabilitation? General and Geriatric Rehabilitation? NRS Rehabilitation Group Ontario % Cases 85+ % 80+ Stroke 5,561 19% 34% Neurological % 22% Amputation, Not Lower Extremity 45 7% 20% Amputation, Lower Extremity 987 7% 17% Non-Traumatic Spinal Cord Injury 906 4% 14% Maj Mult Trauma w/brain or SC Injury 153 6% 11% 28 Burns 54 9% 11% % Pulmonary % 41% Traumatic Spinal Cord Injury 299 4% 9% Non-Traumatic Brain Injury % 26% Traumatic Brain Injury % 25% Mult Trauma & Maj Mult Fracture % 23% Fracture of Lower Extremity 5,251 43% 63% Replacement of Lower Extremity 3,297 14% 33% Other Orthopedic 1,613 32% 51% Rheumatoid & Other Arthritis 76 20% 38% Osteoarthritis 70 40% 57% Debility (excl. Cardiac/Pulm.) 2,217 36% 58% Cardiac 1,297 32% 52% Other Disabilities % 51% Medically Complex 5,354 28% 47% Pain % 62% 51 % 32 Page 138

141 PERCENT DISTRIBUTION OF INPATIENT REHAB DISCHARGES BY MODIFIED CIHI REHAB GROUP Hospital LHIN Total Discharges Geriatric Rehabilitation % Distribution by Modified CIHI Rehabilitation Group Stroke Medically Complex Replacement of Lower Extremity Fracture of Lower Extremity Amputation, Lower Extremity Non-Traumatic Brain Injury Central 1,620 38% 16% 9% 8% 11% 0% 1% 17% Central East 2,972 41% 18% 11% 3% 8% 2% 1% 16% Central West 1,103 32% 20% 8% 2% 7% 1% 1% 29% Champlain 3,625 34% 13% 11% 6% 4% 2% 6% 25% Erie St. Clair 1,830 35% 21% 9% 2% 8% 2% 3% 21% HNHB 2,827 30% 25% 5% 6% 4% 3% 2% 25% Miss. Halton 2,512 39% 14% 14% 3% 7% 1% 2% 21% North East % 34% 5% 1% 4% 10% 2% 22% North West % 29% 0% 9% 10% 7% 2% 22% Nth. Simcoe Musk % 38% 5% 2% 7% 7% 1% 19% South East % 26% 2% 7% 7% 2% 4% 25% South West 1,956 30% 24% 7% 4% 6% 7% 1% 20% Toronto Central 9,560 28% 12% 10% 13% 5% 4% 4% 24% Waterloo Well. 1,018 27% 28% 7% 2% 5% 3% 3% 27% Grand Total 31,599 32% 18% 9% 7% 6% 3% 3% 22% 34% of Champlain LHIN NRS discharges categorized as Geriatric Rehab All Others 33 DISTRIBUTION OF CHAMPLAIN LHIN HOSPITAL NRS DISCHARGES BY MODIFIED REHAB GROUP BY HOSPITAL % Distribution by Modified Rehabilitation Group Hospital Total Discharges Geriatric Rehabilitation Stroke Medically Complex Non-Traumatic Brain Injury Replacement of Lower Extremity Pulmonary Fracture of Lower Extremity Elisabeth Bruyere Hospital % 25% 6% 14% 0% 0% 3% 16% Queensway-Carleton Hospital % 7% 10% 3% 3% 6% 5% 12% Ottawa Hospital - General % 0% 30% 2% 19% 1% 9% 15% Hopital Montfort % 7% 11% 1% 5% 6% 1% 19% Ottawa Hospital - Rehab Ctre 465 0% 0% 7% 14% 1% 18% 1% 59% Pembroke Regional % 30% 8% 2% 16% 0% 5% 11% St. Joseph's CC Cornwall % 3% 2% 1% 3% 6% 9% 33% Glengarry Memorial Hospital 89 10% 78% 2% 0% 1% 3% 1% 4% Grand Total 3,625 34% 13% 11% 6% 6% 5% 4% 21% All Others High % of NRS cases categorized as Geriatric Rehab at QCH and Montfort 34 Page 139

142 ACUTE CARE DOCUMENTATION OF DISCHARGE DISPOSITION OF ISCHEMIC STROKE PATIENTS 026-Ischemic Event of CNS 2014/15 % Distribution of Acute Care Live Discharges by Discharge Disposition Hospital LHIN Home Home (no Acute IP Rehab IP CCC LTCH Other Care HC) Care Central % 6.7% 22.1% 28.1% 3.9% 8.1% 1.4% Central East 1, % 6.4% 13.3% 24.6% 6.7% 7.0% 0.2% Central West % 9.9% 25.3% 27.6% 1.9% 8.0% 0.0% Champlain % 5.8% 16.3% 30.4% 8.8% 8.4% 0.2% Erie St. Clair % 4.4% 11.1% 33.2% 2.5% 8.4% 0.8% HNHB 1, % 9.8% 12.1% 28.2% 8.4% 7.8% 0.3% Miss. Halton % 4.6% 29.6% 25.9% 7.7% 6.6% 0.2% North East % 2.0% 13.7% 33.3% 4.4% 5.5% 0.6% North West % 7.8% 12.2% 25.7% 15.5% 5.3% 1.2% Nth. Simcoe Musk % 3.2% 17.2% 37.4% 11.0% 7.8% 1.4% South East % 6.8% 23.9% 30.0% 5.9% 4.8% 0.9% South West % 3.6% 24.4% 25.8% 8.7% 7.1% 0.5% Toronto Central 1, % 7.0% 15.1% 30.1% 5.8% 7.6% 2.4% Waterloo Well % 3.5% 27.8% 26.6% 6.9% 5.8% 1.8% Grand Total 11, % 6.1% 18.4% 28.6% 6.8% 7.2% 0.8% Cases % of acute strokes discharges directly to IP rehab slightly below Ontario average; 30.4% discharged home without any apparent referral to home care? If strokes sent home from acute care aren t getting in home care, do they have access to ambulatory care or other community services? 35 DISCHARGE DISPOSITION OF ISCHEMIC STROKE PATIENTS BY HOSPITAL 026-Ischemic Event of CNS 2014/15 % Distribution of Acute Care Live Discharges by Discharge Disposition Hospital Home Home (no Acute IP Rehab IP CCC LTCH Other Care HC) Care Ottawa Hospital - Civic % 4.5% 18.7% 39.7% 11.2% 6.7% 0.3% Pembroke Regional % 1.0% 7.9% 24.8% 8.9% 5.0% 0.0% Cornwall Community Hospital % 2.2% 14.1% 21.7% 5.4% 12.0% 0.0% Queensway-Carleton Hospital % 1.1% 12.1% 34.1% 3.3% 8.8% 0.0% Ottawa Hospital - General % 7.1% 29.8% 19.0% 11.9% 9.5% 1.2% Hopital Montfort % 2.5% 10.1% 20.3% 3.8% 15.2% 0.0% Hawkesbury & District % 57.1% 3.6% 21.4% 0.0% 17.9% 0.0% Arnprior & District Memorial % 50.0% 0.0% 16.7% 0.0% 0.0% 0.0% Winchester District Memorial % 33.3% 16.7% 33.3% 0.0% 0.0% 0.0% Almonte General Hospital % 0.0% 16.7% 0.0% 66.7% 0.0% 0.0% Glengarry Memorial Hospital 4 0.0% 25.0% 75.0% 0.0% 0.0% 0.0% 0.0% Renfrew Victoria Hospital % 0.0% 25.0% 0.0% 0.0% 0.0% 0.0% Univ. of Ottawa Heart Institute 2 0.0% 0.0% 50.0% 50.0% 0.0% 0.0% 0.0% Kemptville District Hospital % 0.0% 0.0% 0.0% 50.0% 0.0% 0.0% Carleton Place And District % 0.0% 50.0% 0.0% 0.0% 0.0% 0.0% CHEO 2 0.0% 0.0% 0.0% 100.0% 0.0% 0.0% 0.0% Deep River And District 1 0.0% 0.0% 0.0% 0.0% 100.0% 0.0% 0.0% Grand Total % 5.8% 16.3% 30.4% 8.8% 8.4% 0.2% Cases Low % of Ottawa hospital ischemic strokes discharged directly to IP rehab 36 Page 140

143 DISTRIBUTION OF CHAMPLAIN LHIN ACUTE CARE ISCHEMIC STROKE PATIENTS BY DISCHARGE DISPOSITION Discharge Disposition from Acute Care for Champlain LHIN 14/15 IP Activity by Discharge Disposition for 026-Ischemic Event of CNS and (All) Age Group Discharge IP Cases Total Days ALC Days Avg. Disposition # % # % # % LOS % ALC Home % 1, % % % Home Care % 1, % % % Acute % % % % Rehab % 3, % 1, % % CCC % % % % LTC % 1, % 1, % % Died % 1, % % % Other 2 0.2% % - 0.0% % Psych - 0.0% - 0.0% - 0.0% Grand Total % 11, % 3, % % 27.4% of ischemic stroke patients discharged to IP rehab, with average acute care LOS of 14.5 days, and 42.1% of stay in acute care bed spent (on average) as alternate level of care (ALC) High % ALC to rehab suggests barriers to access? 37 ACUTE CARE DOCUMENTATION OF DISCHARGE DISPOSITION OF HEMORRHAGIC STROKE PATIENTS 025-Hemorrhagic Event of CNS 2014/15 % Distribution of Acute Care Live Discharges by Discharge Disposition Hospital LHIN Home Home (no Acute IP Rehab IP CCC LTCH Other Care HC) Care Central % 13.0% 21.2% 21.7% 10.9% 5.4% 1.1% Central East % 7.1% 14.7% 23.5% 10.9% 5.9% 0.4% Central West % 8.8% 22.8% 25.7% 8.1% 6.6% 0.0% Champlain % 4.2% 17.4% 30.5% 17.8% 9.9% 1.4% Erie St. Clair % 4.7% 9.3% 32.6% 18.6% 9.3% 2.3% HNHB % 14.2% 7.9% 28.1% 26.9% 4.0% 0.0% Miss. Halton % 6.5% 16.7% 33.5% 14.0% 4.2% 0.0% North East % 2.0% 8.0% 32.0% 32.0% 6.0% 1.0% North West % 5.8% 9.6% 28.8% 17.3% 0.0% 1.9% Nth. Simcoe Musk % 11.9% 7.5% 32.8% 10.4% 9.0% 7.5% South East % 6.3% 12.6% 31.6% 23.2% 4.2% 0.0% South West % 4.6% 17.0% 26.8% 15.7% 9.8% 2.0% Toronto Central % 6.4% 8.4% 35.9% 14.2% 3.3% 3.9% Waterloo Well % 5.0% 17.8% 20.8% 24.8% 3.0% 2.0% Grand Total 2, % 7.5% 13.8% 29.2% 16.8% 5.6% 1.5% Cases Lowest % discharge directly to IP rehab of all LHINs, and highest % discharged to LTCH 38 Page 141

144 DISTRIBUTION OF CHAMPLAIN LHIN ACUTE CARE HEMORRHAGIC STROKE PATIENTS BY DISCHARGE DISPOSITION Discharge Disposition from Acute Care for Champlain LHIN 14/15 IP Activity by Discharge Disposition for 025-Hemorrhagic Event of CNS and (All) Age Group Discharge IP Cases Total Days ALC Days Avg. Disposition # % # % # % LOS % ALC Home % % % % Home Care % % % % Acute % % 5 0.9% % Rehab % % % % CCC 9 3.3% % % % LTC % % % % Died % % 2 0.3% % Other 3 1.1% 4 0.1% - 0.0% % Psych - 0.0% - 0.0% - 0.0% Grand Total % 2, % % % 39 DISCHARGE DISPOSITION OF HEMORRHAGIC STROKE PATIENTS BY HOSPITAL 025-Hemorrhagic Event of CNS 2014/15 % Distribution of Acute Care Live Discharges by Discharge Disposition Hospital Home Home (no Acute IP Rehab IP CCC LTCH Other Care HC) Care Ottawa Hospital - Civic % 4.7% 15.0% 43.0% 19.6% 3.7% 0.0% Hopital Montfort % 4.3% 17.4% 26.1% 17.4% 8.7% 0.0% Cornwall Community Hospital % 0.0% 27.8% 11.1% 11.1% 11.1% 5.6% Pembroke Regional % 0.0% 6.3% 18.8% 18.8% 12.5% 6.3% Queensway-Carleton Hospital % 0.0% 9.1% 27.3% 9.1% 18.2% 0.0% Ottawa Hospital - General % 0.0% 20.0% 10.0% 20.0% 50.0% 0.0% Hawkesbury & District % 30.0% 0.0% 30.0% 10.0% 30.0% 0.0% CHEO 7 0.0% 0.0% 42.9% 14.3% 42.9% 0.0% 0.0% Glengarry Memorial Hospital 3 0.0% 0.0% 0.0% 0.0% 33.3% 33.3% 33.3% Deep River And District 3 0.0% 0.0% 100.0% 0.0% 0.0% 0.0% 0.0% Renfrew Victoria Hospital % 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% Winchester District Memorial 1 0.0% 0.0% 100.0% 0.0% 0.0% 0.0% 0.0% Univ. of Ottawa Heart Institute 1 0.0% 0.0% 100.0% 0.0% 0.0% 0.0% 0.0% Grand Total % 4.2% 17.4% 30.5% 17.8% 9.9% 1.4% Cases 18.8% of hemorrhagic stroke patients transferred directly from IP acute to IP rehab, 30.5% discharged home, without apparent referral to home care 40 Page 142

145 ONTARIO AND LHIN 2013/14 STROKE REPORT CARDS AND PROGRESS REPORTS JUNE 2015 Report Card includes hospital accountability agreement (HSAA) indicator: Proportion of acute stroke (excluding TIA) patients discharged from acute care and admitted to inpatient rehabilitation Provincial benchmark of 46.3% of stroke patients to be discharged directly from IP acute care to IP rehab Champlain LHIN well below provincial target Area for Improvement Current or Planned Activities Access: Proportion of acute The LHIN has eliminated a large proportion of the stroke patients discharged inpatient stroke rehabilitation capacity since the from acute care and admitted 2011/12 fiscal year with closures at the Cornwall to inpatient rehabilitation Community Hospital, The Ottawa Hospital, and declined (from 30.3% to Bruyère Continuing Care. The CRSN is developing a 27.9%) and is well below the Champlain Regional Stroke Rehabilitation Ontario benchmark of Capacity and Allocation Report for inpatient and 46.3%. outpatient care. 41 STROKE IP REHAB CASES PER 10,000 AGE/GENDER STANDARDIZED POPULATION BY LHIN Overall utilization rate for Champlain LHIN residents for Stroke IP cases is 2 nd lowest in province 42 Page 143

146 INPATIENT REHAB CASES PER 10,000 AGE/GENDER STANDARDIZED POPULATION FOR COUNTIES WITHIN THE LHIN AND FOR ONTARIO OVERALL - STROKE 43 CHAMPLAIN LHIN HOSPITAL STROKE LOS VS. QBP LOS TARGETS Average Champlain LHIN LOS for Stroke patients was 30.6 days in 2014/15, shorter than QBP LOS targets 22 patients assigned to Stroke RPG 1160 were admitted with average LOS of 9.0 days QBP targets suggest not admitting RPG 1160 patients Stroke RPG IP Cases IP Days Avg. LOS QBP LOS Tgt. Avg. RCW , , , , Grand Total , Page 144

147 DISCHARGE DISPOSITION OF IP STROKE REHAB CASES BY LHIN Stroke % Distribution of IP Rehab Cases by Discharge Disposition Hospital LHIN Cases CCC or IP Home IP Acute Died Other LTCH Rehab Central % 18.2% 7.1% 9.9% 1.2% 0.0% Central East % 17.6% 2.6% 4.2% 1.7% 0.4% Central West % 18.2% 0.9% 4.5% 1.4% 0.0% Champlain % 10.8% 8.1% 6.8% 0.9% 0.4% Erie St. Clair % 22.3% 0.3% 5.9% 1.1% 0.0% HNHB % 13.1% 1.1% 2.2% 0.8% 0.3% Miss. Halton % 18.4% 9.6% 5.8% 0.3% 0.0% North East % 6.4% 1.3% 14.6% 0.6% 0.0% North West % 9.7% 0.0% 17.2% 0.0% 0.0% Nth. Simcoe Musk % 4.8% 1.4% 9.5% 0.7% 0.0% South East % 13.9% 1.4% 9.1% 1.0% 0.0% South West % 14.0% 4.1% 7.5% 1.3% 0.4% Toronto Central 1, % 9.3% 0.5% 4.3% 0.0% 0.1% Waterloo Well % 16.3% 0.7% 6.7% 1.4% 0.0% Grand Total 5, % 13.6% 2.7% 6.3% 0.8% 0.2% Champlain Rank Lower % of Champlain LHIN IP Stroke Rehab cases discharged home than Ontario average; high % transferred from one rehab facility to another 45 DISCHARGE DISPOSITION OF CHAMPLAIN LHIN IP STROKE REHAB PATIENTS BY HOSPITAL Stroke % Distribution of IP Rehab Cases by Discharge Disposition Hospital Cases IP Home CCC LTCH Rehab IP Acute Died Other Elisabeth Bruyere Hospital % 2.8% 4.7% 5.7% 4.7% 0.0% 0.0% Pembroke Regional % 0.0% 1.2% 1.2% 12.9% 3.5% 0.0% Glengarry Memorial Hospital % 5.8% 24.6% 0.0% 7.2% 0.0% 0.0% Queensway-Carleton Hospital % 0.0% 4.8% 35.7% 9.5% 2.4% 0.0% Hopital Montfort % 2.6% 20.5% 23.1% 2.6% 0.0% 5.1% St. Joseph's CC Cornwall % 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% Ottawa Hospital - Rehab Ctre % 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% Grand Total % 2.4% 8.4% 8.1% 6.8% 0.9% 0.4% Less than half of QCH and Montfort stroke patients discharged home High % transferred to a second rehab facility; Should stroke patients go directly to ultimate provider of rehab care? High % of Glengarry and Montfort stroke patients discharged to LTCH 46 Page 145

148 ACUTE CARE DOCUMENTATION OF DISCHARGE DISPOSITION OF HIP/FEMUR FIXATION/REPAIR PATIENTS 727-Fixation/Repair Hip/Femur 2014/15 % Distribution of Acute Care Live Discharges by Discharge Disposition Hospital LHIN Home Home (no Acute IP Rehab IP CCC LTCH Other Care HC) Care Central % 8.5% 10.2% 7.7% 3.0% 19.1% 0.0% Central East % 7.8% 9.9% 9.8% 6.3% 22.0% 0.2% Central West % 6.5% 19.3% 8.9% 10.4% 19.0% 0.0% Champlain % 3.7% 15.3% 16.2% 16.5% 24.3% 0.8% Erie St. Clair % 10.8% 17.1% 11.6% 4.1% 17.7% 0.6% HNHB % 20.3% 20.5% 9.9% 11.2% 21.0% 0.6% Miss. Halton % 15.3% 14.6% 7.7% 3.3% 16.6% 0.3% North East % 7.2% 20.6% 11.3% 26.3% 16.6% 0.0% North West % 10.0% 11.2% 11.8% 28.8% 13.5% 0.6% Nth. Simcoe Musk % 2.8% 23.4% 9.1% 34.1% 18.1% 0.3% South East % 5.9% 27.9% 11.0% 9.5% 22.8% 0.9% South West % 6.8% 16.2% 8.9% 27.7% 14.8% 0.7% Toronto Central % 8.7% 6.6% 15.5% 3.4% 9.8% 0.3% Waterloo Well % 13.1% 26.7% 8.9% 11.8% 17.3% 0.3% Grand Total 7, % 9.5% 16.0% 10.8% 12.5% 18.4% 0.4% Cases % of hip fracture patients discharged directly to IP rehab is below average; TC LHIN has established target of 60%, Ontario hip fracture researchers have suggested at least 40% 47 ACUTE CARE DOCUMENTATION OF DISCHARGE DISPOSITION OF FRACTURE/DISLOCATION/RUPTURE PELVIS/SAC/COC PATIENTS 761-Fract/Disloc/Rupt Pelv/Sac/Coc 2014/15 % Distribution of Acute Care Live Discharges by Discharge Hospital LHIN Disposition IP Rehab IP CCC Home (no Home Care Acute Care HC) LTCH Other Central % 11.4% 23.8% 13.0% 2.6% 17.6% 1.0% Central East % 6.8% 24.5% 4.3% 7.8% 14.6% 0.0% Central West % 22.2% 22.2% 23.9% 2.6% 11.1% 0.0% Champlain % 10.9% 21.4% 17.7% 4.4% 16.1% 0.0% Erie St. Clair % 11.9% 20.6% 10.3% 4.0% 21.4% 0.8% HNHB % 21.1% 20.8% 14.1% 8.5% 15.8% 0.3% Miss. Halton % 14.0% 26.7% 9.3% 1.2% 12.8% 0.0% North East % 4.5% 31.3% 18.7% 9.0% 17.9% 0.0% North West % 28.8% 25.4% 23.7% 6.8% 8.5% 0.0% Nth. Simcoe Musk % 6.8% 27.2% 25.2% 7.8% 22.3% 1.0% South East % 13.9% 36.1% 6.9% 5.6% 15.3% 0.0% South West % 10.2% 33.5% 12.7% 12.3% 14.8% 0.0% Toronto Central % 12.1% 9.8% 14.8% 5.6% 6.9% 0.3% Waterloo Well % 16.4% 30.6% 9.0% 3.0% 14.9% 0.7% Grand Total 2, % 13.0% 23.7% 13.5% 6.2% 14.7% 0.3% Cases % of Champlain LHIN acute care hospital patients discharged directly to IP rehab for this CMG is just above average; TC LHIN above 50% 48 Page 146

149 ACUTE CARE DOCUMENTATION OF DISCHARGE DISPOSITION OF HIP REPLACEMENT FOR TRAUMA PATIENTS 726-Hip Replace w Trauma/Compl Tx 2014/15 % Distribution of Acute Care Live Discharges by Discharge Disposition Hospital LHIN Home Home (no Acute IP Rehab IP CCC LTCH Other Care HC) Care Central % 7.7% 9.9% 5.5% 2.8% 15.7% 0.0% Central East % 8.8% 9.1% 9.3% 4.8% 18.1% 0.0% Central West % 7.4% 25.0% 1.5% 11.0% 16.2% 0.0% Champlain % 4.1% 12.4% 8.5% 18.8% 15.8% 0.7% Erie St. Clair % 6.8% 12.2% 8.8% 2.4% 21.0% 0.3% HNHB % 24.2% 19.5% 6.6% 8.8% 17.8% 0.2% Miss. Halton % 14.7% 15.5% 2.8% 1.2% 15.5% 0.0% North East % 9.7% 23.6% 6.9% 24.1% 19.4% 0.9% North West % 1.0% 7.2% 4.1% 25.8% 17.5% 0.0% Nth. Simcoe Musk % 3.3% 20.7% 7.1% 31.0% 19.6% 0.0% South East % 7.4% 20.7% 5.4% 7.0% 24.4% 0.0% South West % 4.1% 15.0% 3.8% 26.4% 17.0% 0.5% Toronto Central % 8.0% 5.9% 3.2% 3.0% 11.4% 0.2% Waterloo Well % 8.6% 36.3% 10.2% 9.8% 12.7% 0.0% Grand Total 4, % 9.5% 15.4% 6.3% 11.0% 17.0% 0.2% Cases SW LHIN hospitals average % of patients discharged directly to IP rehab at 39.7%; TC LHIN at 68.4% /15 REPORTED % OF CMG 727 ACUTE INPATIENTS DISCHARGED DIRECTLY TO INPATIENT REHAB 50 Page 147

150 DISTRIBUTION OF CHAMPLAIN LHIN ACUTE CARE HIP/FEMUR FIXATION/REPAIR PATIENTS BY DISCHARGE DISPOSITION Discharge Disposition from Acute Care for Champlain LHIN 14/15 IP Activity by Discharge Disposition for 727-Fixation/Repair Hip/Femur and (All) Age Group Discharge IP Cases Total Days ALC Days Avg. Disposition # % # % # % LOS % ALC Home % % % % Home Care % 2, % % % Acute % 1, % % % Rehab % 2, % % % CCC % % % % LTC % 2, % 1, % % Died % % % % Other 3 0.4% % 7 0.3% % Psych 3 0.4% % 5 0.2% % Grand Total % 9, % 2, % % 51 DISCHARGE DISPOSITION OF HIP/FEMUR FIXATION/REPAIR PATIENTS BY ACUTE CARE HOSPITAL 727-Fixation/Repair Hip/Femur 2014/15 % Distribution of Acute Care Live Discharges by Discharge Disposition Hospital Home Home (no Acute IP Rehab IP CCC LTCH Other Care HC) Care Ottawa Hospital - General % 5.3% 7.4% 12.6% 29.5% 22.6% 1.6% Ottawa Hospital - Civic % 4.5% 16.5% 17.6% 13.1% 22.2% 0.0% Queensway-Carleton Hospital % 2.6% 17.6% 15.7% 11.1% 24.2% 0.7% Hopital Montfort % 1.7% 14.5% 13.7% 18.8% 33.3% 1.7% Cornwall Community Hospital % 4.5% 18.2% 15.2% 3.0% 28.8% 0.0% CHEO % 0.0% 48.0% 52.0% 0.0% 0.0% 0.0% Grand Total % 3.7% 15.3% 16.2% 16.5% 24.3% 0.8% Cases High % of General site acute cases in this CMG are transferred to another acute care hospital 52 Page 148

151 HIP FRACTURE IP REHAB CASES PER 10,000 AGE/GENDER STANDARDIZED POPULATION BY LHIN Residents of Champlain LHIN utilization of IP rehabilitation (measured as cases per population) was slightly below Ontario average rate 53 INPATIENT REHAB CASES PER 10,000 AGE/GENDER STANDARDIZED POPULATION FOR COUNTIES WITHIN THE LHIN AND FOR ONTARIO OVERALL Rate of IP rehab hospitalization for Hip Fracture below provincial average for residents of all Champlain counties 54 Page 149

152 DISCHARGE DISPOSITION OF IP HIP FRACTURE REHAB CASES BY LHIN Fracture of Lower Extremity % Distribution of IP Rehab Cases by Discharge Disposition Hospital LHIN Cases CCC or IP Home IP Acute Died Other LTCH Rehab Central % 23.1% 4.6% 10.5% 0.8% 0.0% Central East % 10.5% 0.2% 4.7% 0.5% 0.0% Central West % 10.3% 0.5% 5.1% 1.5% 0.0% Champlain % 9.3% 1.4% 7.0% 0.2% 0.2% Erie St. Clair % 26.7% 0.0% 5.1% 0.2% 0.0% HNHB % 5.2% 0.0% 2.3% 0.3% 0.0% Miss. Halton % 14.8% 5.2% 3.4% 0.3% 0.3% North East % 1.1% 1.1% 9.7% 0.0% 0.0% North West % 7.6% 1.0% 8.6% 0.0% 0.0% Nth. Simcoe Musk % 7.9% 0.0% 9.2% 0.0% 0.0% South East % 25.8% 0.0% 9.3% 0.0% 0.0% South West % 11.9% 0.5% 3.4% 1.0% 1.0% Toronto Central 1, % 5.4% 0.4% 5.0% 0.8% 0.1% Waterloo Well % 12.6% 0.0% 4.4% 0.7% 0.0% Grand Total 5, % 11.9% 1.1% 5.6% 0.6% 0.1% Champlain Rank % of Champlain IP rehab Hip Fracture patients are discharged home after rehab 55 DISCHARGE DISPOSITION OF CHAMPLAIN LHIN IP HIP FRACTURE REHAB PATIENTS BY HOSPITAL Fracture of Lower Extremity % Distribution of IP Rehab Cases by Discharge Disposition Hospital Cases IP Home CCC LTCH IP Acute Rehab Died Other Elisabeth Bruyere Hospital % 1.4% 0.7% 0.0% 7.2% 0.0% 0.0% Queensway-Carleton Hospital % 0.0% 10.0% 5.0% 10.0% 1.0% 0.0% Ottawa Hospital - General % 0.0% 3.6% 0.0% 4.8% 0.0% 1.2% St. Joseph's CC Cornwall % 0.0% 20.5% 0.0% 4.5% 0.0% 0.0% Pembroke Regional % 0.0% 7.5% 0.0% 10.0% 0.0% 0.0% Hopital Montfort % 0.0% 37.5% 4.2% 0.0% 0.0% 0.0% Glengarry Memorial Hospital 5 0.0% 0.0% 80.0% 0.0% 20.0% 0.0% 0.0% Ottawa Hospital - Rehab Ctre % 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% Grand Total % 0.5% 8.9% 1.4% 7.0% 0.2% 0.2% 5% of QCH hip fracture rehab patients discharged to 2 nd rehab facility High % of St. Joseph s and Montfort patients discharged to LTCH 56 Page 150

153 ACUTE CARE DOCUMENTATION OF DISCHARGE DISPOSITION OF PNEUMONIA PATIENTS 138-Viral/Unspecified Pneumonia 2014/15 % Distribution of Acute Care Live Discharges by Discharge Disposition Hospital LHIN Home Home (no Acute IP Rehab IP CCC LTCH Other Care HC) Care Central 1, % 2.6% 25.4% 51.4% 1.7% 15.9% 1.1% Central East 2, % 2.1% 20.0% 57.1% 3.3% 13.4% 0.6% Central West 1, % 0.8% 13.5% 67.4% 1.6% 13.4% 0.2% Champlain 2, % 1.6% 23.1% 50.2% 3.8% 16.2% 0.7% Erie St. Clair % 1.6% 18.8% 56.5% 3.2% 16.6% 0.0% HNHB 2, % 4.8% 23.2% 54.5% 1.9% 13.3% 0.8% Miss. Halton 1, % 4.0% 25.6% 55.2% 1.5% 9.7% 0.2% North East 1, % 1.2% 20.0% 63.5% 4.3% 9.1% 0.8% North West % 3.7% 14.1% 70.1% 5.1% 6.6% 0.4% Nth. Simcoe Musk % 1.0% 25.6% 56.1% 3.7% 11.9% 1.4% South East % 1.3% 24.3% 53.4% 2.8% 15.3% 1.2% South West 2, % 2.0% 24.5% 53.0% 3.7% 15.0% 0.5% Toronto Central 2, % 3.2% 21.5% 58.1% 1.4% 11.3% 0.3% Waterloo Well % 1.1% 25.1% 57.7% 2.8% 10.5% 0.8% Grand Total 20, % 2.4% 22.1% 56.4% 2.8% 13.1% 0.6% Cases Champlain LHIN acute care hospitals have highest % of pneumonia patients discharged directly to IP rehab; Does this reflect use of IP rehab for activation/restoration? Is this where pneumonia patients should be sent? 57 ACUTE CARE DOCUMENTATION OF DISCHARGE DISPOSITION OF GENERAL SYMPTOMS/SIGNS PATIENTS 811-General Symptom/Sign 2014/15 % Distribution of Acute Care Live Discharges by Discharge Disposition Hospital LHIN Home Home (no Acute IP Rehab IP CCC LTCH Other Care HC) Care Central % 3.9% 35.2% 39.6% 0.8% 13.7% 1.4% Central East % 5.7% 35.5% 34.5% 1.8% 12.8% 1.0% Central West % 3.8% 26.0% 45.1% 4.8% 6.8% 8.9% Champlain 1, % 6.1% 29.9% 32.7% 4.4% 16.3% 0.9% Erie St. Clair % 4.9% 24.8% 41.5% 3.2% 16.1% 1.7% HNHB 1, % 8.8% 33.9% 37.8% 1.7% 11.9% 2.2% Miss. Halton % 6.7% 37.1% 32.6% 1.6% 9.9% 1.8% North East 1, % 3.7% 27.7% 45.7% 5.3% 9.0% 5.2% North West % 15.6% 26.2% 41.3% 5.7% 8.8% 1.5% Nth. Simcoe Musk % 1.4% 32.3% 40.4% 1.8% 13.5% 9.4% South East % 2.8% 35.8% 40.7% 4.7% 9.8% 2.3% South West 1, % 4.1% 36.5% 36.8% 3.6% 14.2% 1.6% Toronto Central 1, % 3.6% 38.9% 40.3% 1.2% 7.5% 0.5% Waterloo Well % 3.0% 39.8% 37.2% 2.0% 9.8% 2.6% Grand Total 11, % 5.4% 33.3% 38.7% 2.9% 11.5% 2.5% Cases Champlain LHIN acute care hospitals have 2 nd highest rate of discharge directly to IP rehab, and highest rate to LTCH Is inpatient rehab the most appropriate placement for these patients? 58 Page 151

154 JOINT REPLACEMENT IP REHAB CASES PER 10,000 AGE/GENDER STANDARDIZED POPULATION BY LHIN Rate of use of IP rehab for joint replacement patients equal to provincial average 59 INPATIENT REHAB CASES PER 10,000 AGE/GENDER STANDARDIZED POPULATION FOR COUNTIES WITHIN THE LHIN AND FOR ONTARIO OVERALL High rate of use of IP rehab for joint replacement patients for residents of Renfrew county 60 Page 152

155 DISCHARGE DISPOSITION OF IP JOINT REPLACEMENT REHAB CASES BY LHIN Replacement of Lower Extremity % Distribution of IP Rehab Cases by Discharge Disposition Hospital LHIN Cases CCC or IP Home IP Acute Died Other LTCH Rehab Central % 7.7% 2.6% 4.1% 0.5% 0.0% Central East % 7.7% 0.0% 2.8% 0.7% 0.0% Central West % 13.8% 0.0% 3.4% 0.0% 0.0% Champlain % 4.2% 0.0% 4.8% 0.0% 0.0% Erie St. Clair % 20.8% 0.0% 3.9% 0.0% 0.0% HNHB % 1.4% 0.0% 2.4% 0.7% 0.3% Miss. Halton % 6.9% 6.9% 0.7% 0.0% 0.0% North East % 6.7% 0.0% 20.0% 0.0% 0.0% North West % 4.9% 0.0% 6.6% 0.0% 0.0% Nth. Simcoe Musk % 6.7% 0.0% 6.7% 0.0% 0.0% South East % 9.7% 0.0% 4.3% 0.0% 0.0% South West % 5.8% 0.7% 1.4% 0.0% 0.0% Toronto Central 1, % 0.8% 0.7% 1.7% 0.1% 0.1% Waterloo Well % 16.2% 0.0% 5.4% 0.0% 0.0% Grand Total 3, % 3.5% 0.8% 2.6% 0.2% 0.1% 61 DISCHARGE DISPOSITION OF CHAMPLAIN LHIN IP JOINT REPLACEMENT REHAB PATIENTS BY HOSPITAL Replacement of Lower Extremity % Distribution of IP Rehab Cases by Discharge Disposition Hospital Cases IP Home CCC LTCH IP Acute Rehab Died Other Ottawa Hospital - General % 0.0% 0.7% 0.0% 4.5% 0.0% 0.0% Pembroke Regional % 0.0% 0.0% 0.0% 10.8% 0.0% 0.0% Hopital Montfort % 0.0% 18.2% 0.0% 2.3% 0.0% 0.0% Queensway-Carleton Hospital % 0.0% 6.3% 0.0% 0.0% 0.0% 0.0% Elisabeth Bruyere Hospital % 0.0% 15.4% 0.0% 0.0% 0.0% 0.0% St. Joseph's CC Cornwall % 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% Ottawa Hospital - Rehab Ctre % 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% Glengarry Memorial Hospital % 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% Grand Total % 0.0% 4.2% 0.0% 4.8% 0.0% 0.0% High % of Montfort joint replacement rehab patients discharged to LTCH 62 Page 153

156 MEDICALLY COMPLEX IP REHAB CASES PER 10,000 AGE/GENDER STANDARDIZED POPULATION BY LHIN Great variation in rates of IP cases categorized as Medically Complex ; is this true variation in rehab practice or variation in coding? Champlain has 2 nd highest rate 63 INPATIENT REHAB CASES PER 10,000 AGE/GENDER STANDARDIZED POPULATION FOR COUNTIES WITHIN THE LHIN AND FOR ONTARIO OVERALL 64 Page 154

157 DISCHARGE DISPOSITION OF IP MEDICALLY COMPLEX REHAB CASES BY LHIN Medically Complex % Distribution of IP Rehab Cases by Discharge Disposition Hospital LHIN Cases CCC or IP Home IP Acute Died Other LTCH Rehab Central % 11.4% 3.3% 9.8% 2.0% 0.0% Central East % 8.9% 0.1% 7.6% 2.5% 0.1% Central West % 9.4% 0.0% 9.4% 1.2% 0.0% Champlain % 8.1% 1.0% 10.9% 0.5% 1.6% Erie St. Clair % 11.1% 0.0% 9.6% 0.0% 0.4% HNHB % 6.5% 0.0% 14.7% 1.1% 0.0% Miss. Halton % 9.5% 5.6% 8.0% 1.7% 0.6% North East % 11.3% 0.0% 5.0% 3.8% 0.0% North West 1 0.0% 100.0% 0.0% 0.0% 0.0% 0.0% Nth. Simcoe Musk % 0.0% 0.0% 16.0% 0.0% 0.0% South East % 3.8% 0.0% 11.5% 0.0% 0.0% South West % 10.1% 0.8% 5.9% 1.7% 0.8% Toronto Central 1, % 6.3% 0.6% 10.2% 0.3% 0.0% Waterloo Well % 9.0% 4.5% 10.8% 0.9% 0.0% Grand Total 5, % 8.2% 1.4% 9.5% 1.0% 0.4% 65 DISCHARGE DISPOSITION OF CHAMPLAIN LHIN IP MEDICALLY COMPLEX REHAB PATIENTS BY HOSPITAL Medically Complex % Distribution of IP Rehab Cases by Discharge Disposition Hospital Cases IP Home CCC LTCH IP Acute Rehab Died Other Ottawa Hospital - General % 0.4% 2.2% 0.4% 11.9% 0.0% 0.0% Queensway-Carleton Hospital % 0.5% 7.0% 2.3% 8.9% 1.4% 0.9% Elisabeth Bruyere Hospital % 4.8% 0.0% 0.0% 11.2% 0.5% 0.0% Hopital Montfort % 0.0% 27.8% 0.8% 3.2% 0.0% 8.7% Pembroke Regional % 0.0% 0.0% 0.0% 28.9% 0.0% 0.0% Ottawa Hospital - Rehab Ctre % 0.0% 0.0% 0.0% 24.2% 0.0% 0.0% St. Joseph's CC Cornwall % 0.0% 12.5% 12.5% 12.5% 0.0% 0.0% Glengarry Memorial Hospital % 0.0% 25.0% 0.0% 0.0% 0.0% 0.0% Grand Total % 1.3% 6.8% 1.0% 10.9% 0.5% 1.6% Very high % of Montfort Medically Complex IP rehab patients discharged to LTCH 66 Page 155

158 DEBILITY IP REHAB CASES PER 10,000 AGE/GENDER STANDARDIZED POPULATION BY LHIN 67 INPATIENT REHAB CASES PER 10,000 AGE/GENDER STANDARDIZED POPULATION FOR COUNTIES WITHIN THE LHIN AND FOR ONTARIO OVERALL Very high rate of use of IP rehab for Debility for residents of SDG 68 Page 156

159 OTHER ORTHOPAEDIC IP REHAB CASES PER 10,000 AGE/GENDER STANDARDIZED POPULATION BY LHIN 69 CARDIAC REHAB IP CASES PER 10,000 AGE/GENDER STANDARDIZED POPULATION BY LHIN Variation across province in extent to which IP cardiac rehab is provided 70 Page 157

160 INPATIENT REHAB CASES PER 10,000 AGE/GENDER STANDARDIZED POPULATION FOR COUNTIES WITHIN THE LHIN AND FOR ONTARIO OVERALL 71 LOWER EXTREMITY AMPUTATION REHAB IP CASES PER 10,000 AGE/GENDER STANDARDIZED POPULATION BY LHIN Champlain LHIN residents have lowest rate of IP rehab for amputation of lower extremity 72 Page 158

161 INPATIENT REHAB CASES PER 10,000 AGE/GENDER STANDARDIZED POPULATION FOR COUNTIES WITHIN THE LHIN AND FOR ONTARIO OVERALL 73 INPATIENT REHAB CASES PER 10,000 AGE/GENDER STANDARDIZED POPULATION FOR COUNTIES WITHIN THE LHIN AND FOR ONTARIO OVERALL 74 Page 159

162 VARIATION IN PROVISION OF IP PULMONARY REHAB BY LHIN 75 PULMONARY REHABILITATION Substantial variation in use of inpatient rehab for pulmonary patients Some hospitals have structured inpatient pre-hab programs for lung transplant candidates, but program duration varies: William Osler 2 weeks Ottawa Rehab Centre 4 weeks St. Joseph s Hamilton and West Park Toronto 6 weeks Other hospitals rely primarily on day hospital and ambulatory care What advice re planning parameters for provision of pulmonary rehabilitation in capacity planning model? 76 Page 160

163 A-3 USE OF INPATIENT COMPLEX CONTINUING CARE 77 DATA SOURCE Records were obtained from the MOHLTC IntelliHealth system for every patient discharged from a designated chronic bed in Ontario during fiscal year 2014/15, and for every assessment (usually on a quarterly basis for long-stay patients) Each record contained the mandatory data elements required to be reported by the Canadian Institute for Health Information (CIHI) using the Continuing Care Reporting System (CCRS) In some facilities, beds that are formally designated as chronic (and funded via the HBAM chronic performance measurement methodology) are used for other purposes, such as supportive care, restorative care or transitional care The CCRS records do not contain information about this alternate use of the beds, i.e. all are considered to be chronic beds CCRS records are categorized by RUG group depending on the clinical characteristics of the patient, and the care they are receiving 78 Page 161

164 2014/15 DISTRIBUTION OF CCRS ASSESSMENTS BY RUG % Distribution of Assessments by RUG Hospital LHIN Assessments (1) Special Rehab - Ultra High (2) Special Rehab - Very High (3) Special Rehab - High (4) Special Rehab - Medium (5) Special Rehab - Low Low % of Champlain CCRS assessments in Medium to Ultra High Special Rehab, but high % in Low Special Rehab and Extensive Care 79 (6) Extensive Care (7) Special Care (8) Clinically Complex Care (9) Impaired Cognition (10) Behavioural Problems (11) Reduced Physical Functions Central 893 1% 3% 9% 33% 1% 37% 6% 11% 0% 0% 0% Central East 1,600 0% 0% 0% 23% 14% 12% 9% 33% 2% 1% 6% Central West 459 1% 2% 7% 36% 0% 21% 8% 17% 0% 0% 9% Champlain 3,346 0% 0% 1% 18% 19% 37% 8% 13% 1% 0% 4% Erie St. Clair 1,456 0% 0% 2% 20% 7% 23% 11% 28% 2% 1% 8% HNHB 4,518 2% 3% 6% 43% 10% 15% 7% 12% 1% 0% 2% Miss. Halton 1,633 0% 0% 4% 36% 9% 15% 6% 27% 0% 0% 2% Nth. Simcoe Musk % 2% 7% 19% 0% 13% 19% 35% 0% 0% 4% North East 1,193 0% 0% 2% 35% 5% 12% 8% 21% 5% 1% 11% North West 1,423 0% 2% 5% 33% 7% 13% 11% 15% 3% 0% 10% South East 913 1% 2% 3% 37% 12% 10% 8% 17% 2% 0% 8% South West 1,660 0% 0% 2% 22% 9% 16% 12% 25% 2% 0% 11% Toronto Central 8,943 1% 2% 6% 35% 12% 22% 6% 10% 1% 0% 6% Waterloo Well. 1,303 0% 0% 0% 32% 16% 21% 14% 15% 0% 0% 1% Ontario 29,819 1% 1% 4% 32% 11% 20% 8% 16% 1% 0% 5% Champlain Rank CHAMPLAIN LHIN HOSPITAL DISTRIBUTION OF CCRS ASSESSMENTS BY RUG Hospital Assessments (1) Special Rehabilitation -Ultra High (2) Special Rehabilitation - Very High % Distribution of Assessments by RUG (3) Special Rehabilitation -High (4) Special Rehabilitation -Medium (5) Special Rehabilitation - Low Variation in % concentration of assessments by RUG across hospitals in the LHIN (6) Extensive Care (7) Special Care (8) Clinically Complex Care (9) Impaired Cognition (10) Behavioural Problems (11) Reduced Physical Functions St.-Vincent Hospital 2,411 0% 0% 0% 15% 22% 47% 7% 8% 0% 0% 1% St. Joseph's Cornwall 305 0% 0% 0% 23% 1% 15% 16% 27% 3% 0% 16% Hawkesbury & District 190 1% 1% 3% 56% 4% 5% 5% 25% 1% 0% 1% Pembroke Regional 117 0% 0% 0% 0% 2% 2% 14% 44% 4% 1% 34% Almonte General 99 0% 0% 0% 3% 45% 5% 13% 25% 2% 0% 6% Winchester DM 94 0% 0% 9% 46% 20% 9% 6% 10% 0% 0% 1% Arnprior & District 51 0% 0% 0% 0% 0% 2% 8% 51% 2% 2% 35% St. Francis Memorial 45 0% 0% 0% 0% 47% 13% 31% 7% 0% 0% 2% Renfrew Victoria 18 0% 0% 0% 6% 0% 28% 17% 39% 0% 0% 11% Kemptville District 16 0% 0% 0% 0% 13% 6% 6% 50% 13% 0% 13% Grand Total 3,346 0% 0% 1% 18% 19% 37% 8% 13% 1% 0% 4% 80 Page 162

165 PERCENT FOCUS ON HIGH REHABILITATION OF LARGEST CCC FACILITIES IN ONTARIO Large variation in focus of large CCC hospitals on high rehabilitation (as reflected by RUG assignment) Bruyere is (along with Sunnybrook, which contains Veteran s care) at the low end of the spectrum re % focus on high rehabilitation Trend in Ontario towards reducing differentiation between rehab and CCC roles CCC increasingly seen as temporary provider of care, rather than final destination Should the future Champlain LHIN sub-acute system emphasize distinct roles for rehab vs CCC units? Medium % Med. to Ultra to Ultra Hospital High High Special Spec. Rehab Rehab Bruyere Continuing Care 2, % Niagara HS 1, % Sunnybrook HSC 1, % Bridgepoint Hospital 1,600 1, % St. Joseph's CG, Thunder Bay 1, % Hamilton HSC 1, % Baycrest % Providence HC, Scarborough % Runnymede Healthcare Centre % University Health Network % Halton Healthcare % Grand River Hospital % Trillium Health Partners % Assessments 81 Hospital CHAMPLAIN LHIN HOSPITAL DISTRIBUTION OF CCRS ASSESSMENTS BY RUG Assessments (1) Special Rehab - Ultra High (2) Special Rehab - Very High (3) Special Rehab - High % Distribution of Assessments by RUG (4) Special Rehab - Medium (5) Special Rehab - Low (6) Extensive Care (7) Special Care (8) Clinically Complex Care (9) Impaired Cognition (10) Behavioural Problems (11) Reduced Physical Functions St.-Vincent Hospital 2,411 0% 0% 0% 15% 22% 47% 7% 8% 0% 0% 1% St. Joseph's CC, Cornwall 305 0% 0% 0% 23% 1% 15% 16% 27% 3% 0% 16% Hawkesbury & District 190 1% 1% 3% 56% 4% 5% 5% 25% 1% 0% 1% Pembroke Regional 117 0% 0% 0% 0% 2% 2% 14% 44% 4% 1% 34% Almonte General Hospital 99 0% 0% 0% 3% 45% 5% 13% 25% 2% 0% 6% Winchester District Mem. 94 0% 0% 9% 46% 20% 9% 6% 10% 0% 0% 1% Arnprior & District Memorial 51 0% 0% 0% 0% 0% 2% 8% 51% 2% 2% 35% St. Francis Memorial Hosp. 45 0% 0% 0% 0% 47% 13% 31% 7% 0% 0% 2% Renfrew Victoria Hospital 18 0% 0% 0% 6% 0% 28% 17% 39% 0% 0% 11% Kemptville District Hospital 16 0% 0% 0% 0% 13% 6% 6% 50% 13% 0% 13% Grand Total 3,346 0% 0% 1% 18% 19% 37% 8% 13% 1% 0% 4% Variation in % concentration of assessments by RUG across hospitals in the LHIN High % reduced physical function at Almonte and Arnprior potential candidates for transfer to LTCH? 82 Page 163

166 COMPARISON OF CHAMPLAIN LHIN CCC PATIENT LENGTH OF STAY WITH PROVINCIAL AVERAGE LENGTH OF STAY RUG Category Discharges Champlain Activity Ontario Avg. LOS Expected Ont. LOS Days Over/(Under) Expected (1) Special Rehabilitation - Ultra High (65) (2) Special Rehabilitation - Very High (23) (3) Special Rehabilitation - High (230) (4) Special Rehabilitation - Medium , ,108 1,609 (5) Special Rehabilitation - Low , ,379 29,499 (6) Extensive Care , ,362 (224) (7) Special Care 89 10, ,090 1,557 (8) Clinically Complex Care , ,124 (1,828) (9) Impaired Cognition 6 1, , (10) Behavioural Problems (151) (11) Reduced Physical Functions 48 7, ,531 (2,368) Total 1, , ,762 28,169 IP Days If Champlain LHIN CCC patients had LOS equal to the provincial average for each RUG category, there would have been 28,169 fewer CCC inpatient days used in 2014/15, or the equivalent of 80 beds Avg. LOS 83 AGE/GENDER STANDARDIZED CCC IP CASES PER 10,000 POPULATION BY RUG BY LHIN Patient LHIN (1) Special Rehab -Ultra High (2) Special Rehab - Very High (3) Special Rehab -High (4) Special Rehab - Medium (5) Special Rehab - Low (6) Extensive Care (7) Special Care (8) Clinically Complex Care (9) Impaired Cognition (10) Behavioural Problems (11) Reduced Phys. Functions Central Central East Central West Champlain Erie St. Clair HNHB Miss. Halton North Sim. Musk North-East North-West South East South West Toronto Central Waterloo Well Ontario Champlain Rank Residents of Champlain LHIN have highest rate of CCC Extensive Care cases per population, but very low for most Special Rehab Grand Total 84 Page 164

167 A-4 CONVALESCENT BEDS IN LONG TERM CARE 85 ASSESSMENTS OF LTCH RESIDENTS IN CHAMPLAIN LTCH IN BEDS CATEGORIZED AS CONVALESCENT BY RUG 463 discharges from Convalescent beds in Champlain LTCH in 2014/15 Average LOS for these discharges was 54 days RUG Category Cases Days Avg. LOS (1) Extensive Care (2) Special Rehabilitation 138 8, (3) Special Care 104 4, (4) Clinically Complex Care 138 7, (5) Impaired Cognition (6) Behavioural Problems (7) Reduced Physical Functions 58 3, Grand Total , Page 165

168 DISCHARGE DISPOSITION OF CHAMPLAIN PATIENTS IN LTCH CONVALESCENT BEDS 49% of discharges went home, either with or without home care Almost one third were transferred back to inpatient rehabilitation Strengthening in Convalescent bed for rehab? Discharge Avg. Cases Days Disposition LOS Home , IP Rehab 151 8, IP Acute Care 48 1, LTC Home 18 1, Retirement Home Home Care Service IP CCC Died Grand Total , % Home, incl. HCS 49% 87 A-5 USE OF CCAC IN-HOME CARE 88 Page 166

169 DATA SOURCE RAI-HC eligibility records for every client assessed for In-Home care by a CCAC in Ontario during 2014/15 extracted from MOHLTC IntelliHealth Assessment records contained: Application Date Assess Start Date Days Apply to Assess Assessment Outcome Admission Date Assess to Admit Days Program Requested Initial Service Care Goal Discharge Date Service LOS Client LHIN Client County Sex Age Grp (5yr) CCAC (application) CCAC (admission) Discharge Status Xfer From Inst. # Xfer from Instit. Name Transfer From Type Referral From Source Living Arrangement Residence Type Referral To Encrypted HN SRC 89 AGE/GENDER STANDARDIZED SERVICES PER 10,000 POPULATION BY CCAC BY SERVICE ACTIVITY CCAC PSW and Homemaking Nursing-Visit Case Management Physiotherapy Occupational Therapy Nursing-Shift (Hour) Speech Language Therapy Other Social Work Nutrition/Dietetic Rapid Response Nursing Visit Specialist Physician Office Central 17,484 4,574 1,150 1, ,197 Central East 18,843 4,001 1, ,092 Central West 16,428 3,481 1, ,335 Champlain 17,791 4,158 1, ,106 Erie St. Clair 21,195 6,855 1, ,655 HNHB 22,612 6,188 1, ,323 Miss. Halton 17,927 4,065 1, ,027 North East 19,257 4,646 3, ,424 North West 26,444 6,884 1, ,022 Nth. S. Musk. 18,167 4,932 1, ,289 South East 24,582 5,258 1, ,274 South West 16,200 5,382 1, ,595 Toronto Cent. 21,019 5,004 1, ,486 Wat. Well. 20,507 4,652 1, ,332 Ontario 19,364 4,833 1, ,617 Champlain Rank Rate of utilization of In-Home Physiotherapy and SLT for Champlain residents is below Ontario average, but OT rate is slightly higher NP Palliative Visit Other Disciplines Grand Total 90 Page 167

170 CCAC SERVICES PER 10,000 AGE/GENDER STANDARDIZED POPULATION BY CCAC PHYSIOTHERAPY VISITS Much higher rate of CCAC physiotherapy visits per capita for residents of Central LHIN than for residents of other LHINs Very low rate of PT services per population for Champlain residents 91 CCAC SERVICES PER 10,000 AGE/GENDER STANDARDIZED POPULATION BY CCAC OCCUPATIONAL THERAPY VISITS Utilization of in-home OT by Champlain LHIN residents is slightly higher than Ontario average 92 Page 168

171 CCAC SERVICES PER 10,000 AGE/GENDER STANDARDIZED POPULATION BY CCAC SPEECH LANGUAGE THERAPY SERVICES Much higher rate of CCAC Speech Language Therapy services per capita for residents of North East LHIN than for residents of other LHINs; Champlain resident utilization is 4 th lowest 93 AGE/GENDER STANDARDIZED SERVICES PER 10,000 POPULATION BY CCAC BY SERVICE RECIPIENT CATEGORY (SRC) CCAC 93 - Maintenance 94 - LT Supportive 91 - Acute 95 - End of Life 92 - Rehabilitation 47 - LTC Placement 49 - Convalescent Care 48 - Short Stay Respite Central 17,655 3,276 1,613 1,182 1, ,197 Central East 6,854 14,261 1,943 1,642 1, ,092 Central West 8,355 8,787 1,801 1,279 1, ,146 23,335 Champlain 4,502 16,088 1,960 1, ,106 Erie St. Clair 17,498 5,864 3,442 2,782 1, ,655 HNHB 19,070 6,010 2,725 1,623 2, ,323 Miss. Halton 13,173 4,592 2,379 2,577 2, ,027 North East 7,583 15,447 2,777 1,606 1, ,424 North West 20,421 10,059 2,475 1,748 2, ,022 Nth. Sim. Musk. 2,875 17,713 2,226 2, ,289 South East 19,503 6,298 2,522 1,050 3, ,274 South West 4,992 14,622 2,582 1,539 1, ,595 Toronto Central 14,398 10,849 1,317 1,207 1, ,486 Waterloo Well. 15,341 5,667 2,287 2,219 2, ,332 Ontario 12,086 9,707 2,177 1,638 1, ,617 Champlain Rank Rate of use of In-Home services by Rehabilitation clients is 2 nd lowest in province All Others Grand Total 94 Page 169

172 CCAC SERVICES PER 10,000 AGE/GENDER STANDARDIZED POPULATION BY CCAC SRC 92 REHABILITATION 95 CCAC SERVICES PER 10,000 AGE/GENDER STANDARDIZED POPULATION BY CCAC SRC 93 MAINTENANCE 96 Page 170

173 CCAC SERVICES PER 10,000 AGE/GENDER STANDARDIZED POPULATION BY CCAC SRC 94 LONG- TERM SUPPORTIVE Champlain LHIN residents have 2 nd highest rate of In Home long term supportive services per population 97 CCAC SERVICES PER 10,000 AGE/GENDER STANDARDIZED POPULATION BY CCAC SRC 95 END OF LIFE Champlain LHIN rate of use of CCAC in-home End of Life services is below the provincial average 98 Page 171

174 CCAC SERVICES PER 10,000 AGE/GENDER STANDARDIZED POPULATION BY CCAC SRC 48 SHORT STAY RESPITE High rate of use by Champlain LHIN residents of in-home short stay respite CCAC services 99 CCAC SERVICES PER 10,000 AGE/GENDER STANDARDIZED POPULATION BY CCAC SRC 49 CONVALESCENT CARE 100 Page 172

175 AVERAGE LENGTH OF SERVICE FOR IN-HOME REHABILITATION CLIENTS Average days from application to assessment of 17.5 days is second longest in province, almost double the provincial average of 8.9 days Average length on time on service after admission of 98.3 days is 4 th longest in province Initial Service Care Goal: Rehabilitation (In-Home) CCAC # of Assess. Avg. Days Avg. Days Apply to Assess to Assess Admit Avg. Svce. LOS Erie St. Clair 4, South West 11, Waterloo Well. 7, HNHB 13, Central West 7, Miss. Halton 7, Toronto Central 8, Central 10, Central East 10, South East 6, Champlain 7, Nth. Simcoe Musk. 1, North East 5, North West 2, Ontario 107, IN-HOME REHAB CASES PER 10,000 AGE/GENDER STANDARDIZED POPULATION FOR COUNTIES WITHIN THE LHIN AND FOR ONTARIO OVERALL Rate of Cases per 10,000 for In-Home rehab for residents of Ottawa is well below the provincial average 102 Page 173

176 IN-HOME MAINTENANCE AND LT SUPPORTIVE CASES PER 10,000 AGE/GENDER STANDARDIZED POPULATION FOR COUNTIES WITHIN THE LHIN AND FOR ONTARIO OVERALL Little variation in combined in-home Maintenance and LT Supportive Care across Champlain counties 103 IN-HOME END OF LIFE CASES PER 10,000 AGE/GENDER STANDARDIZED POPULATION FOR COUNTIES WITHIN THE LHIN AND FOR ONTARIO OVERALL For all Champlain counties, except Lanark, the rates of in-home End of Life clients for residents is above the Ontario average Suggests fewer services per client since services per population was below provincial average? 104 Page 174

177 PROVISION OF IN-HOME CARE FOR RETIREMENT HOME RESIDENTS 11.7% of Champlain CCAC in-home services are provided to residents of retirement homes, highest rate in province Little opportunity to increase service to Retirement Home residents to reduce pressure on LTCH? Service Location for In Home Care Patient LHIN % % Home/ Retirement Apt. Home Erie St. Clair 5.8% 91.9% South West 5.6% 91.2% Waterloo Well. 7.2% 91.2% HNHB 6.5% 90.1% Central West 3.7% 94.0% Miss. Halton 5.1% 91.1% Toronto Central 2.7% 93.0% Central 4.5% 92.1% Central East 4.5% 92.7% South East 4.8% 92.6% Champlain 11.7% 84.8% Nth. Simcoe Musk. 6.4% 91.4% North East 3.5% 91.5% North West 4.2% 91.5% Unknown 1.2% 89.7% Total 5.5% 91.3% 105 A-6 OTHER COMMUNITY SERVICES 106 Page 175

178 DATA SOURCES Relatively little data available to comprehensively describe provision of community support services (CSS) Ontario Management Information System (MIS) service activity and cost data for CSS cost centres (i.e. functional centres) downloaded from Ontario MOHLTC data portal No individual service record data available 107 CHAMPLAIN LHIN REPORTED EXPENSES AND CLIENTS FOR COMMUNITY SUPPORT SERVICES FOR HIGHEST COST FUNCTIONAL CENTRES Functional Centre Net Expenses Clients Served % of Total Expense 28.7% of Champlain LHIN CSS expenses were for Assisted Living Services in 2014/15 Cumul. % COM IH & CS - Assisted Living Services $18,445,254 1, % 28.7% COM IH & CS - Personal Support/Independence $6,678,953 2, % 39.1% Training COM IH & CS - Day Services $6,566,891 3, % 49.4% COM IH & CS - Transportation - Client $5,897,464 10, % 58.6% COM IH & CS - Respite $5,042,758 1, % 66.4% COM IH & CS - Visiting - Social and Safety $2,577,261 4, % 70.4% COM IH & CS - Meals Delivery $2,339,953 7, % 74.1% COM IH & CS - Social and Congregate Dining $2,218,679 9, % 77.5% Residential Hospice- End of Life (EOL) - Nursing Shift $1,490, % 79.8% COM IH & CS - Caregiver Support $1,387,557 7, % 82.0% CSS ABI - Personal Support/Independence Training $1,263, % 84.0% COM IH & CS - Service Arrangement/Coordination $1,215,195 6, % 85.9% COM Health Promotion Education - Psycho-Geriatric $1,194, % 87.7% COM IH & CS - Homemaking $815,972 1, % 89.0% COM IH & CS - Vision Impaired Care Services $758,934 2, % 90.2% 108 Page 176

179 2014/15 REPORTED EXPENSES AND ACTIVITY FOR ASSISTED LIVING ABI BY LHIN LHIN Net Expenses Res. Days Indiv. Served Days per Indiv. Cost per Day Cost per Indiv. Central $7,221,860 23, $308 $104,665 Central East Central West Champlain $537,467 1, $344 $107,493 Erie St. Clair $546,815 2, $217 $78,116 HNHB $12,608,180 29, $427 $143,275 Miss. Halton $5,375,599 9, $566 $191,986 North East $1,727,558 5, $322 $90,924 North West $2,423,108 8, $278 $80,770 Nth. Simcoe Musk. South East $2,173,526 3, $597 $197,593 South West $3,812,456 9, $417 $131,464 Toronto Central Waterloo Well. $1,806,057 6, $275 $64,502 Grand Total $38,232,626 99, $ 383 $121,760 Does low number of clients and funding reflect limited availability of service, or variation in specificity of reporting (i.e. ABI captured in general assisted living category)? 109 COMPARISON OF ASSISTED LIVING EXPENSES AND CLIENTS BY LHIN LHIN Net Expenses Res. Days Indiv. Served Days per Indiv. Cost per Day Cost per Indiv. Indiv. Expenses Served Pop'n 65+ per Pop'n per 1, Pop'n 65+ Central $28,652, ,379 2, $47 $11, ,716 $ Central East $20,907, ,611 2, $38 $7, ,838 $ Central West $8,687, , $43 $10, ,210 $ Champlain $18,445, ,563 1, $88 $12, ,343 $ Erie St. Clair $10,205,220 86, $119 $33, ,528 $ HNHB $29,634, ,518 2, $64 $13, ,305 $ Miss. Halton $31,884, ,847 2, $63 $13, ,511 $ North East $18,530, ,499 1, $66 $10, ,274 $ North West $9,629, , $39 $11,491 39,460 $ Nth. Sim. Musk. $6,381,422 98, $65 $11,666 86,263 $ South East $2,628,300 46, $56 $22, ,114 $ South West $17,869, , $115 $30, ,947 $ Toronto Central $42,629, ,985 4, $45 $9, ,031 $ Waterloo Well. $6,855,376 53, $128 $6, ,236 $ Grand Total $252,940,731 4,468,433 21, $ 57 $ 11,761 2,138,776 $ nd shortest average LOS for clients in assisted living Assisted living expenses per population and individuals served per population are both below the provincial average 110 Page 177

180 LHIN 2014/15 CSS PERSONAL SUPPORT/INDEPENDENCE TRAINING EXPENSES AND SERVICES BY LHIN Net Expenses Service Hours Indiv. Served Hours per Indiv. Cost per Hour Cost per Indiv. Pop'n 65+ Indiv. Expenses Served per Pop'n per 1, Pop'n 65+ Central $5,992, , $36 $26, ,716 $ Central East $1,061,592 34, $31 $16, ,838 $ Central West $1,081,298 31, $35 $4, ,210 $ Champlain $6,678, ,189 2, $43 $2, ,343 $ Erie St. Clair $3,491, , $35 $18, ,528 $ HNHB $10,240, ,090 1, $33 $9, ,305 $ Miss. Halton $4,703, ,193 1, $31 $2, ,511 $ North East $4,078, , $40 $5, ,274 $ North West $1,463,821 48, $30 $17,221 39,460 $ Nth. Sim. Musk. $1,666,219 53, $31 $1,747 86,263 $ South East $3,944,679 68, $57 $31, ,114 $ South West $4,816, , $29 $14, ,947 $ Toronto Central $9,532, ,733 1, $50 $8, ,031 $ Waterloo Well. $4,005, , $32 $18, ,236 $ Grand Total $62,758,183 1,708,466 9, $ 37 $ 6,637 2,138,776 $ Champlain LHIN has highest number of individuals, and highest rate per population of CSS personal support/independence training 111 A-7 APPLICATION OF THE REHABILITATIVE CARE ALLIANCE FRAMEWORK 112 Page 178

181 DISTRIBUTION OF NRS DISCHARGES BY RCA BEDDED LEVEL OF CARE BY CHAMPLAIN LHIN HOSPITAL Rehabilitation Activation Restoration % Activation/ Hospital Restoration Cases Days Avg. Avg. Cases Days LOS LOS Cases Days Ottawa Hospital 1,019 26, % 1% Bruyere Continuing Care , % 0% Queensway-Carleton Hospital , % 7% Pembroke Regional 277 7, % 3% Hopital Montfort 349 4, , % 35% St. Joseph's CC Cornwall 126 2, , % 31% Glengarry Memorial Hospital 89 3, % 0% Grand Total 3,305 81, , % 6% High % of Montfort and St. Joseph s NRS cases categorized as Activation/ Restoration 113 AGE/GENDER STANDARDIZED INPATIENT DAYS IN DESIGNATED REHAB BEDS PER 10,000 LHIN POPULATION Patient LHIN Specialized General/ Geriatric Activation/ Restoration Total Nth. Simcoe Musk South East Waterloo Well HNHB South West North East Grand Total Erie St. Clair Champlain Central Central West North West Miss. Halton Central East Toronto Central Champlain LHIN residents had higher than average rates of use of IP rehab beds (as measured by days) for each of Specialized Rehab, General/Geriatric Rehab, and Activation/Restoration 114 Page 179

182 RCA REHABILITATION IP REHAB CASES PER 10,000 AGE/GENDER STANDARDIZED POPULATION BY LHIN 115 RCA ACTIVATION/ RESTORATION IP REHAB CASES PER 10,000 AGE/GENDER STANDARDIZED POPULATION BY LHIN 116 Page 180

183 % DISTRIBUTION OF 2014/15 CCRS ASSESSMENTS BY HOSPITAL LHIN Hospital LHIN Assessments Rehabilitation % Distribution of Assessments by RCA Category Activation/ Restoration Medically Complex - ST Medically Complex - LT End of Life Respite Care Other Other - Dementia Central % 0% 32% 14% 35% 0% 0% 0% Central East 1,600 10% 7% 26% 24% 14% 0% 9% 10% Central West % 0% 44% 17% 2% 0% 10% 5% Champlain 3,346 10% 4% 13% 28% 20% 0% 20% 6% Erie St. Clair 1,456 14% 3% 18% 25% 16% 0% 13% 12% HNHB 4,518 29% 3% 28% 12% 22% 0% 4% 2% Miss. Halton 1,633 20% 3% 17% 16% 29% 0% 7% 7% Nth. Simcoe Musk % 1% 36% 9% 16% 0% 14% 4% North East 1,193 25% 4% 17% 14% 8% 0% 16% 15% North West 1,423 19% 3% 27% 14% 10% 0% 17% 9% South East % 9% 28% 16% 16% 2% 7% 4% South West 1,660 14% 9% 25% 16% 15% 1% 13% 7% Toronto Central 8,943 27% 3% 10% 24% 16% 0% 8% 11% Waterloo Well. 1,303 18% 11% 24% 17% 18% 1% 9% 2% Ontario 29,819 21% 4% 19% 20% 18% 0% 10% 8% Champlain Rank Champlain LHIN hospitals had low % of CCC assessments categorized as Rehabilitation and Medically Complex ST, and highest % categorized as Medically Complex LT and Other (ALC?) 117 % DISTRIBUTION OF CHAMPLAIN LHIN CCC ASSESSMENTS BY RCA CATEGORY BY HOSPITAL Hospital Assessments Rehabilitation % Distribution of Assessments by RCA Activation/ Restoration Medically Complex - ST Medically Complex - LT St.-Vincent Hospital 2,411 9% 4% 8% 33% 24% 0% 18% 5% St. Joseph's CC, Cornwall % 0% 5% 29% 3% 0% 39% 5% Hawkesbury & District % 7% 55% 1% 11% 0% 1% 1% Pembroke Regional 117 0% 3% 5% 10% 24% 0% 32% 25% Almonte General Hospital 99 4% 6% 1% 32% 7% 0% 22% 27% Winchester District Memorial 94 17% 5% 68% 2% 4% 0% 1% 2% Arnprior & District Memorial 51 0% 0% 35% 10% 27% 0% 18% 10% St. Francis Memorial Hospital 45 0% 2% 31% 31% 4% 0% 20% 11% Renfrew Victoria Hospital 18 6% 0% 11% 28% 6% 0% 50% 0% Kemptville District Hospital 16 0% 0% 0% 6% 6% 0% 31% 56% Grand Total 3,346 10% 4% 13% 28% 20% 0% 20% 6% End of Life Respite Care Other Other - Dementia Variation across LHIN in use of CCC beds; high % rehabilitation at St. Joseph s and Hawkesbury High % Other (ALC?) for St. Joseph s 118 Page 181

184 AGE/GENDER STANDARDIZED CCC IP CASES PER 10,000 POPULATION BY RCA BEDDED LEVEL OF CARE BY LHIN Patient LHIN Rehabilitation Activation/ Restoration Medically Complex - ST Medically Complex - LT End of Life Respite Care Other Other - Dementia Central Central East Central West Champlain Erie St. Clair HNHB Miss. Halton North Sim. Musk North-East North-West South East South West Toronto Central Waterloo Well Ontario Champlain Rank Low population based rate of CCC cases for Champlain LHIN residents for Rehabilitation and Medically Complex - ST Grand Total 119 IP CCC DAYS PER 10,000 AGE/GENDER STANDARDIZED POPULATION BY RCA CATEGORY BY LHIN Patient LHIN Rehabilitation Activation/ Restoration Medically Complex - ST Medically Complex - LT End of Life Respite Care Other Other - Dementia Central ,931 Central East ,584 Central West ,081 Champlain ,543 Erie St. Clair ,296 HNHB ,170 Miss. Halton ,030 North Sim. Musk North-East , , ,801 North-West ,602 South East ,250 South West ,150 Toronto Central 1, , ,527 Waterloo Well ,424 Ontario ,087 Champlain Rank Lowest population based rate of CCC days for Champlain LHIN residents for Medically Complex ST; High rate for Medically Complex LT and Other Grand Total 120 Page 182

185 RCA REHABILITATION IP CCC CASES AND DAYS PER 10,000 AGE/GENDER STANDARDIZED POPULATION BY LHIN Low rates of use of CCC beds in Champlain LHIN for RCA Rehabilitation category 121 RCA ACTIVATION/ RESTORATION IP CCC CASES AND DAYS PER 10,000 AGE/GENDER STANDARDIZED POPULATION BY LHIN Low rate of cases for Activation/Restoration in Champlain LHIN CCC beds, but high average LOS puts day rate just above Ontario average 122 Page 183

186 RCA MEDICALLY COMPLEX SHORT TERM IP CCC CASES AND DAYS PER 10,000 AGE/GENDER STANDARDIZED POPULATION BY LHIN Very low use of South West LHIN CCC beds for Medically Complex Short Term, with shorter LOS than in most LHINs 123 RCA MEDICALLY COMPLEX LONG TERM IP CCC CASES AND DAYS PER 10,000 AGE/GENDER STANDARDIZED POPULATION BY LHIN Very high use of IP CCC beds in Champlain LHIN hospitals for Medically Complex Long Term 124 Page 184

187 END OF LIFE IP CCC CASES AND DAYS PER 10,000 AGE/GENDER STANDARDIZED POPULATION BY LHIN High rate of patients per population for End of Life care in Champlain CCC beds, but low rate per day because of shorter average LOS 125 OTHER IP CCC CASES AND DAYS PER 10,000 AGE/GENDER STANDARDIZED POPULATION BY LHIN Very high rate of patients per population for Other in Champlain CCC beds; ALC reduction opportunity? 126 Page 185

188 OTHER - DEMENTIA IP CCC CASES PER 10,000 AGE/GENDER STANDARDIZED POPULATION BY LHIN Low rate of CCC patients for Other Dementia 127 INPATIENT CCC DAYS PER 10,000 AGE/GENDER STANDARDIZED POPULATION FOR COUNTIES WITHIN THE LHIN AND FOR ONTARIO OVERALL 128 Page 186

189 INPATIENT RCA REHABILITATION CCC DAYS PER 10,000 AGE/GENDER STANDARDIZED POPULATION FOR COUNTIES WITHIN THE LHIN AND FOR ONTARIO OVERALL Little rehab in CCC beds for residents of Renfrew and Lanark 129 INPATIENT RCA ACTIVATION/RESTORATION CCC DAYS PER 10,000 AGE/GENDER STANDARDIZED POPULATION FOR COUNTIES WITHIN THE LHIN AND FOR ONTARIO OVERALL 130 Page 187

190 INPATIENT RCA MEDICALLY COMPLEX CCC DAYS PER 10,000 AGE/GENDER STANDARDIZED POPULATION FOR COUNTIES WITHIN THE LHIN AND FOR ONTARIO OVERALL 131 INPATIENT END OF LIFE CCC DAYS PER 10,000 AGE/GENDER STANDARDIZED POPULATION FOR COUNTIES WITHIN THE LHIN AND FOR ONTARIO OVERALL End of Life days in CCC beds above average for Ottawa residents, but below elsewhere in LHIN 132 Page 188

191 INPATIENT RCA OTHER CCC DAYS PER 10,000 AGE/GENDER STANDARDIZED POPULATION FOR COUNTIES WITHIN THE LHIN AND FOR ONTARIO OVERALL Higher than provincial average Other days in CCC beds for all counties except Prescott and Russell 133 INPATIENT RCA OTHER-DEMENTIA CCC DAYS PER 10,000 AGE/GENDER STANDARDIZED POPULATION FOR COUNTIES WITHIN THE LHIN AND FOR ONTARIO OVERALL 134 Page 189

192 COMPARISON OF CCC ACTIVITY BY RCA LEVELS OF BEDDED CARE ONTARIO AND CHAMPLAIN LHIN RCA Level of Bedded Care Disch. Ontario Days Avg. LOS Avg. Patient Age Disch. Champlain Days Avg. LOS Avg. Patient Age Rehabilitation 4, , , Activation/ Restoration , , Medically Complex - ST 5, , , Medically Complex - LT 1, , , Respite Care 63 2, End of Life 3, , , Other , , Other - Dementia , , Grand Total 17,058 1,547, , , In RCA Framework 11, , ,769 % in RCA Framework 68% 64% 53% 57% Champlain LHIN CCC patients tend (on average) to be younger than the average CCC patient in Ontario, but have a longer LOS Champlain End of Life patients in CCC beds are (on average) younger, and have a shorter LOS in CCC (i.e. 37 days vs. Ontario avg. of 52 days) 135 COMPARISON OF CCC ACTIVITY BY RCA LEVELS OF BEDDED CARE ONTARIO AND ST. VINCENT HOSPITALS RCA Level of Bedded Care Disch. Days Ontario Avg. LOS Avg. Patient Age Disch. St.-Vincent Hospital Days Avg. LOS Avg. Patient Age Rehabilitation 4, , , Activation/ Restoration , , Medically Complex - ST 5, , , Medically Complex - LT 1, , , Respite Care 63 2, End of Life 3, , , Other , , Other - Dementia , , Grand Total 17,058 1,547, , , In RCA Framework 11, , ,444 % in RCA Framework 68% 64% 45% 58% St. Vincent CCC patients are younger than the Ontario average, but have an average LOS 42 days longer Less than half of St. Vincent patients fit within the RCA framework categories, and the St. Vincent Other patients in CCC beds stay almost a year on average 136 Page 190

193 COMPARISON OF CCC ACTIVITY BY RCA LEVELS OF BEDDED CARE ONTARIO AND ST. JOSEPH S HOSPITAL RCA Level of Bedded Care Disch. Ontario Days Avg. LOS Avg. Patient Age St. Joseph's CC, Cornwall Disch. Days Avg. LOS Avg. Patient Age Rehabilitation 4, , , Activation/ Restoration , Medically Complex - ST 5, , Medically Complex - LT 1, , , Respite Care 63 2, End of Life 3, , Other , , Other - Dementia , Grand Total 17,058 1,547, , In RCA Framework 11, , ,970 % in RCA Framework 68% 64% 73% 67% St. Joseph s CCC patients are younger than the provincial average, but have more than double the average LOS 137 DISCHARGE DISTRIBUTION OF CHAMPLAIN LHIN CCC PATIENTS BY RCA LEVEL OF BEDDED CARE Hospital LHIN: Champlain RCA Bedded Level of Care Discharges Deceased Inpatient Acute Care Home Care Service Home LTCH Retirement Facility Inpatient Rehab Inpatient Continuing Care Other Service Rehabilitation 204 2% 18% 18% 29% 9% 3% 10% 1% 8% Activation/ Restoration 60 18% 27% 13% 15% 13% 5% 3% 0% 5% Medically Complex - ST % 26% 30% 13% 5% 5% 7% 1% 4% Medically Complex - LT % 39% 1% 19% 16% 1% 1% 0% 5% End of Life % 4% 2% 4% 3% 1% 0% 0% 2% Respite Care 1 0% 0% 0% 100% 0% 0% 0% 0% 0% Other 164 9% 33% 8% 12% 31% 3% 2% 1% 1% Other - Dementia 45 18% 11% 7% 4% 49% 7% 4% 0% 0% Grand Total 1,511 35% 20% 11% 13% 11% 3% 4% 0% 4% 50% of Champlain CCC Rehabilitation patients are discharged home or to a retirement home 138 Page 191

194 DISTRIBUTION OF CHAMPLAIN LTCH PATIENTS IN CONVALESCENT BEDS BY RCA FRAMEWORK 59% of residents discharged from Champlain LTCH convalescent beds fell into RCA bedded levels of care No residents were assigned to Rehabilitation level of care RCA Level of Care Cases Days Avg. LOS Rehabilitation - - Activation/ Restoration , Medically Complex 107 6, Respite End of Life - - Other 161 7, Other - Dementia Grand Total , In RCA Framework , % in RCA Framework 59% 66% 139 DISCHARGE DISTRIBUTION OF CHAMPLAIN LHIN RCA RESIDENTS DISCHARGED FROM LTCH CONVALESCENT BEDS Cases by RCA Category Average LOS by RCA Category Discharge Disposition Rehabiliation Activation/ Restoration Medical Complex Total Rehabiliation Activation/ Restoration Medical Complex Died Home Home Care Service IP Acute Care IP CCC IP Rehab LTC Home Retirement Home Grand Total % Home 48% 49% 48% Activation/Restoration and Medically Complex residents equally likely to be discharged home Total 140 Page 192

195 2014/15 DISTRIBUTION OF ONTARIO CCAC ADMISSIONS BY INITIAL SERVICE GOAL In addition to client service recipient category, CCAC admission records also track initial service goal Progression (in Green) includes: Rehabilitation/Rehab Complex Care Restorative Assess and Restore Maintenance (in Yellow) includes: Maintenance Long-Term Supportive Complex Care Medically Complex Complex Care Behavioural Initial Service Goal - Clients with Completed Service Plan Only # of Avg. HC Admissions LOS Acute (In-Home) 128, Rehabilitation (In-Home) 60, Maintenance (In-Home) 19, Referred In - No Recovery 13, Long-Term Supportive (In-Home) 7, Complex Care Restorative 2, Complex Care End Of Life 2, Rehab 1, Complex Care Medically Complex Referred In End Of Life (In-Home) Complex Care Behavioral Historically Unavailable Assess And Restore CSS Services (CCAC Reimbursed) Grand Total 237, RCA Progression Level 64, RCA Maintenance Level 28, /15 HOME CARE ADMISSIONS PER 10,000 AGE/GENDER STANDARDIZED POPULATION BY INITIAL SERVICE GOAL AND CLIENT LHIN Rates of admission to inhome care per 10,000 population, age/gender standardized to account for differences in demographics of LHIN populations Overall provincial rates of admission to in-home care are virtually identical for Progression and Maintenance, but the balance between the two varies by LHIN Champlain LHIN residents have 2 nd lowest rate of inhome care admissions for Progression Client LHIN Acute In Home End of Life Progression Maintenance LTC Placement Other Grand Total Central Central East Central West Champlain Erie St. Clair HNHB Miss. Halton Nth. Sim Musk North East North West South East South West Toronto Central Waterloo Well Ontario Champlain Rank Page 193

196 CCAC PROGRESSION SERVICES PER 10,000 AGE/GENDER STANDARDIZED POPULATION BY LHIN Champlain LHIN residents have 2 nd lowest rate of In-Home services for Progression 143 CCAC PROGRESSION CLIENTS PER 10,000 AGE/GENDER STANDARDIZED POPULATION Residents of Ottawa have lowest rate per population of CCAC Progression services per population Could this reflect greater local access to bedded care in Ottawa, or should home care services be increased? 144 Page 194

197 CCAC MAINTENANCE SERVICES PER 10,000 AGE/GENDER STANDARDIZED POPULATION BY LHIN Low rate of CCAC Maintenance services per population for residents of Champlain LHIN 145 CCAC MAINTENANCE CLIENTS PER 10,000 AGE/GENDER STANDARDIZED POPULATION Rates of CCAC Maintenance clients per population below the provincial average for residents of Renfrew and Lanark 146 Page 195

198 CCAC END OF LIFE SERVICES PER 10,000 AGE/GENDER STANDARDIZED POPULATION BY LHIN Residents of Champlain LHIN have lower rate of CCAC End of Life Services per population; Does this reflect better than average access to other services (e.g. hospice) or should CCAC services be increased? 147 CCAC END OF LIFE CLIENTS PER 10,000 AGE/GENDER STANDARDIZED POPULATION Rate of CCAC End of Life Clients higher than provincial average for residents of most Champlain counties Rates of End of Life Services per population not available at county level, but low overall Champlain End of Life Services per population likely means Champlain LHIN residents receive fewer services per client 148 Page 196