Community and. Patti-Ann Allen Manager of Community & Population Health Services

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1 Community and Population Health Services Patti-Ann Allen Manager of Community & Population Health Services October 2017

2 Community and Population Health Services-HHS ALC Corporate Planning Site Admin Managers Centralized Care and Transitions Team Patient Flow Health Links Integrated Comprehensive Care Program Consultative Psychiatric Liaison Team

3 Centralized Care and Transitions Team Formerly known as Seniors Mobile and Restore Team (SMART)

4 Assess and Restore Guideline Are delivered by integrated teams that include regulated health professionals with expertise in geriatrics. Directed at increasing strength, mobility, and functional ability. A&R interventions are targeted to frail seniors and other persons who: have experienced a recent loss of functional ability following a medical event or decline in health; are at high risk for imminent hospitalization or admission into a long-stay Long-Term Care (LTC) home bed as a result of that functional loss ('high-risk ); and have the potential to regain that functional loss so that they are no longer at high risk ( restorative potential ).

5 Centralized Care and Transition Team Previously known as the SMART team We are a specialized interprofessional team available at both the Hamilton General and Juravinski hospitals Funding from the LHIN includes 1 OT and 1 PT per site 5

6 Our Teams at HGH and JHCC 2 occupational therapists & 1 Physiotherapist 2 Social workers (SW) 1 Pharmacist 1 Clinical Nurse Specialist (CNS) 1 CCAC Care Coordinator at each site

7 Our Goals Reduce functional and cognitive decline associated with hospital admissions and facilitate timely and safe discharges for frail and high risk individuals Admission Avoidance via ED Reduce transitions to ALC and prolonged hospital stay by providing early intervention and planning.

8 Patient Criteria for CCaTT Patients > 65 years of age Patients with an Assessment Urgency Algorithm (AUA) score of 5 or 6 Patients from Independent living Patients that are medically stable and able to participate

9 LHIN Results 16/17 Is CCaTT team making a difference?

10 CCaTT (SMART) Improves The Patient Experience Through Quality, Integration and Value (HNHB LHIN) Key Findings Performance Data Improves Quality of Care Increases capacity Improves function, prevents decline Promotes discharge home, decreases need for post-acute rehabilitative care Integrates Services Eliminates transition points, associated referrals, assessments and wait times Early Identification Provides the right support at the right time Adds Value Decreases LOS in bedded post-acute rehabilitative care Cost avoidance 3,923 individuals served 33% increase in function (Barthel) 89% discharged home 7% require post-rehabilitative care 27% decrease in Alternate Level of Care (ALC) days * SMART post-acute care LOS days Compared to similar CMG LOS days =Difference of 4.13 days in post-acute care 2,515 day decrease in acute ALC LOS for individuals waiting for bedded post-acute rehabilitative care Source: Hospital SMART quarterly reports (6 sites) *HNHB LHIN level data. Access 10 to care iport

11 Total Cost Avoidance Juravinski Measure Volume Cost Total 1. Decrease LOS of CCaTT patients compared to similar CMG s not seen by CCaTT in post- acute rehab care days X 96 patients X $ $167, Assume 1/3 of patients seen by CCaTT and discharged had been admitted and then had an average LOS (21.99 days) for post-acute rehab care. 3. Decrease in the number of ALC days for patients discharged to CC LTD. 6,853 patient days 361 ALC days in Acute beds X $ $3,182, X $1, $449, Cost Avoidance Minus total cost for CCaTT including admin 11 Total Cost avoidance 3,798, , ,040,825.62

12 Total Cost Avoidance Hamilton General Measure Volume Cost Total Decrease LOS of CCaTT patients compared to similar CMG s not seen by CCaTT in post- acute rehab care days X 63 patients X $ $44, Assume 1/3 of patients seen by CCaTT and discharged had been admitted and then had an average LOS (21.99 days) for post-acute rehab care. Decrease in the number of ALC days for patients discharged to CC LTD. 8,304 patient days 458 ALC days in Acute beds X $ $3,855, X $1, $569, Cost Avoidance Minus total cost for CCaTT including admin 12 Total Cost avoidance 4,469, , ,712,245.37

13 Cost Analysis Limitations: Utilizing comparison population groups such as CMGs has limitations as not all individuals with a similar CMG would have had restorative potential. Cost analysis data is based on site specific manual data reports which are subject to reporting error. LOS data will not be reflective of individuals discharged from post-acute rehabilitative care after the last data request April Each hospital site contributes in-kind resources that are not reflected in the cost analysis. 10

14 Consultative Psychiatric Liaison Team Real time access to Psychiatric services at HHS

15 What the CL program does...? The Consultation-Liaison Psychiatry Service works at the interface of medicine and psychiatry Provides psychiatric consultation for patients admitted to medical/surgical units across the hospital Provides an inter-professional model of consultation including psychiatry, nursing, psychology, and medical learners Provides an inter-professional model of teaching for learners in psychiatry, nursing, psychology, and other medical/surgical areas

16 How the CL program helps... We service individuals who are suffering from mental health conditions who are admitted to one of our medical / surgical units. We service individuals who develop signs and symptoms of psychiatric distress while they are in hospital for a medical or surgical reason. We help and support family members of individuals who are in hospital for medical reasons, suffering from psychiatric symptoms or mental health issues. We provide expert psychiatric consultation to medical and surgical teams in caring for their patients with mental health issues.

17 Integrated Comprehensive Care Program In partnership with St. Joseph s Hospital COPD CHF

18 Chronic Lung Disease and Heart Failure HNHB LHIN (Pop. 1.4 million) 4,500 Hospital Admissions 9,157 Emergency Room Visits 1,489 Hospital Readmissions 2,200 Home Care Referrals $3,000,000+ In Home Care Costs 44% return to the ED in 60 days 33% readmitted with 60 days 18

19 Goals 1. Establish a seamless patient experience from hospital to home 2. Improve provider satisfaction 3. Improve quality and health system outcomes Reduce number of days in hospital Reduce unplanned ER visits and readmissions Improve productivity of hospital and homecare and reduce overall cost 4. Improve efficiency of the healthcare system by integrating resources across the continuum 5. Improve patient experience and inform provincial policy by implementing ICC LHIN wide. 6. To fully engage key stakeholders (e.g. physicians) and patient/family in the HNHB LHIN ICC Program 19

20 EIGHT ELEMENTS of ICC Client Centered Care Integrated Care Coordinators Integrated team committed to standardization A shared electronic health record Simple, available technology Ready access to medical care Flexibility in the delivery of care Bundled Funding 20

21 Who is eligible? Community dwelling patient (excludes residents of LTC) Admitted to HNHB hospital for COPD or CHF and requires home care at discharge Patients on CCAC at time of hospital admission have choice to remain on CCAC services or transition to ICC Some palliative patients 21

22 What does ICC mean for patient(s)? Key Features: Integrated Care Coordinators - to manage the seamless care pathway across the continuum Integrated Care Paths to standardize care across LHIN hospitals and community Lead Homecare Agency (St. Joseph s Home Care) to maximize continuity, expertise and efficiency Strong Client and Team Engagement 24/7 Availability ICC Team has timely access to medical expertise Integrated clinical information across the continuum - electronic Client Health Record

23 Hospital in HNHB LHIN Before ICC ICC Length of Stay in Hospital % Patients with ED Visits Within 60 days (all cause) % Patients with Unplanned Readmissions Within 60 days (all cause) Average Length of Stay for Readmissions 74% 61% 42% 33%

24 ALC Corporate Planning ALC Workplan Senior Advisor Discharge Specialist ALC Navigators New Integrated Managers

25 Goal: The goal of discharge planning is to enhance the patient experience and outcomes in the transition from hospital to home, with the goal of reducing adverse events and preventable readmissions.

26 Home First is an evidence-based, person-centered, transition management philosophy focused on keeping patients,-specifically seniors with high care requirements,-safe in their homes for as long as possible with community supports.

27 Community Care Service Changes Capacity Home and Community Care (HCC) has changed its approach and is accepting patients from hospital beyond service maximum guidelines Intensive Services Home First Refresh is underway to be launched within 4-6 weeks LHIN HCC led process in partnership with Hospitals Hospital wide and community wide education and refresh Refreshed ALC to LTC process guidelines Refreshed access and process for crisis designation (hospital and community) Extensive engagement with executive level Community Service provider agencies to develop community based capacity strategy

28 Discharge-related Policies Available on the Policy Library of Hamilton Health Sciences Intranet Discharge Planning Protocol Guidelines for Use of the Discharge Risk Screening Tool/Discharge Overview Form Patient Discharge Planning to Regional LTC & Complex Cont. Care Policy Alternate Level of Care (ALC) Designation Policy Repatriation Protocol Bed Management Policy

29 Role of the Transitional Care / Discharge Specialist: Works with clinical teams for both patients who are ALC and non-alc. Can assist with a complex discharge, when patients &/or family members are refusing to accept your discharge plan, & act as a resource Leads and implements quality improvement projects internally and externally for better patient flow.

30 Role of ALC Navigator Provide consultation to safely discharge complex ALC cases. Identify / assist with system and process barriers to discharge. Mobilize utilization of resources and explore discharge options. Appropriately communicate and document identified issues. 30

31 Senior Advisor - ALC Provide leadership to the Discharge Transition team. Advise clinical and administrative staff in regards to special requirements and provincial and regional trends in ALC. Implement and guide work of the ALC Workplan in partnership with the LHIN Home and Community Care Services.

32 Introduction Health Links

33 HHS Outreach Model of Care 6 full-time Health Professionals working in Hamilton & Niagara North West The recipient of the Minister s Medal presented by the Minister of Health and Long Term Care, October The Minister s Medal recognizes this team as a leader in placing patients at the center of the circle of care while promoting value and quality in the health care system. Apply standardized criteria to identify highest risk patients. Engage patients through use of motivational communication and viewing patients through a trauma-informed care lens. Complete routine screening for frailty, cognitive impairment and mood. Findings communicated to primary care to trigger further assessment, diagnosis, planning. Help patients access adequate nutrition, housing, medical equipment, supplies and transportation to medical appointments. Support self-management of chronic conditions using teach-back and patient action plans. Partner with patients, caregivers, families, hospital, primary care, specialists, homecare and community support service agencies to enact patient action plans based on what matters most to patients. 33

34 Characteristics of Health Links Patients Target population typically has: 4 or more chronic conditions Difficulty self-managing conditions; frequent exacerbations resulting in frequent trips to hospital Literacy/health literacy challenges Cognitive impairment Living in poverty Socially isolated and/or have family with similar life circumstances Transportation barriers; often don t get to appointments Prescriptions not filled and/or consistently followed 34

35 Evaluation Quantitative & Qualitative results achieved to date

36 Evaluation Quantitative measures related to system improvements achieved by the Hospital Outreach Team 6 months post-care planning include: Measure ED visits Inpatient visits 30-day readmissions Ambulatory care sensitive conditions Pre-Post 6 Months Change 25.2% reduction 50.0% reduction 55.8% reduction 41.9% reduction 36

37 What our patients say Victor You are an Angel. You are always there to support me when needed. Robert You always look out for me. Thank you for what you do for me. Betty Health Links is the only people I have to help me. I have no one else to help me. I now get to all my appointments and when I need anything I know who to call as you always help me. It makes me feel good to have people I trust that check on me and get me the help I need. Stephen Thank you for listening to me. I want to keep my mother home and it is good to talk about how hard it can be sometimes. Thank you for all your help. Terry You are on the side of the patient. Destiny Thank you again. I do not usually say this to doctors and other but you coming into my life has been a blessing and you helped me so much. I think you area amazing and have become such a great support to me. Carl You are my angel. I had suicidal thoughts before I started receiving this help and support from Health Links. I know who to call and you are always there to help me. 37 Sue She has never done so well with her physical health and mood since having the support your team has been able to provide. She never got to specialist appointments before your team was involved. She would not have been able to get her eye surgery without the support your team provided and now she can see. Michael You are my guardian angel. You coming into my life has helped me so much. I was not getting the help I needed and now I do. I appreciate everything the team has done for me. You lift my spirits. Lisa Knowing I have someone to call who will call me back and will help me whenever I need something makes me feel less anxious. I suffer from depression and I have been feeling much better since having this help and knowing there is someone to help me when I have questions and need things. I get nervous and do not know how to figure these things out on my own. Kathleen I trust you. I feel that I can talk to you about anything and I have not been able to do that with other professionals. It makes me feel better. You brighten my day. William I enjoy talking to you. You are a good listener. Thank you for all you do to help me.

38 Site Administrative Coordinators Manage Flow, Beds, Resources Support clinical staff in decision making

39 Site Administrative Managers The Site Administrative Manager is responsible for site coordination, planning and oversight of daily bed management and patient flow activities. As a delegate of the Site Administrator/ Director-on-Call, the Site Administrator Manager functions as a centralized resource and contact for decision making and communication. The Site Administrative Manager will chair daily Bed Management meetings; receive up to date information regarding patient flow to/from departments; and identify and prioritize bed assignments and activity. The Site Administrative Manager will proactively identify, support and facilitate ongoing advancement of improvement opportunities and best practice patient flow activities.

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