Northeastern Ontario Clinical Services Review

Transcription

1 Northeastern Ontario Clinical Services Review FINAL PROJECT REPORT Hay Group Health Care Consulting March, Hay Group Limited. All rights reserved

2 Contents 1.0 EXECUTIVE SUMMARY BACKGROUND AND OBJECTIVES EVALUATION FRAMEWORK MODELS OF CARE FOR MEDICAL QBPS MODELS OF CARE FOR SURGICAL QBPS MODELS OF CARE FOR OUTPATIENT QBPS SUMMARY OF IMPLICATIONS OF PROPOSED MODELS OF CARE IMPLEMENTATION PLAN INTRODUCTION BACKGROUND AND OBJECTIVES OBJECTIVES APPROACH STEERING COMMITTEE DISCUSSION OF QBP FUNDING BACKGROUND WHAT ARE WE MOVING TOWARDS? HOW WILL WE GET THERE? WHAT ARE QUALITY-BASED PROCEDURES? HOW WILL QUALITY-BASED PROCEDURES ENCOURAGE INNOVATION IN HEALTH CARE DELIVERY? FUNDING FOR QBP SERVICES THE CARVE OUT EVALUATION FRAMEWORK CONGESTIVE HEART FAILURE QBP HANDBOOK CURRENT CHARACTERISTICS OF CHF SERVICE DELIVERY IN NE LHIN PROPOSED MODEL FOR DELIVERY OF CHF SERVICES IMPLICATIONS OF PROPOSED MODEL FOR CHF SERVICES AMBULATORY CARE EVALUATING THE CHF INTEGRATION MODEL CHRONIC OBSTRUCTIVE PULMONARY DISEASE QBP HANDBOOK CURRENT CHARACTERISTICS OF COPD SERVICE DELIVERY IN NE LHIN PROPOSED MODEL FOR DELIVERY OF COPD SERVICES IMPLICATIONS OF PROPOSED MODEL FOR COPD SERVICES AMBULATORY CARE EVALUATING THE COPD CLINICAL INTEGRATION MODEL STROKE QBP HANDBOOK CURRENT CHARACTERISTICS OF STROKE CARE IN NE LHIN PROPOSED MODEL FOR DELIVERY OF STROKE SERVICES IMPLICATIONS OF PROPOSED MODEL FOR STROKE SERVICES REHABILITATION... 84

3 7.6 AMBULATORY CARE EVALUATING THE QBP INTEGRATION MODEL CATARACTS QBP HANDBOOK CURRENT CHARACTERISTICS OF CATARACT SERVICE DELIVERY IN NE LHIN PROPOSED MODEL FOR DELIVERY OF CATARACT SURGERY IMPLICATIONS OF PROPOSED MODEL FOR CATARACT SURGERY EVALUATING THE CATARACT SURGERY CLINICAL INTEGRATION MODEL TOTAL JOINT REPLACEMENTS QBP HANDBOOK CURRENT CHARACTERISTICS OF TJR SERVICE DELIVERY IN NE LHIN PROPOSED MODEL FOR DELIVERY OF TJR SERVICES IMPLICATIONS OF PROPOSED ACUTE CARE MODEL FOR TJR SERVICES IMPLICATIONS OF TJR MODEL OF CARE FOR INPATIENT REHABILITATION AMBULATORY CARE EVALUATING THE QBP INTEGRATION MODEL HIP FRACTURES QBP HANDBOOK CURRENT CHARACTERISTICS OF HIP FRACTURE SERVICE DELIVERY IN NE LHIN PROPOSED MODEL FOR DELIVERY OF HIP FRACTURE SERVICES IMPLICATIONS OF PROPOSED MODEL FOR QBP SERVICES INPATIENT REHABILITATION AMBULATORY CARE EVALUATING THE QBP INTEGRATION MODEL VASCULAR SURGERY QBP HANDBOOK CURRENT CHARACTERISTICS OF QBP VASCULAR SURGERY IN NE LHIN PROPOSED MODEL FOR DELIVERY OF VASCULAR SURGERY IMPLICATIONS OF QBP MODEL FOR VASCULAR SURGERY SERVICES ENDOSCOPY QBP HANDBOOK CURRENT CHARACTERISTICS OF QBP SERVICE DELIVERY IN NE LHIN PROPOSED MODEL FOR DELIVERY OF ENDOSCOPY SERVICES IMPLICATIONS OF PROPOSED MODEL FOR QBP SERVICES EVALUATING THE QBP INTEGRATION MODEL CHEMOTHERAPY QBP HANDBOOK CURRENT CHARACTERISTICS OF CHEMOTHERAPY SERVICE DELIVERY IN NE LHIN PROPOSED MODEL FOR DELIVERY OF SYSTEMIC THERAPY SERVICES EVALUATING THE CHEMOTHERAPY INTEGRATION MODEL SUMMARY OF IMPLICATIONS OF QBP CLINICAL INTEGRATION MODELS OF CARE INPATIENT ACUTE CARE INPATIENT REHABILITATION OUTPATIENT CARE

4 14.4 ACUTE CARE COSTS AND REVENUES IMPLEMENTATION PLAN: STAGING AND PHASING GOVERNANCE OF QBP SERVICES SINGLE MODEL OF CARE FOR QBP SERVICES IMPLEMENTING THE QBP MODELS OF CARE WITHIN A HUB SINGLE QBP PROGRAM ACROSS MULTIPLE SITES APPENDIX A: PROPOSED MODELS OF CARE FOR QBP SERVICES APPENDIX B: COMMENTS AND CONCERNS FROM HUB CLINICAL INTEGRATION WORKSHOPS APPENDIX C: GENERAL ASSUMPTIONS AND PLANNING PARAMETERS USED IN MODELING APPENDIX D: CURRENT AND FUTURE NE LHIN QBP UTILIZATION CHARACTERISTICS UNDER CURRENT MODELS OF CARE

5 1.0 Executive Summary 1.1 Background and Objectives Health System Funding Reform Health System Funding Reform Historically, hospitals have received global or base funding (an across-the-board increase each year). In April 2012 Ontario initiated funding reform, moving to a funding model that compensates health care organizations based on how many patients they look after, the services they deliver, the evidence-based quality of those services, and the specific needs of the broader population they serve. Health system funding reform (HSFR) uses two funding models: the healthbased allocation model (HBAM) and the Quality-Based Procedures model (QBP). Together it is hoped that these models will ensure that funding is allocated equitably to healthcare providers based on the delivery of high quality healthcare services Quality Based Procedures Quality-Based Procedure is a term for selected medical procedures and surgeries for which evidence-based bestpractices have been established A fee for providing a QBP service QBP Price A Quality-Based Procedure (QBP is a term for selected medical conditions and surgical procedures for which evidence-based bestpractices have been established by clinical consensus alongside the evidence-based cost of the best-practice. Under the Quality Based Procedures model, hospitals (and soon other providers) will be paid a standard rate for providing selected services. Over time the fee for all QBP services will be based on the cost of efficiently providing best practice models of care and providers will be compensated for the volume of service that they deliver. It is expected that the same fee will be paid to all providers delivering the service. Under QBP funding providers will be paid a fee (the QBP Price) for delivering a defined QBP service. The total fees paid will replace the portion of the hospital s funding that was devoted to the delivery of those services in the base year (the carve out ) for that QBP service 1. QBP funding, initially, has not been applied to small hospitals 2. The QBP price is initially being set at the provincial average cost per HBAM Inpatient Grouper (HIG) weighted case for the prior year. 1 2 The base year for most of the QBP services considered here is 2011/12. In Ontario, for funding purposes, a small hospital is defined to be a hospital that provides care for fewer than 2700 acute inpatient and SDS cases in a year. Page 1

6 This price will be paid to a hospital for each QBP weighted case 3 cared for at the hospital, but only up to the QBP volume that has been assigned to the hospital by the LHIN/MOHLTC Project Objectives Best approach to configuring the acute care clinical services currently anticipated for QBP funding The 25 hospitals and the CCAC in the North East LHIN, in collaboration with the LHIN itself have engaged Hay Group to explore the best approach to configuring the clinical services currently anticipated for QBP funding. It is hoped that this will provide a feasible and realizable plan for achieving the best practice models of care for the delivery of QBP services in the North East. The services considered in this project have been the QBP funded acute care services related to Stroke; Congestive Heart Failure; Chronic Obstructive Pulmonary Disease; Total Joint Replacement; Hip Fracture; Cataract; Vascular Surgery; Endoscopy; and Chemotherapy Approach The project was conducted under the direction of a Steering Committee representing a cross-section of key stakeholder representatives from across the Northeast. The project included the following key elements: Project Initiation Confirmation of Construct for Quality Based Procedures Development of a Decision Making Framework Analysis of Current Distribution of QBPs Among Hospitals Projection of Future Demand for QBP Care Analysis of Alternative Models of Care Integration Opportunity Workshops for Hub Medical and Clinical Leaders Integration Models Workshops for Hub Medical and Clinical Leaders Refinement of QBP Organization and Service Delivery Models Development of Implementation Plan Development of Project Report 3 It is expected that in future years the price will be set as the price per case rather than the price per weighted case. Page 2

7 1.2 Evaluation Framework Criterion-based decision making focusing on access, quality, consistency and economy The Steering Committee developed an evaluation framework to be used for decision-making in this project. It was hoped that the proposed models for integrating care within the LHIN would provide for improvements in: access; quality; consistency and economy. Evaluative criteria were defined for use in evaluating the model for integrating/consolidating services and then for assessing the siting of services given the potential realignment options for clinical services among one or more hospital sites in the LHIN. 1.3 Models of Care for Medical QBPs Consistent model of care and clinical pathway/order set for medical QBP patients across the region The medical QBPs considered in this project are Congestive Heart Failure (CHF), Chronic Obstructive Pulmonary Disease (COPD) and Stroke. The Hub workshops developed and the Project Steering Committee confirmed models for the care of medical QBP patients in North East LHIN hospitals that are based on the best practice models of care as presented in the QBP Clinical Handbooks. These models of care are very similar; the underlying theme is that patients across the northeast should have equitable access to consistent, high quality care. To this end NE LHIN hospitals will be expected to use consistent models of care and clinical pathways/order sets in caring for CHF, COPD and Stroke patients across the region Congestive Heart Failure and Chronic Obstructive Pulmonary Diseases Average acuity CHF and COPD patients should be admitted and managed at the hospital where the patient first presents to the ED The Hub Workshops and the Steering Committee developed models of care based on the best practices articulated in the QBP clinical handbooks that are quite similar for CHF and COPD. The key characteristics of these models of care are: 1. Low acuity patients should be discharged from EDs across the LHIN Average acuity patients should be admitted and managed at the hospital where the patient first presents to the ED. All hospitals with an ED should be able to care for average acuity CHF and COPD patients. However, when required, clinical support via telemedicine should be available from hub hospitals to clinicians looking after average acuity patients in local hospitals. 4 For modeling purposes we have used current NE averages for % of CHF and COPD patients in each patient group. Page 3

8 High acuity CHF and COPD patients should be transferred to and admitted at Hub hospitals 3. In general high acuity patients should be transferred to and admitted at Hub hospitals (SAH, TADH, HSN, NBRHC) It is expected that the hospitals will achieve provincial average length of stay performance or better (CHF) or QBP targets (COPD) in caring for each CHF and COPD patient admitted to inpatient care. 5. It is expected that hospitals will significantly reduce the number of extremely long stay patients thus reducing the number of atypical patients High acuity patients who have stabilized at a Hub hospital but who are not ready for discharge should be repatriated to their local hospital to complete their inpatient care. 7. Importantly, it is noted that if hospitals in the NE LHIN are to achieve the targeted lengths of stay there will need to be significant and sufficient investments in community resources to provide both transitional care and CCAC services. 8. Each hub hospital should provide a Heart Failure Clinic and COPD Clinic to support the transitional phase of care for these patients. It is suggested that consideration should be given to offering a combination Heart Failure/Respiratory Clinic at each Hub hospital. The clinics will require access to and support from community resources to monitor patients and prevent readmissions to hospitals. The hub clinics and the community resources should seek opportunities to partner with FHTs to care for these patients. 9. The expertise in the hub sites should be made available to the more remote locations using telemedicine to reduce burden of travel for patients. Implications of CHF/COPD models of care Implementation of the proposed model of care will result in movement of patient volume (all high acuity CHF and COPD patients) from the local hospitals to the hub hospitals. There will be a reduction in the total volume of cases due to elimination of inpatient 5 6 There should be some ability for some high acuity patients to be cared for with BiPAP for 6-12 hours at the site where they present and then, if the patient stabilizes, continue to be managed locally for the remainder of their stay. For modeling purposes, the Steering Committee has assumed that NE LHIN hospitals can reduce the % of atypical cases to the lowest percentage achieved by hospitals in other LHINs in the province. Page 4

9 transfers from local to hub hospitals 7. There will also be a decrease in the total number of patient days across all hospitals as hospitals adjust their care processes to achieve. A more consistent ALOS that is less than or equal to the provincial average for typical CHF cases and A reduction in the number of long-stay atypical CHF cases 8. The reduction in the number of long stay atypical cases will result in a reduction in the number of HIG weighted cases because each of the long stay atypical medical QBP cases likely has a higher HIG weight than a typical case. These reductions in cases and patient days, if realized, will also result in a reduction in the costs of caring for medical QBP patients in NE LHIN hospitals. Ambulatory Care Impact on hub and local hospitals The recommended models of care for medical CHF and COPD patients suggest that ambulatory clinics should be offered at each hub hospital. A significant percentage of hospital discharges will require the services of these clinics. The hub hospitals will need to make significant investments in these services if the proposed LOS targets are to be achieved. The current QBP price does not reflect nor does QBP funding currently provide for these services. It is unclear how the hospitals will be able to redirect their funds to support these clinics without securing some additional global budget funding. Thus local hospitals will need to work with their hub hospitals to develop protocols and agreements to facilitate transfer of high acuity CHF and COPD patients from the local hospital s ED to the hub hospital. Similarly, local hospitals will need to be able to accommodate transfers of COPD/CHF patients when their condition stabilizes at the hub hospital. Hub hospitals will need to reduce the lengths of stay for their CHF and COPD patients and they will be expected to significantly enhance their ambulatory CHF/COPD care Stroke The hub workshops and the Steering Committee developed a model of care for stroke that is consistent with the model proposed by the 7 8 Because high acuity patients will be transferred directly from the ED to inpatient care at a hub hospital, the patient will no longer be counted twice; once after to local hospital and once, after inpatient transfer to the hub hospital. Best Practice (i.e. Lowest) % Atypical cases of all Ontario LHINs for each QBP has been applied to NE LHIN hospitals, with cases being converted from Atypical to Typical and then given the target LOS for the QBP and the NE LHIN average weight per Typical case for the QBP. Page 5

10 Northeastern Ontario Stroke Network (NEOSN). 9 This model provides for a Regional Stroke Centre at Health Science North (HSN) and District Stroke Centres at Sault Area Hospital (SAH), Timmins and District Hospital (TDH) and North Bay Regional Health Centre (NBRHC). Key elements of the model include: When a stroke patient requires admission to inpatient care they should be transferred from the ED where they present to the stroke unit at the appropriate designated stroke centre 1. Inpatient acute and rehabilitative stroke care should be consolidated at the regional and district stroke centres which should establish inter-professional stroke teams. 2. Admissions of TIA patients from the ED should be reduced to the provincial average rate of admission When a stroke patient (TIA, Ischemic, Haemorrhagic) requires admission to inpatient care they should be transferred from the ED where they present for admission to the stroke unit at the appropriate designated stroke centre Current provincial TIA ALOS will be the target length of stay for TIA patients that are admitted to inpatient care. 5. QBP length of stay targets for Ischemic and Hemorrrhagic stroke care will be achieved by NE LHIN acute stroke units. These targets are 5 day ALOS for Ischemic Stroke and 7 day ALOS for Haemorrhagic Stroke. 6. The number of extremely long stay patients should be reduced significantly thus reducing the number of atypical patients Approximately 40% of Stroke patients should receive inpatient rehabilitation after completing their inpatient acute care. 8. Stroke patients requiring inpatient rehabilitation should stay at the regional/district stroke centers to receive this care. Upon completion of their inpatient rehabilitation; they should be discharged to home If a patient is designated ALC-LTC Placement at any time during the patient s acute or rehabilitation care stay then the patient should be repatriated to her/his home hospital See NE LHIN Hospital Based Stroke Care: Impact of Consolidating Care. This will provide for an almost 40% reduction in the number of ED TIA patients admitted to inpatient care. This can be achieved through enhancement of the existing Regional Stroke Prevention Clinic model. For many hospitals this will be a change in practice. Protocols and formal agreements among hospitals to facilitate these transfers will need to be developed. For modeling purposes, the Steering Committee has assumed that NE LHIN hospitals can reduce the % of atypical cases to the lowest percentage achieved by hospitals in other LHINs in the province. This is a significant and important change from current practice. Page 6

11 10. Like the performance targets for CHF and COPD, these clinical performance targets will only be achieved if outpatient clinic resources are enhanced. The existing Stroke Prevention Clinics (SPCs) at each Hub hospital should be enhanced to ensure that TIA patients who are not admitted to inpatient care 14 can receive diagnostic and therapeutic care within 48 hours of presentation to an Emergency Department in the North East. Also, outpatient stroke clinics at the hub hospitals should be enabled to also provide for the post discharge needs of stroke patients who are discharged from acute and inpatient rehabilitation 15. Implications of the proposed model of care for TIA and stroke patients Implications of Stroke Model of Care for Inpatient Rehabilitation Like CHF and COPD patients, there will be movement of TIA and stroke patient volume from the local hospitals to the acute stroke units at the hub hospitals. More importantly, there will also be a significant decrease in the total number of patients and patient days across all hospitals as hospitals adjust their care processes to achieve the provincial average rate of admissions for TIA patients and lengths of stay for stroke patients. The recommended model of care suggests that 40% of stroke patients should be discharged to inpatient rehabilitation with an ALOS of approximately 32 days. This would be a modest increase from current practice wherein 36% of stroke patients at hub hospitals are currently being discharged to inpatient rehabilitation. Under the recommended model of care, there would be an additional 75 cases discharged to inpatient rehabilitation. With this increase, the NE LHIN stroke patients would require 8,435 patient days and 25.7 beds 16 in total devoted to stroke rehabilitation Majority of TIA patients do not require admission to hospital and should be referred to an urgent TIA/Stroke Prevention Clinic or comparable ambulatory setting for rapid diagnostic and medical evaluation, within 48 hours of symptom onset/visit to ED. It has been suggested by NEOSN that a regional Stroke Re-Check Clinic model should be established (with clinics located at each Hub hospital) to ensure stroke patients discharged home are followed by an interdisciplinary team for a minimum of one year following their discharge. These clinics will address the medical and rehabilitation needs of stroke patients and assist in decreasing hospital readmissions for post-stroke complications. Telemedicine should be used when possible and appropriate to provide this service to patients living in rural communities. Additionally, a regional Stroke Outpatient Services model should be established to ensure stroke patient that do not qualify for CCAC services, can access stroke-specific outpatient services within a 45 minute drive of their home.. These clinics would also be connected with the Northern Ontario Independent Living Association (NILA) Regional Post-Stroke Program to assist with stroke community navigation well beyond hospital discharge. Assuming 90% occupancy for rehabilitation beds. Page 7

12 Impact on hub and local hospitals Thus local hospitals will no longer admit TIA or stroke patients; they will need to work with their hub hospitals to develop protocols and agreements to facilitate transfer of TIA and stroke patients from the local hospital s ED to the hub hospital. Hub hospitals will need to reduce the lengths of stay for their TIA and stroke patients, enhance the rehabilitation service they provide to acute stroke care patients and expand and enhance their post acute care stroke rehabilitation services. Additionally, hub hospitals will need to significantly enhance their ambulatory stroke care. 1.4 Models of Care for Surgical QBPs Consistent model of care and clinical pathway/order set for surgical QBP patients across the region The surgical QBPs considered in this project are Cataracts, Total Joint Replacements (TJR) 17, Hip Fractures and Vascular Surgery. The Hub workshops developed and the Project Steering Committee confirmed models of care for surgical QBP patients in North East LHIN hospitals. These models of care are based on best practice models of care as articulated in the QBP Clinical Handbooks where available and the NE LHIN Integrated Orthopedic Capacity Plan. These models of care are very similar; the underlying theme is that patients across the northeast should have equitable access to consistent, high quality care. The key characteristics of these models of care are: NE LHIN hospitals should use consistent models of care and clinical pathways/order sets across the region in caring for each of cataract, TJR, hip fracture and vascular surgery patients. NE LHIN hospitals should establish integrated clinical programs in each hub for the delivery of cataract surgery and for orthopaedic surgery. Also, the involved hospitals should establish a single, integrated, LHIN-wide program for vascular surgery. The specific models of care proposed for each of the surgical QBPs are described briefly in the sections following Cataract Surgery A single clinical program for cataract surgery in each hub The proposed model of care suggests that within each hub clinical program for cataract surgery 18 : Total Joint Replacement QBPs include primary, unilateral knee replacement and primary, unilateral hip replacements. It should be noted that concurrent with the work of the Clinical Services Review Steering Committee, work has begun in the LHIN to interpret and implement the findings and recommendations of A Vision for Ontario, Strategic Recommendations for Ophthalmology in Ontario. The development of models Page 8

13 Cataract surgery procedures should be consolidated at the Hub hospitals Specialist diagnostic and follow up clinics should be provided at local hospitals Simple procedures should be provided at local hospitals at the discretion of the hub clinical program for cataract surgery All cataract surgery should be provided within the hub where the patient lives. Implications of Proposed Model for Cataract Surgery It is expected that implementation of the proposed model for cataract surgery will result in the following changes in the delivery of cataract surgery within the LHIN: All cataracts will be consolidated in the 4 Hub hospitals; all patients will receive their cataract surgery within the hub where they live; and cataracts will be repatriated from outside- of- LHIN hospitals Total Joint Replacement Continue TJR in the 5 hospitals currently providing The proposed model of care suggests that TJRs should be provided as part of an integrated hub wide orthopaedic surgery program 19. Key characteristics of the proposed TJR model of care are: 1. The modeling assumes that TJR surgery will continue in the 5 hospitals currently providing this surgery. 2. Each hospital providing TJRs, should establish/maintain a Joint Assessment Centres (JACs) as the only point of access to TJR. 3. TJRs should be provided by a hospital in the LHIN where the patient resides. In the future 100% of TJRs for NE LHIN residents will be provided within the NE LHIN NE LHIN orthopaedic surgery programs should adopt the QBP target for ALOS of 4.4 days. 5. The number of extremely long stay patients should be reduced significantly thus reducing the number of atypical patients for the delivery of cataract surgery should take into account this broader work related to the delivery of all ophthalmology services in the LHIN. Within each hub-wide orthopaedic program, if a hospital/surgeon is providing major orthopaedic surgery; it should also provide hip fracture treatment and should provide for hip fracture treatment 7 days per week. Hospitals participating in the hub wide orthopaedic program should develop a clear framework for urgent call coverage. Both primary TJRs and revisions will be provided within the LHIN. Page 9

14 6. NE LHIN orthopaedic surgery programs should adopt the QBP target for discharge disposition with 90% of patients discharged to home; and 10% discharged to inpatient rehabilitation Patients can and should be repatriated from the TJR surgery site to their local hospitals for inpatient rehabilitation with access to telemedicine for rehabilitation support TJR patients should have enhanced access to physiotherapy in the community with initial therapy provided by CCAC as appropriate to the needs of the patient and continuing therapy provided in group sessions by hospitals as ambulatory care. Repatriation will provide a significant increase in TJR volumes in NE LHIN hospitals Implementation of the proposed TJR model of care will result in repatriation of significant patient volume from outside-of-lhin hospitals that will cause an increase in cases within the LHIN. There will also be a decrease in the total number of patient days across all hospitals as hospitals adjust their care processes to achieve: A more consistent and shorter ALOS that is less than or equal to the provincial average for their typical cases and A reduction in the number of atypical cases. 24 Although patient days will decline, costs will increase significantly as the increased number of cases will increase the number of surgical procedures. These additional costs may be offset by increased QBP funding if the additional volumes are allocated to the hospitals and if the hospitals costs are less than the QBP prices for TJR procedures. Implications of TJR Model of Care for Inpatient Rehabilitation Very few NE LHIN knee replacements are currently discharged to inpatient rehabilitation (0.5%). The proposed model of TJR care for NE LHIN suggests that 10% of TJR inpatients should be discharged directly from acute care to inpatient rehabilitation with an estimated For modeling purposes, the Steering Committee has assumed that NE LHIN hospitals can reduce the % of atypical cases to the lowest percentage achieved by hospitals in other LHINs in the province. This would be a significant increase from current practice wherein only approximately 1% of TJR patients are discharged to inpatient rehabilitation. Enhanced rehabilitation resourcing and support in smaller communities will be needed to facilitate effective repatriation. Cross - training of RN s, RPN s and PSWs in hip fracture rehabilitation in smaller communities will facilitate effective repatriation. Best Practice (i.e. Lowest) % Atypical cases of all Ontario LHINs for each QBP has been applied to NE LHIN hospitals, with cases being converted from Atypical to Typical and then given the target LOS for the QBP and the NE LHIN average weight per Typical case for the QBP. Page 10

15 average length of stay of 14 days. This represents a 20 fold increase over the current use of inpatient rehabilitation by NE LHIN TJR patients. This will be a significant increase in the volume of inpatient rehabilitation cases and the associated need for beds and care. As of now, there is no indication that there will be QBP funding to support the inpatient rehabilitation component of the care for TJR patients. If there is no QBP funding, it will have to be determined how the hospitals will provide for the rehabilitation aspect of the best practice model of care for TJR patients? Implications of TJR Model of Care for Ambulatory Care Implications for hub and local hospitals TJR patients that do not get inpatient rehabilitation will need continuing rehabilitation either in their homes through CCAC or in a clinic setting. Currently there is very limited homecare or hospital based ambulatory rehabilitative care available for TJR patients. As of now, there is also no indication that there will be QBP funding to support the outpatient rehabilitation component of care for TJR patients. If there is no QBP funding for ambulatory rehabilitation, it will have to be determined how hospitals and/or the CCAC will provide for this additional outpatient rehabilitation. Thus, under the proposed model for TJR care hub hospitals will experience an increase in TJR cases but a decrease in TJR patient days. Hub hospitals and local hospitals will need to provide increased capacity for inpatient TJR rehabilitation Hip Fractures The proposed model of care suggests that Hip Fracture patients should be cared for as part of an integrated hub wide orthopaedic surgery program 25. Key characteristics of the proposed hip fracture model of care are: 1. Assume that both the current NE LHIN average percentage of ED Hip Fractures being admitted to inpatient care and the current hospital specific Hip Fx transfer out rate are appropriate (i.e. assume that minor hip fractures are appropriately being treated locally by general surgeons; with more significant fractures being transferred out to a hub hospital). 2. All hip fracture transfers should be from the local ED to inpatient care at the appropriate hospital within the hub. Hip fracture patients should not be forced to wait as inpatients in a referring 25 Within each hub-wide orthopaedic program, if a hospital/surgeon is providing major orthopaedic surgery; it should also provide hip fracture treatment and should provide for hip fracture treatment 7 days per week. Page 11

16 hospital; they should be transferred from the referring hospital ED to inpatient or pre operative status in the receiving hospital Hospitals participating in the hub wide orthopaedic programs should establish a clear framework for urgent call coverage. 4. Hospitals treating hip fractures should achieve the provincial median ALOS performance (or better) for inpatient acute care. 5. The number of extremely long stay patients should be reduced significantly thus reducing the number of atypical patients % of Hip Fracture patients discharged from acute care in a NE LHIN hospital should be discharged directly to inpatient rehabilitation. 7. Patients can and should be repatriated from the acute hip fracture treatment site to their local hospitals for inpatient rehabilitation with a plan of rehabilitative care and access to telemedicine for rehabilitation support 28. Implications of Proposed Model for Care of Hip Fracture Patients 8. Hospitals providing rehabilitative care for hip fracture patients should achieve the provincial median ALOS performance for inpatient rehabilitation for hip fracture patients. With implementation of the proposed model of care there will be some movement of patient volume from the local hospitals to the hub hospitals. There will also be a significant decrease in the total number of patient days (and HIG weighted cases) across all hospitals as hospitals adjust their care processes to achieve: A more consistent ALOS that is less than or equal to the provincial average for typical cases and A reduction in the number of atypical cases For many hospitals this will be a change in practice. Protocols and formal agreements among hospitals to facilitate these transfers will need to be developed. For modeling purposes, the Steering Committee has assumed that NE LHIN hospitals can reduce the % of atypical cases to the lowest percentage achieved by hospitals in other LHINs in the province. Enhanced rehabilitation resourcing and support in smaller communities will be needed to facilitate effective repatriation. Cross - training of RN s, RPN s and PSWs in hip fracture rehabilitation in smaller communities will facilitate effective repatriation. Best Practice (i.e. Lowest) % Atypical cases of all Ontario LHINs for each QBP has been applied to NE LHIN hospitals, with cases being converted from Page 12

17 Implications for Inpatient Rehabilitation Implications for Ambulatory Care Implications for hub and local hospitals There will also be a significant increase in the use of inpatient rehabilitation for hip fracture patients. The proposed model of care for the NE LHIN hospitals suggests that 80% of hip fracture inpatients should be discharged directly from acute care to inpatient rehabilitation. If the LHIN hospitals achieve this target, then each hub will experience a significant increase in the volume of inpatient rehabilitation cases and the associated need for beds and care. As of now, there is no indication that there will be QBP funding to support the inpatient rehabilitation component of the care for hip fracture patients. If there is no QBP funding, it will have to be determined how the LHIN will provide for the rehabilitation aspect of the best practice model of care for hip fracture patients. Both hip fracture patients that do not get inpatient rehabilitation and hip fracture patients that do receive inpatient rehabilitation will need continuing rehabilitation either in their homes or in a clinic setting. Currently there is very limited homecare or hospital based ambulatory rehabilitation care for hip fracture patients. As of now, there is no indication that there will be QBP funding to support the outpatient rehabilitation component of the care for hip fracture patients. If there is no QBP funding for ambulatory rehabilitation for hip fracture patients, it will have to be determined how hospitals will be able to fund this additional outpatient rehabilitation. Thus local hospitals will need to work with their hub hospitals to develop protocols and agreements to facilitate transfer of hip fracture patients from the local hospital s ED to the hub hospital. Also, both hub and local hospitals will need to provide significantly increased capacity for inpatient rehabilitation for hip fracture patients QBP Vascular Surgery Services Narrow definition of vascular surgery for QBP funding QBP funding for vascular surgery will be applied only to very narrowly defined elective Aortic Aneurysm Repairs and Repairs for Lower Extremity Occlusive Disease. Currently, these QBP vascular procedures are being provided by the Sault Area Hospital (SAH) and Health Sciences North. EVARs are only provided at Health Sciences North (HSN). There are three vascular surgeons located at HSN and one vascular surgeon at SAH. The proposed model of care suggests the following approach to organizing and delivering care for QBP Vascular Surgery patients in NE LHIN hospitals. Atypical to Typical and then given the target LOS for the QBP and the NE LHIN average weight per Typical case for the QBP. Page 13

18 QBP vascular surgery procedures should be provided as part of an integrated LHIN wide vascular surgery program 1. NE LHIN hospitals should use a consistent model of care and clinical pathways/order sets in caring for vascular surgery patients across region. 2. QBP vascular surgery procedures should be provided as part of a single, integrated LHIN wide vascular surgery program. 3. The LHIN wide vascular surgery program should operate under an integrated clinical governance and management model. It is further suggested that the clinicians involved in vascular surgery working with a small task force should provide leadership in the interpretation of the QBP Clinical Handbook for Vascular Surgery (and the recent and continuing work of the Cardiac Care Network) to fully develop a definitive model of care for the delivery of vascular surgery in the NE LHIN and to determine how best to operationalize the LHIN wide vascular surgery program Models of Care for Outpatient QBPs The outpatient QBPs considered in this project are Endoscopy and Chemotherapy. The Hub workshops developed and the Project Steering Committee confirmed models for the care for outpatient QBP patients in the North East LHIN. The specific models of care proposed for each of the outpatient QBPs are described briefly in the sections following QBP Endoscopy Services QBP colonoscopies should be provided in hospitals unless significant advantages in out-ofhospital premises QBP funding of endoscopy is currently focused on colonoscopy procedures 31. It is recommended that NE LHIN hospitals should use a consistent model of care in performing colonoscopies across region. As a general rule, QBP colonoscopies should be provided in hospitals. Unless there are significant clinical and economic advantages to providing colonoscopies in out-of-hospital premises 32, in the NE A model that can be used to guide this process is provided in section 15.3 of this report. It should be noted that CCO has recently indicated that all GI endoscopic procedures will be included in QBP funding. If QBP funded colonoscopies are to be provided in OHPs, then binding covenants must be provided to ensure that physicians participating in these OHPs continue to be actively involved in the GI on-call system of the hospital. Page 14

19 LHIN, QBP funded colonoscopies should be restricted to hospital facilities 33. Given that colonoscopies are likely to continue being provided by hospitals and the single out-of-hospital provider in Sault Ste Marie, the proposed clinical integration model of care should not result in any significant change in the volumes of procedures provided by them or the cost per procedure at each site Chemotherapy The Hub clinical workshops developed and the Steering Committee reviewed, refined and confirmed the following model for systemic therapy in NE LHIN hospitals. The process has recommended that the NE LHIN should continue the current consolidated model of care as defined by CCO. This includes the following key elements: A network of Community Oncology Clinics comprised of the Northeastern Ontario community hospitals that work closely with the North East Regional Cancer Program to provide drug treatments closer to patients homes. Sault Area Hospital Algoma District Cancer Program. An extensive regional ambulatory oncology information system that supports Computerized Physician Order Entry in Sudbury with remote use for 90% of satellite chemotherapy treatments across the region. 1.6 Summary of Implications of Proposed Models of Care Ensuring timely and equitable patient access to high quality care Implementation of the proposed clinical integration models for each inpatient QBP will have a significant and positive impact on the care provided to QBP patients in all the hospitals in the North East LHIN. The most significant impacts will come from changes in clinical practices to ensure timely and equitable patient access to high quality care. The most significant of these changes are: There will be consistent clinical models of care, pathways and order sets for all QBPs across all LHIN hospitals. Local hospitals will transfer all stroke cases directly to hub hospitals rather than admitting and treating these patients locally. 33 The only exception is in Sault Ste Marie where the existing OHP provider of colonoscopies should be allowed to continue and, depending on the emerging policy for Community Based Specialty Clinics, it should be considered for QBP funding for the colonoscopies that it is providing. Page 15

20 Local hospitals will transfer higher acuity CHF, COPD and Hip Fracture cases from their Emergency Departments directly to hub hospitals rather than first admitting, stabilizing and then transferring. Local hospitals will focus on lower and moderate acuity CHF COPD cases; these will all be admitted and cared for locally. Lengths of stay for stroke patients will be reduced so as to achieve an average length of stay equivalent to the QBP target lengths of stay; lengths of stay for all other QBPs will be reduced to be no more than the provincial average length of stay for that QBP. The percentage of atypical patients for a QBP will be reduced to the lowest percentage of Ontario LHINs. Once a QBP patient s condition is stabilized at a hub hospital, the patient will be transferred to his/her local hospital for the completion of his/her acute care and/or for rehabilitation. However, stroke patients will complete both their acute and rehabilitation care at the hub hospital. There will be an increase in the percentage of stroke, hip fracture and TJR patients transferred to inpatient rehabilitation both at hub hospitals and at local hospitals. Hub hospitals will offer outpatient clinics to provide post acute and chronic disease management care for CHF, COPD, TIA and Stroke patients. There will be integrated clinical programs across each hub to provide care for hip fracture and TJR patients and for cataract patients. There will be an integrated, LHIN wide clinical program to provide care for vascular surgery patients Impact on Hospital Activity Dramatic reduction in the number of acute care patient days The following table presents the projected impact on inpatient acute care across all of the LHIN hospitals of the implementation of the proposed clinical integration models for each inpatient QBP. The most significant impact will be a dramatic reduction in the number of acute care patient days resulting from significantly shorter lengths of stay that are less than or equal to the provincial average for the typical cases in the QBP. Also, although there will be an increase in cases primarily as a result of repatriation of TJR and cataract cases from out-of- LHIN hospitals, there will be a concurrent reduction in HIG weighted cases resulting primarily from a reduction in the number of atypical cases. Page 16

21 IP Cases % Atyp. Case IP Days Avg. LOS HIG Wtd Cases. IP Cases % Atyp. Case IP Days Avg. LOS HIG Wtd Cases. IP Cases IP Days HIG Wtd Cases. Exhibit 1: Projected Impact on NE LHIN IP Hospital Activity of Proposed Models of QBP Care Inpatient QBP 2012/13 Actual Activity Proposed Activity Change In Activity CHF 1,386 22% 11, ,103 1,347 14% 6, , , COPD 2,168 19% 18, ,103 2,144 14% 9, , , TIA 286 9% 1, % Ischemic Stroke % 7, , % 2, , , Haem Stroke 64 33% 1, % THR 625 5% 2, , % 2, , TKR 1,337 4% 5, ,059 1,585 1% 5, , Hip Fracture % 10, , % 3, , , AAA Repair 94 38% % LEOD % % Total 7,361 59, ,473 7,519 33, , , Inpatient Rehabilitation More than triple the number of patients being discharged to inpatient rehabilitation Implementation of the proposed clinical models of care for Stroke, TJR and Hip Fracture will dramatically change the current approach to the organization and delivery of rehabilitation services in the North East LHIN. The proposed models of care will more than triple the number of patients being discharged to inpatient rehabilitation. Given the suggested ALOS for these patients in rehabilitation, these patients would require 80.2 inpatient rehabilitation beds. The inpatient rehabilitation for stroke patients is to be provided in the hub hospitals. The inpatient rehabilitation for TJR and Hip Fracture patients can be provided in the patients local hospitals, in a CCC/Rehabilitation hospital or in the hub hospital. This increase in the use of rehabilitation beds will require significant planning and potential repurposing of beds that are no longer required for acute care because of the significant reduction in the need for acute care patient days under the proposed models of care. Page 17

22 Exhibit 2: Inpatient Rehabilitation Requirements of Proposed Models of Care Discharge to IP Rehabilitation Current Proposed Models of Care QBP % Number % Number Pat. Days Beds Stroke 36.0% % 264 8, TJR 1.7% % 237 3, Hip Fx 12.6% % , Totals , Outpatient Care Enhanced and/or expanded outpatient medical and rehabilitation care The medical and surgical QBP models of care will require enhanced and/or expanded outpatient medical and rehabilitation care as part of the continuum care. These services will be delivered and/or supported by clinicians at the hub hospitals. To improve access to care, telemedicine and/or telehomecare will be used to support care provided by local hospitals and/or home care providers in patients home communities Acute Care Costs and Revenues Based on their current cost per weighted case, the projected QBP revenue for the large hospitals will be approximately $1.7 million less than the estimated cost of care for QBP patients Reductions in the number of atypical cases and the associated weighted cases along with reductions in the lengths of stay in acute care for these QBP patients will result in a reduction in the estimated cost of care in the larger/qbp funded hospitals of approximately $1.8 million. However, it should be noted that, based on the current cost per weighted case of care in these hospitals, the projected QBP revenues for the larger hospitals will be approximately $1.7 million less than the estimated cost of caring for QBP patients. If these hospitals are successful in reducing the lengths of stay for typical cases, they may be able to reduce their cost of caring for these patients to be less than the price being paid and thus move from a loss to a profit position in caring for QBP patients 34. This should be an immediate objective for these QBP funded hospitals. 34 The hospitals cost per weighted case is based on the cost of caring for all patients; not just QBP patients. As a result, we have not modelled the impact on the hospitals cost per HIG wtd case of reducing lengths of stay for QBP patients. The reduction should be significant and may result in the hospitals achieving a notional profit on QBP patients. The actual cost of caring for QBP patients under the proposed models of care and lengths of stay, as opposed to the implied cost as reflected in the use of costs per weighted case, will likely be much less than the current QBP price. The current QBP price is based on the provincial average cost per HIG wtd case; not the actual cost per case of caring for patients under the QBP best practice models of care. Page 18

23 Exhibit 3: Projected Inpatient Acute Care Activity and Profit/Loss for QBP Care of in Large NE LHIN Hospitals Inpatient QBP HIG Wtd. Cases Proposed Activity Estimated Cost QBP Revenue Net Profit/ Loss for Large Hospitals CHF 1,672 $8,886,456 $8,546,489 -$339,967 COPD 2,445 $13,017,867 $13,086,600 $68,733 TIA 117 $647,732 $645,051 -$2,681 Ischemic Stroke 1,176 $6,296,462 $5,845,007 -$451,456 Haem Stroke 133 $711,168 $723,854 $12,685 THR 1,310 $7,096,942 $6,828,561 -$268,381 TKR 2,383 $12,901,242 $12,361,599 -$539,643 Hip Fracture 1,418 $7,560,130 $7,371,263 -$188,867 AAA Repair 338 $1,763,134 $1,804,539 $41,405 LEOD 214 $1,120,826 $1,049,813 -$71,013 Total 11,206 $60,001,960 $58,262,776 -$1,739, Implementation Plan The Steering Committee developed a plan to guide the implementation of the recommended changes in the organization and delivery of QBP services. The following are the key elements of this implementation plan Key Elements of Implementation Plan A Steering Committee to oversee implementation Effective engagement of key stakeholders Refinement of Clinical Integration Models Oversight for implementation of the integration models across the LHIN should again be entrusted to an Implementation Steering Committee made up of representatives of the hospitals, physicians and community agencies from across the LHIN. Key to success of the proposed changes in the organization and delivery of QBP services will be effective engagement with and communication to the key stakeholders in this change. A fundamental step in implementing the QBP clinical integration models will be the engagement of the clinical leadership of the hospitals in the LHIN. They will need to be engaged in three interrelated processes. First they will need to refine the work of this project to develop a single model of care and consistent clinical pathway/order sets for each QBP and then provide leadership for their implementation in each hospital in the LHIN. Page 19

24 Operating policies and agreements for medical QBP patient transfers between hospitals Structures to provide surgical QBP services within one integrated program on multiple sites within a hub or across the LHIN Funding for post acute care services Accommodating the transitional discordance between costs and funding Secondly, the clinical leadership and management of each hospital will need to develop and implement operating policies to facilitate the implementation of the QBP models of care for the medical QBPs (CHF, COPD and Strokes) within each hub grouping of hospitals. At a minimum, these operating policies will need to provide: Formal intra hub agreements on transfer and acceptance of ED patients as required for the QBP models. Formal intra hub agreements on patient repatriation as required for the QBP models. Formal intra hub agreements describing how support will be provided by the hub hospital and its medical staff to other hospitals in the hub and their medical staff as necessary to care for inpatients and outpatients as required for the QBP model. Thirdly, the clinical leadership and management of each hospital will need to develop and implement formal program management structures as well as operating policies to facilitate delivery of surgical QBP services as a one integrated program on multiple sites within a hub or across the LHIN. This will be required for cataracts, hip fractures and total joint replacements where there will be one program for each Hub and for vascular surgery where there will be one program across the LHIN. The LHIN should work with the MOHLTC, with the support of the hospitals in the LHIN, to clarify and resolve the special issues in care delivery in the north, the current paucity of post acute care services related to the QBP services, the need to repurpose beds to provide for required inpatient rehabilitation and potential need to redirect funding to address these issues. The LHIN, in concert with other similarly affected LHINs should work with the MOHLTC to clarify and address the transitional funding issues that hospitals will have in the year that they absorb volumes from across the LHIN and from other LHINs. QBP volume targets and related funding should be set so as to allow for and accommodate the realignment of volumes among hospitals. It should be noted, that these transitional problems will likely resolve themselves over time as care delivery practices stabilize to reflect the better practice models of care. Similarly, the LHIN should work with the MOHLTC to address the transitional funding issues that hospitals may have as they reduce the number of atypical cases to reflect the better practice models of care. Although costs will decline with the reduction in patient days (and weighted cases), they may not decline as quickly as will be required Page 20

25 to accommodate the potentially dramatic reduction in QBP funding. Again, it should be noted, that as care delivery practices stabilize, these problems will likely resolve themselves over time Initial Focus for Change Success in implementing the stroke model of care will significantly improve outcomes of care Work on the stroke model of care can serve as framework for implementation of the CHF and COPD models of care The proposed Implementation Steering Committee should take advantage of the work of the Northeastern Ontario Stroke Network (NEOSN) to first focus on implementing the proposed stroke model of care. Much of this work has already been started by NEOSN and is a long way to completion. Success in implementing the stroke model of care will significantly improve the outcomes of care for stroke patients in the NE LHIN. The work on the stroke model of care can provide guidance for the implementation of the other two medical QBP models of care; CHF and COPD. It will provide the framework for: Engagement of the clinical leadership who are involved in the care of these QBP patients in NE LHIN hospitals. In the local hospitals many will be the same physicians who were involved in the NEOSN work. Developing a single model of care and consistent clinical pathway/order sets for each QBP. Formal intra hub processes, protocols and agreements for transfer and acceptance of ED patients as required for the QBP models. Formal intra hub processes, protocols and agreements for patient repatriation as required for the QBP models. Formal intra hub agreements describing how support will be provided by the hub hospital and its medical staff to other hospitals in the hub and their medical staff as necessary to care for inpatients and outpatients as required for the QBP model. Success in implementing the medical QBPs will provide a significant reduction in patient days and the use of medical beds in NE LHIN hospitals. These beds and the associated resources would then be available to be repurposed to provide for the significant amount of inpatient (and outpatient) rehabilitation that will be required in implementing the proposed stroke, hip fracture and TJR models of care. Success in implementing the medical QBP models of care will also provide a framework for the subsequent implementation of the surgical QBP models of care. Page 21

26 2.0 Introduction 2.1 Background and Objectives Excellent Care for All Act Ontario s Action Plan for Health Care The last few years have seen the Ministry of Health and Long Term Care (MOHLTC) introduce several initiatives that focus on rebuilding Ontario s health system and improving the quality of care people receive. In June 2010, Ontario passed the Excellent Care for All Act (ECFAA). The intent of this legislation was to demonstrate Ontario s commitment to ensuring that: Care is organized around the person to support their health, Quality and its continuous improvement is a critical goal across the health care system, Quality of care is supported by the best evidence and standards of care, and Payment, policy and planning support quality and the efficient use of resources. In January 2012, the Ontario Government presented Ontario s Action Plan for Health Care. With an aim to provide patient centred care, the Action Plan focuses on three main priorities: 1. Keeping Ontario healthy 2. Faster access and a stronger link to family health care 3. The right care, at the right time, in the right place The Action Plan proposes significant reforms that will result in major changes to the way in which services have historically been organized, delivered and funded. The MOHLTC states the following with respect to its Health System Funding Reform initiative: Health System Funding Reform HBAM and QBP Funding Historically, hospitals have received global or base funding (an across-the-board increase each year). In April 2012 Ontario initiated funding reform, moving to a funding model that reflects the needs of the patients served by each hospital and its surrounding community. This model compensates health care organizations based on how many patients they look after, the services they deliver, the evidencebased quality of those services, and the specific needs of the broader population they serve. Health system funding reform uses two funding models: the healthbased allocation model (HBAM) and the Quality-Based Procedures model (QBP). Together it is hoped that these models will ensure that Page 22

27 funding is allocated based on the number of patients and the procedures that are the most successful and efficient at delivering high-quality care. A Quality-Based Procedure is a term for selected medical procedures and surgeries for which evidence-based best-practices have been established by clinical consensus alongside the evidence-based cost of the best-practice. QBP funding will help to standardize care and, along with that, minimize practice variation and allow patients, wherever they may be, to receive the best care possible. Under the Quality Based Procedures model, hospitals (and soon other providers) will be paid a fee for providing selected services. Over time the fee for all QBP services will be based on the cost of efficiently providing best practice models of care and providers will be compensated for the volume of service that they deliver. It is expected that the same fee will be paid to all providers delivering the service. Community Based Specialty Clinics At the same time, the MOHLTC is planning to move selected procedures from hospitals to specialized clinics in the community. It is believed that these procedures can be performed at the same quality as in hospital but at a lower cost by these clinics. These Community- Based Specialty Clinics will be non-profit health providers that will offer selected low-risk procedures that are currently provided in acute-care hospital settings. Specialty clinics will focus on providing high volume procedures, such as routine cataract procedures, colonoscopies, and other procedures that do not require overnight stays in a hospital. Specialty clinics will ensure high quality, oversight and accountability. They will provide OHIP-insured services with no additional fees. Community-Based Specialty Clinic models fall into two categories: A public hospital operating in a new site (i.e., a satellite or ambulatory care centre) under the Public Hospitals Act (PHA). A non-profit Independent Health Facility (IHF) licensed under the Independent Health Facilities Act (IHFA). Both the OHA and the OMA have expressed support for both of these initiatives, but also recognize that implementation may result in the redistribution of QBP funded services among health service providers. Service redistribution raises a number of issues related to patient access, disruptions to hospital and community services and displacement or disruptions to clinicians. Page 23

28 Also, the Provincial Rehabilitative Care Alliance has been established to provide direction regarding the model of care for rehabilitation services in the province. Recommendations related to standardized definitions, eligibility criteria, levels of care, sites of care, restorative care philosophy, best practices, and outcome measurement will serve to inform the work of the Clinical Services Review Implementation Team described later in this report. 2.2 Objectives Best approach to configuring the acute care clinical services currently anticipated for QBP funding The 25 hospitals and the CCAC in the North East LHIN, in collaboration with the LHIN itself have engaged Hay Group to explore the best approach to configuring the clinical services currently anticipated for QBP funding. The services considered in this project have been the QBP funded acute care services related to: Stroke Congestive Heart Failure Chronic Obstructive Pulmonary Disease Total Joint Replacement Hip Fracture Cataract surgery Vascular Surgery Endoscopy Chemotherapy The process has engaged clinicians and provider organizations in the northeast to consider alternative approaches to the organization and delivery of QBP funded services that would: Align with the provincial clinical expert groups/panels and implement the best paths developed by these committees; and/or Improve quality and safety by grouping together clinical or medical/surgical specialists, their teams and appropriate physical resources; and/or Expand or create new programs that would not be viable or sustainable at multiple sites; and/or Create centres that generate confidence of the NE LHIN residents to receive services within the NE LHIN and as close-to-home as possible; and/or Page 24

29 Create operational and clinical efficiencies that would allow hospitals to focus on, and improve, their core programs to meet community need to core acute care programs within budget; or Lead to redefinition of the core services delivered by small hospitals. This report presents the findings and recommendations emanating from this process. 2.3 Approach The project was conducted under the direction of a Steering Committee representing a cross-section of key stakeholder representatives from across the Northeast. The project included the following key elements: Project Initiation Context for Quality Based Procedures in NE LHIN Decision Making Framework Current Distribution of QBPs Among Hospitals Future Demand for QBP Care Analysis of Alternative Models of Care Integration Opportunity Workshops Integration Model Workshops QBP Organization and Service Delivery Models Implementation Plan Project Report Project Initiation Steering Committee to provide leadership in the development of the hospital s plan for reconfiguring its clinical services The first step in this project involved organizing a Steering Committee to oversee the work of the project and to provide leadership in the development of the plan for reconfiguring and realigning QBP clinical services. The Steering Committee then met to confirm the objectives for the work, the overall approach to the project and the approach to engaging stakeholders in the clinical services reconfiguration process. Page 25

30 2.3.2 Context for Quality Based Procedures in NE LHIN There remain many unknowns regarding the details of QBF for Year 2 and beyond A first step in the project was a review of the current, known status of Quality Based Funding in the province. This included: Current status of best practice clinical models of care for Year 1 and Year 2 QBPs. What clinical activities are likely to be included as QBPs for Years 3 and beyond that should be considered as part of this project. Current and likely pricing structures for QBPs. For the purposes of this project, the Steering Committee decided that: Year 1 and 2 QBPs will be the focus of the project. Additionally the project will consider Hip Fractures given that these are inextricably related to the delivery of Total Joint Replacements and are likely to be a Year 3 QBP Decision Making Framework Criterion based decisionmaking The Steering Committee developed an evaluation framework to be used for decision-making in this project. Evaluative criteria were defined for use in determining whether to integrate/consolidate services and then for assessing potential realignment options for the clinical services among one or more hospital sites in the LHIN. This evaluation framework is discussed below in section Current Distribution of QBPs Among Hospitals Volumes of QBP acute care services used by the residents of the NE LHIN and the market share and volumes provided by each of the hospitals within the LHIN and by hospitals outside the LHIN We analyzed the most recent then available (2012/13) Discharge Abstract Database (DAD) data to determine the volumes of QBP acute care services used by the residents of each hub within the NE LHIN and the market share and volumes provided by each of the hospitals within the LHIN and by hospitals outside the LHIN. The North East LHIN hubs are 35 : Algoma Cochrane Coast Manitoulin, Parry Sound, Sudbury (MPSS) Nipissing/Temiskaming 35 For purposes of QBP planning, the Steering Committee has determined that St. Joseph s Elliot Lake should be considered to be part of the MPSS hub rather than the Algoma hub. Page 26

31 Similarly, we developed an inventory of the total volumes of QBP cases provided by each of the hospitals within the LHIN for patients from inside and outside the LHIN combined. We analyzed the current use of hospital (and non-hospital) post acute care services (Inpatient Rehabilitation, CCC and CCAC) used by QBP cases. These were measured in terms of the propensity of QBP cases to use post acute care services. This analysis is presented in Appendix C to this report Analysis of Alternative Models of Care Development and scenario modeling regarding the projection of demand against changes in the delivery model We applied each of the Year 1 and Year 2 Quality Based Procedures models of care to the current and projected volumes of care to develop projections for the QBPs separately and in the aggregate for the LHIN as a whole and for each hospital of: Ambulatory Surgery Case Volumes Inpatient Case Volumes Acute Care Patient Days and Required Beds Rehabilitation Patient Days and Required Beds 36 Assuming they were to operate in accordance with the prescribed models of care. These analyses are presented in an Appendix to this report Integration Opportunity Workshops Determination of integration opportunities (short and long-term) for Quality Based Procedures, based on quality, access and service volumes Once the analysis of the implications of QBP funding had been completed, regional workshops were conducted for the clinical and administrative leadership of each of the hospitals in each of the LHIN hubs. The workshop presented the analyses related to current and projected future activity related to QBP procedures and introduced two fundamental questions: How should the QBP best practice models of care be introduced into the north east? Will the best practice models of care require service consolidation/integration into a smaller number of sites? 36 We looked at rehabilitation beds selectively based on the importance of inpatient rehabilitation to QBP model of care. Page 27

32 The agenda for each workshop was: 1. Project Background and Objectives 2. Introduction to HSFR and QBP 3. Current Activity in Your Hub 4. Implications of QBF for Individual Hospitals 5. Short and Long-Term Integration Opportunities/ Requirements for QBPs 6. Potential Integration Models for QBPs 7. Evaluation Framework Models for service delivery, integration and siting of each QBP were developed Based on the discussions at these workshops preliminary models for service delivery, integration and siting of each QBP were developed and the evaluation framework was applied to each. These findings and analyses were considered by the Steering Committee and the models were refined for further consideration by clinical and administrative staff from the hub hospitals. These models provided: Approach to clinical care in the North East for each QBP. Specification of the current and future volumes (ambulatory procedures, cases and days) of QBP services that would be hosted by each NE LHIN hospital (and the change from current volumes). Specification of the current and future beds that would be required in each NE LHIN hospital to host QBP services (and the change from the current beds). Efficiency opportunities that might be realized through introduction of improved models of QBP care and/or through the realignment of clinical activity. Changes in funding and costs for each hospital as a result of the movement of QBP volumes among the hospitals. Impacts on hospitals that give up QBP volumes Potential cost reductions from reduced patient volumes Net Impact on hospitals that receive QBP volumes QBP funding for projected volumes Costs of projected patient volumes Page 28

33 2.3.7 Integration Model Workshops Considering potential clinical integration models A second set of regional workshops for the clinical and administrative leadership of each of the hospitals in the LHIN was convened. The workshop considered the integration models and the supporting analyses demonstrating the impact of the proposed model on the clinical activity, costs and clinical staffing of each hospital in the LHIN. The comments, criticisms and suggestions of the workshops were documented for consideration by the Steering Committee. An overview of these is presented in an appendix to this report. In its own workshop session, the Steering Committee considered the findings from the hub workshops and developed further refinement of the QBP service delivery and clinical integration models for potential application across the LHIN. In this session the Steering Committee also considered and incorporated plans for repatriation of clinical activity from hospitals outside the LHIN to hospitals within the LHIN QBP Organization and Service Delivery Models Implications of QBP Clinical Integration Models The final QBP service delivery and integration model was then applied to current and future volumes of QBP activity to determine the implications for each hospital in the LHIN. This included an estimate for each hospital and for the LHIN overall of: Changes in clinical activity Changes in revenues (increases and decreases) Changes in operating costs (increases and decreases that would be required for and available from the introduction of new models of QBP care and/or from the realignment of QBP clinical activity Implementation Plan Finally, the Steering Committee developed a plan to guide the implementation of the recommended changes in the organization and delivery of QBP services Project Report Finally this project report has been prepared for formal consideration by the hospitals and the LHIN. Page 29

34 2.4 Steering Committee The steering committee that directed the work on this project was made up of the following individuals. Martha Auchinleck Senior Director, Health System Transformation and Implementation, NE LHIN Robert Barnett Director, Strategic Planning & Integration at North East CCAC Dr. David Boyle Medical Director of the Surgical Program, HSN Marc Demers Officer, System Performance, NE LHIN Cynthia Desormiers President & Chief Executive Officer, WNGH Carol Halt Rehab Complex Continuing Care Lead, NE LHIN Mark Hartman Vice President Cancer Services and Medical Imaging, HSN Darryn Jermyn Regional Program Director. Northeastern Ontario Stroke Network, HSN Joan Ludwig Chief Nursing Officer, TDH David McNeil - Vice-President of Clinical Programs, Chief Nursing Officer, and lead for HSN s Seniors Strategy Marie Paluzzi Vice President & Chief Operating Officer, SAH Ben Petersen Vice President & Chief Financial Officer, HSN Glenn Scanlan Chief Executive Officer, KDH Tiz Silveri Vice President, Clinical Services, NBRHC The Steering Committee was assisted in its work by staff from Hay Group Health Care Consulting. Page 30

35 3.0 Discussion of QBP Funding Background Quality-Based Procedures (QBPs) are an integral part of Ontario s Health System Funding Reform (HSFR) Quality-Based Procedures (QBPs) are an integral part of Ontario s Health System Funding Reform (HSFR) and a key component of Patient-Based Funding (PBF). This reform plays a key role in advancing the government s quality agenda and it s Action Plan for Health Care. HSFR has been identified as an important mechanism to strengthen the link between the delivery of high quality care and fiscal sustainability. Ontario s health care system has been living under global economic uncertainty for a considerable period of time. Simultaneously, the pace of growth in health care spending has been on a collision course with the provincial government s deficit recovery plan. In response to these fiscal challenges and to strengthen the commitment towards the delivery of high quality care, the Excellent Care for All Act (ECFAA) received royal assent in June ECFAA is a key component of a broad strategy that improves the quality and value of the patient experience by providing them with the right evidence-informed health care at the right time and in the right place. ECFAA positions Ontario to implement reforms and develop the levers needed to mobilize the delivery of high quality, patientcentred care. Ontario s Action Plan for Health Care advances the principles of ECFAA, reflecting quality as the primary driver towards system solutions, value, and sustainability. 3.2 What Are We Moving Towards? Paradigm shift from a culture of cost containment to that of quality improvement Prior to the introduction of HSFR, a significant proportion of hospital funding was allocated through a global funding approach, with specific funding for some select provincial programs and wait times services. However, a global funding approach reduces incentives for health service providers to adopt best practices that result in better patient outcomes in a cost-effective manner. To support the paradigm shift from a culture of cost containment to that of quality improvement, the Ontario government is committed to 37 Taken directly from: Quality-Based Procedures: Clinical Handbook for Stroke, Health Quality Ontario & Ministry of Health and Long-Term Care. Page 31

36 moving towards a patient-centred, evidence-informed funding model that reflects local population needs and contributes to optimal patient outcomes (Exhibit 1). Patient-based funding (PBF) models have been implemented internationally since at least Ontario is one of the last leading jurisdictions to move down this path. This puts the province in a unique position to learn from international best practices and the lessons others have learned during implementation, thus creating a funding model that is best suited for Ontario. Providing incentives for health care providers to become more efficient and effective PBF supports system capacity planning and quality improvement through directly linking funding to patient outcomes. PBF provides an incentive to health care providers to become more efficient and effective in their patient management by accepting and adopting best practices that ensure Ontarians get the right care at the right time and in the right place. Exhibit 4: Patient Based Funding Future State Current State How do we get there? Future State Based on a lump sum, outdated historical funding Fragmented system planning Funding not linked to outcomes Does not recognize efficiency, standardization and adoption of best practices Maintains sector specific silos Strong Clinical Engagement Current Agency Infrastructure System Capacity Building for Change and Improvement Knowledge to Action Toolkits Transparent, evidence-based to better reflect population needs Supports system service capacity planning Supports quality improvement Encourages provider adoption of best practice through linking funding to activity and patient outcomes Ontarians will get the right care, at the right place and at the right time Meaningful Performance Evaluation Feedback Figure 1: Current and Future States of Health System Funding 3.3 How Will We Get There? The Ministry of Health and Long-Term Care has adopted a 3-year implementation strategy to phase in a PBF model and will make modest funding shifts starting in fiscal year 2012/13. A 3-year outlook has been provided to support planning for upcoming funding policy changes. Page 32

37 Transition from the current, provider-centred funding model towards a patientcentred model The Ministry has released a set of tools and guiding documents to further support the field in adopting the funding model changes. For example, a QBP interim list has been published for stakeholder consultation and to promote transparency and sector readiness. The list is intended to encourage providers across the continuum to analyze their service provision and infrastructure in order to improve clinical processes and, where necessary, build local capacity. The successful transition from the current, provider-centred funding model towards a patient-centred model will be catalyzed by a number of key enablers and field supports. These enablers translate into actual principles that guide the development of the funding reform implementation strategy related to QBPs. These principles further translate into operational goals and tactical implementation (Exhibit 2). Exhibit 5: Quality Based Procedure Principles Principles for developing QBP implementation strategy Cross-Sectoral Pathways Evidence-Based Operationalization of principles to tactical implementation (examples) Development of best practice patient clinical pathways through clinical expert advisors and evidence-based analyses Balanced Evaluation Integrated Quality Based Procedures Scorecard Alignment with Quality Improvement Plans Transparency Publish practice standards and evidence underlying prices for QBPs Routine communication and consultation with the field Sector Engagement Clinical expert panels Provincial Programs Quality Collaborative Overall HSFR Governance structure in place that includes key stakeholders LHIN/CEO Meetings Knowledge Transfer Applied Learning Strategy/ IDEAS Tools and guidance documents HSFR Helpline; HSIMI website (repository of HSFR resources) Figure 2: Principles Guiding Implementation of Quality-Based Procedures Abbreviations: HSFR, Health System Funding Reform; HSIMI, Health System Information Management and Investment: IDEAS, Improving the Delivery of Excellence Across Sectors; LHIN, Local Health Integration Network; QBP. Quality-Based Procedures. Page 33

38 3.4 What Are Quality-Based Procedures? QBPs involve clusters of patients with clinically related diagnoses or treatments QBPs involve clusters of patients with clinically related diagnoses or treatments. For example, stroke was chosen as a QBP using an evidence- and quality-based selection framework that identifies opportunities for process improvements, clinical redesign, improved patient outcomes, enhanced patient experience, and potential cost savings. The evidence-based framework used data from the Discharge Abstract Database (DAD) adapted by the Ministry of Health and Long-Term Care for its Health-Based Allocation Model (HBAM) repository. The HBAM Inpatient Grouper (HIG) groups inpatients based on their diagnosis or their treatment for the majority of their inpatient stay. Day surgery cases are grouped in the National Ambulatory Care Referral System (NACRS) by the principal procedure they received. Additional data were used from the Ontario Case Costing Initiative (OCCI). Evidence in publications from Canada and other jurisdictions and World Health Organization reports was also used to assist with the patient clusters and the assessment of potential opportunities. The evidence-based framework assessed patients using 4 perspectives, as presented in Exhibit 3. This evidence-based framework has identified QBPs that have the potential to both improve quality outcomes and reduce costs. Exhibit 6: QBP Evidence Based Framework Does the clinical group contribute to a significant proportion of total costs? Is there significant variation across providers in unit costs/ volumes/ efficiency? Is there potential for cost savings or efficiency improvement through more consistent practice? How do we pursue quality and improve efficiency? Is there potential areas for integration across the care continuum? Are there clinical leaders able to champion change in this area? Is there data and reporting infrastructure in place? Can we leverage other initiatives or reforms related to practice change (e.g. Wait Time, Provincial Programs)? Is there a clinical evidence base for an established standard of care and/or care pathway? How strong is the evidence? Is costing and utilization information available to inform development of reference costs and pricing? What activities have the potential for bundled payments and integrated care? Is there variation in clinical outcomes across providers, regions and populations? Is there a high degree of observed practice variation across providers or regions in clinical areas where a best practice or standard exists, suggesting such variation is inappropriate? Page 34

39 3.4.1 Practice Variation Opportunities to improve patient outcomes by reducing practice variation and focusing on evidenceinformed practice The DAD stores every Canadian patient discharge, coded and abstracted, for the past 50 years. This information is used to identify patient transition through the acute care sector, including discharge locations, expected lengths of stay and readmissions for each and every patient, based on their diagnosis and treatment, age, gender, comorbidities and complexities, and other condition-specific data. A demonstrated large practice or outcome variance may represent a significant opportunity to improve patient outcomes by reducing this practice variation and focusing on evidence-informed practice. A large number of Beyond Expected Days for length of stay and a large standard deviation for length of stay and costs are flags to such variation. Ontario has detailed case-costing data for all patients discharged from a case-costing hospital from as far back as 1991, as well as daily utilization and cost data by department, by day, and by admission Availability of Evidence Best practice clinical guidelines and pathways can be developed for QBPs A significant amount of Canadian and international research has been undertaken to develop and guide clinical practice. Using these recommendations and working with the clinical experts, best practice guidelines and clinical pathways can be developed for these QBPs, and appropriate evidence-informed indicators can be established to measure performance Cost Impact Directly linking quality with funding The selected QBP should have no fewer than 1,000 cases per year in Ontario and represent at least 1% of the provincial direct cost budget. While cases that fall below these thresholds may, in fact, represent an improvement opportunity, the resource requirements to implement a QBP may inhibit the effectiveness for such a small patient cluster, even if there are some cost efficiencies to be found. Clinicians may still work on implementing best practices for these patient subgroups, especially if they align with the change in similar QBP groups. However, at this time, there will be no funding implications. The introduction of evidence into agreed-upon practice for a set of patient clusters that demonstrate opportunity as identified by the framework can directly link quality with funding. Page 35

40 Exhibit 7: Quality-Based Evidence Framework for Stroke Figure 4: Quality-Based Procedures Evidence-Based Framework for Stroke Abbreviations: ALC, alternate level of care; HQO, Health Quality Ontario; LHIN, Local Health Integration Network; OHTAC, Ontario Health Technology Advisory Committee. Sources: Hall et al, 2012 (2) Discharge Abstract Database 2010/ How Will Quality-Based Procedures Encourage Innovation in Health Care Delivery? Encouraging health care providers to adopt best practices in their care delivery models Implementing evidence-informed pricing for the targeted QBPs will encourage health care providers to adopt best practices in their care delivery models and maximize their efficiency and effectiveness. Moreover, best practices that are defined by clinical consensus will be used to understand required resource utilization for the QBPs and further assist in developing evidence-informed pricing. Implementation of a price x volume strategy for targeted clinical areas will motivate providers to: Adopt best practice standards Re-engineer their clinical processes to improve patient outcomes Develop innovative care delivery models to enhance the experience of patients Page 36

41 Clinical process improvement may include better discharge planning, eliminating duplicate or unnecessary investigations, and paying greater attention to the prevention of adverse events, such as, postoperative complications. These practice changes, together with adoption of evidence-informed practices, will improve the overall patient experience and clinical outcomes and help create a sustainable model for health care delivery. 3.6 Funding for QBP Services A fee for providing a QBP service Under QBP funding, providers will be paid a fee (the QBP Price) for delivering a defined QBP service. The total fees paid will replace the portion of the hospital s funding that was devoted to the delivery of those services in the previous year (the carve out ). QBP funding, initially, will not be available to and will not be applied to small 38 hospitals QBP Price The QBP price is initially being set at the provincial average cost per HBAM Inpatient Grouper (HIG) weighted case for the prior year. This price will be paid to a hospital for each QBP case cared for at the hospital up to the QBP volume that has been assigned to the hospital by the LHIN. 3.7 The Carve Out QBP funding is designed to replace the amount of money that the hospital spent on QBP cases in prior years. This amount needs to be carved out of the hospital s base funding. Under Health System Funding Reform, the hospital s base funding allocation from the Ministry of Health and Long Term Care is being determined using the Health Based Allocation Model (HBAM). The carve out for a QBP for a hospital is based on the number of QBP cases provided in the previous, base fiscal year by that hospital times the estimated cost per case for providing the QBP services by that hospital. This estimate is derived from the hospitals HBAM cost per HIG weighted case (minus the HBAM allowances for teaching, Level of Care and distance) In Ontario, for funding purposes, a small hospital is defined to be a hospital that provides care for fewer than 2700 acute inpatient and SDS cases in a year. While the carve out and QBP funding will not be applied to small hospitals, the MOHLTC has recently prepared and distributed mock 2013/14 QBP carve-out and funding amount for small hospitals to be used for information purpose and for planning and discussion. Only hospitals with more than 10 cases of each QBP were included. Page 37

42 multiplied by the number of HIG weighted cases attributable to the QBP cases cared for by the hospital. The HIG weight assigned to a case is a function of the HIG group (a specified set of HIG groups makes up a QBP) and the length of stay for that case (long stay cases, cases cared for in an ICU and cases discharged to home care get extra weight under the current HIG weighting system). Page 38

43 4.0 Evaluation Framework Criterion-based decision making The Steering Committee developed an evaluation framework to be used for decision-making in this project. It was hoped that the models for integrating care within the LHIN would provide improvements in: Access Quality Consistency Economy Evaluative criteria were defined for use in evaluating the model for integrating/consolidating services and then for assessing the siting of services given the potential realignment options for clinical services among one or more hospital sites in the LHIN. The criteria that were used in evaluating the integration characteristics of a potential model of care are presented in the following table. Exhibit 8: Criteria for Evaluation of Integration Characteristics of Potential Model of Care 1 Maintain/ Improve quality 2 Appropriate critical mass 3 Access to Care 4 Potential repatriation 5 Criteria Maintain/ Improve operating efficiency/achieve economies of scale 6 Attract/retain specialized clinical skills Integration Definitions The distribution of clinical services will ensure quality of care standards and practices, clinical outcomes; safety and risk management are optimized The distribution of clinical services will be structured to ensure that programs/services have appropriate crticial mass (i.e. volume) to allow for the provision of safe, effective, efficient and timely services while reflecting remote considerations Supports access to care requiring multi-system specialized services (e.g. cancer, cardiology). The distribution of services will improve access to care and/or reduce medical, emotional and financial impact on patients. The distribution of clinical services will enhance the potential to deliver the appropriate services within the north east The distribution of clinical services will be structured to create a more cost effective and efficient service cost profile in the LHIN and will not require increased system funding for operations The distribution of clinical services will be structured to enhance the potential of recruiting and/or retaining specialized skills required for delivery of the service and will not result in the hospital losing physician or other HHR The criteria used to evaluate the potential siting of clinical services under a potential model of care are presented in the following table. Page 39

44 Exhibit 9: Criteria for Evaluation of Potential Siting of Clinical Services Under Potential Model of Care Criteria 8 Meets community need 9 Improves access to elective care 10 Improves access to emergent care Siting Criteria Definitions The distribution of clinical services will help to minimize variation in health outcomes across the region The distribution of clinical services will be structured to improve patients' access to high quality programs/services closer to home. The distribution of services will provide timely access to care 24/7, 365 days/year Supports clinical interdependencies and clinical coherence Meets current & future capacity limitations at site The distribution of clinical services will be aligned by site to ensure that clinical interdependencies and patient flow is optimized and efficient The distribution of clinical services will consider the current capacity of the potential host site and potential future capacity changes at the host site. 13 Enhance Regional Capability There is capacity and capability of the site to provide district or regional support to satellites if service is provided as a single program Page 40

45 5.0 Congestive Heart Failure 5.1 QBP Handbook CHF patients grouped into three patient categories: The QBP clinical handbook for Congestive Heart Failure (CHF) has suggested that CHF patients can be grouped into three patient categories: Low Intensity: Can be treated in the ED or in outpatient settings and discharged home without requiring an inpatient admission Average Intensity: Require inpatient admission with normal nurse-to-patient staffing High Intensity: Require ventilation (either noninvasive or invasive ventilation) and/or admission to intensive care unit But the handbook does not provide estimates of the percentage of cases that can be expected in each of these patient groups. Also the handbook does not suggest the appropriate acute care LOS; however it does note the provincial average lengths of stay in 2010/11: Low Intensity generally do not need admission Average Intensity days High Intensity days The handbook does recommend 4 phases for an episode of acute care for CHF patients: Acute stabilization first hours after admission, where the clinical status of the patient is assessed Sub-acute stabilization hours after admission Discharge preparation day 2 to hospital discharge Transitional care phase hospital discharge (or 24 hours prior to discharge) to 8-12 weeks after discharge The handbook also recommends that the Post Acute Care/ Transitional Care Phase should include access to specialized community-based heart failure clinics for transitional care. These heart failure clinics should include: Mechanisms that enable rapid access to the clinic Collaboration/communication between heart failure specialists, hospital inpatient physicians and primary care providers Page 41

46 Referral from the clinic back to primary care with a care management plan 5.2 Current Characteristics of CHF Service Delivery in NE LHIN 64% of CHF ED visits to NE LHIN hospitals admitted to inpatient acute care The following table presents the number CHF ED patient visits to each NE LHIN hospital 40 and the percentage of these visits that result in admission to inpatient care. As can be seen, overall, 64% of the CHF ED visits to NE LHIN hospitals are admitted to inpatient acute care; this is comparable to the province as a whole where 68% of CHF visits across the province are admitted to acute care. Exhibit 10: 2012/13 ED Visits and Admissions for CHF in NE LHIN Hospitals NE LHIN Hospital ED Visits ED Admits % Admit Health Science North % Sault Area Hospital % North Bay RHC % Timmins & District % West Parry Sound HC % Temiskaming Hospital % Manitoulin HC % St. Joseph's, Elliot Lake % Kirkland & District Hospital % Espanola General Hospital % Sensenbrenner Hospital % West Nipissing General % Lady Minto Hospital % Weeneebayko Area HA % Notre Dame Hospital % Blind River Dist Hlth Ctr % Mattawa General Hospital % Anson General Hospital % 40 Note re ED Admission and Inpatient Case Reconciliation: NACRS (ambulatory) data used to identify number of ED patients who present, and are admitted, within a QBP. DAD (inpatient) data used to identify QBP inpatients. But diagnosis groupings in ED data don t exactly match inpatient QBP specifications. As a result there will be some discrepancies between the ED count of admitted patients from the NACRS data and the inpatient count from the DAD data. E.g. ED data identified 1,014 CHF IP admissions from ED, while IP data identified 1,386 CHF cases. Another part of the discrepancy is explained by transfers between sites; some of the IP cases reflect the same patient counted twice (i.e. Multiple IP stays). Page 42

47 NE LHIN Hospital ED Visits ED Admits % Admit Lady Dunn Health Centre % Englehart & District Hospital % Chapleau Hlth Serv % Hornepayne Community % Bingham Memorial Hospital % Smooth Rock Falls Hospital % Grand Total 1,577 1,014 64% As can be seen in the following exhibit, the categorization of these ED visits into one of the three patient intensity groups is also quite similar to the provincial average 41. Exhibit 11: Comparison of Distribution of NE LHIN and Ontario CHF Cases by Intensity Hospital Distribution of Cases by Intensity % Distribution Low Medium High Total Low Medium High Health Science North % 70% 9% Sault Area Hospital % 69% 8% North Bay RHC % 60% 16% Timmins & District % 74% 4% West Parry Sound HC % 32% 39% Temiskaming Hospital % 51% 17% Manitoulin HC % 52% 0% St. Joseph's, Elliot Lake % 38% 26% Sensenbrenner Hospital % 40% 29% West Nipissing General % 70% 0% Kirkland & District Hospital % 22% 29% Espanola General Hospital % 56% 0% Weeneebayko Area HA % 54% 4% Lady Minto Hospital % 42% 0% Englehart & District Hospital % 67% 0% Chapleau Hlth Serv % 75% 0% Mattawa General Hospital % 56% 0% Anson General Hospital % 50% 0% Lady Dunn Health Centre % 38% 0% Blind River Dist Hlth Ctr % 32% 0% 41 The CHF QBP Handbook provided limited guidance on assigning CHF patients to categories. For simplicity if a CHF ED visit was not admitted then the patient was assigned to the Low Intensity CHF category; if a CHF patient was admitted and spend time in a Special Care Unit then the patient was assigned to the High Intensity CHF category; all other admitted CHF patients were assigned to the Medium Intensity CHF category. Page 43

48 Hospital Distribution of Cases by Intensity % Distribution Low Medium High Total Low Medium High Smooth Rock Falls Hospital % 83% 0% Notre Dame Hospital % 21% 0% Bingham Memorial Hospital % 100% 0% Hornepayne Community % 60% 0% NE LHIN Total 563 1, ,949 29% 60% 11% Ontario Total 8,861 17,968 4,172 31,001 29% 58% 13% Significant variation among the hospitals in each hub and between hubs The following tables present the current (2012/13) volumes and characteristics of CHF inpatients in each hospital in each NE LHIN Hub. Hub Exhibit 12: 2012/13 NE LHIN CHF Inpatient Activity by Hub and Hospital Hospital CHF IP Cases IP Days Avg. LOS % ALC Days Avg. RIW Avg. HIG Wght. Algoma Blind River Dist Hlth Ctr % Hornepayne Community % Lady Dunn Health Centre % Sault Area Hospital 282 2, % Algoma Total 301 2, % MPSS Espanola General Hospital % Health Science North 406 4, % Manitoulin HC % St. Joseph's, Elliot Lake % West Parry Sound HC % MPSS Total 573 5, % Nip-Temisk Englehart & Dist Hospital % Kirkland & District Hospital % Mattawa General Hospital % North Bay RHC 178 1, % Temiskaming Hospital % West Nipissing General % Nip-Temisk Total 303 2, % Cochrane & Coast Anson General Hospital % Bingham Memorial Hospital % Chapleau Hlth Serv % Lady Minto Hospital % Notre Dame Hospital % Sensenbrenner Hospital % Smooth Rock Falls Hospital % Timmins & District % Weeneebayko Area HA % Cochrane & Coast Total 209 1, % Grand Total 1,386 11, % Page 44

49 As can be seen, there is significant variation in the number of cases, the ALOS, and Average RIW and HIG weights among the hospitals in each hub and between hubs. 5.3 Proposed Model for Delivery of CHF Services The Hub workshops have developed and the Project Steering Committee has confirmed the following model for the care of CHF patients in North East LHIN hospitals. Consistent model of care and clinical pathway/order set for CHF patients across the region It is recommended that NE LHIN hospitals should use a consistent model of care and clinical pathway/order set across the region in caring for CHF patients. Clinicians should provide leadership in the interpretation of the CHF handbook to develop this model of care and clinical pathway/order set. The LHIN should provide coordination for this initiative. The model and approach to care should incorporate the following elements: 1. Low intensity patients should be discharged from EDs across the LHIN Average intensity patients should be admitted and managed at the hospital where the patient first presents. All hospitals with an ED should be able to care for average intensity CHF patients. However, when required, telemedicine should be available from hub hospitals to clinicians looking after average intensity patients in local hospitals. 3. In general high intensity patients should be transferred to and admitted to Hub hospitals (SAH, TADH, HSN, NBRHC). However, there should be some ability for some high intensity patients to be cared for with BiPAP for 6-12 hours at the site where they present and then continue to be managed locally for the remainder of their stay. Thus, all high intensity patients may not need to be transferred to a Hub hospital. The NE LHIN model of care for CHF patients assumes that 10% of high intensity patients can be and will be managed locally; with the use of a virtual ICU to facilitate care of high intensity CHF patients at the local hospitals. Thus, the model assumes that only 90% of high intensity CHF ED patients should be and will be transferred to Hub hospitals. 42 For modeling purposes we have used current NE averages for % of CHF patients in each patient group. Page 45

50 4. It is expected that the hospitals will achieve provincial average length of stay performance (or better) in caring for each CHF patient admitted to inpatient care. The target maximum length of stay for medium intensity patients is 7.2 days. The target maximum length of stay for high intensity patients is 9.6 days. The number of extremely long stay patients will be reduced significantly thus reducing the number of atypical patients High intensity patients who have stabilized at a Hub hospital but who are not ready for discharge should be repatriated to their local hospital to complete their inpatient care. 6. Importantly, it is noted that the hospitals in the NE LHIN will only be able to achieve the provincial average lengths of stay and reduce the number of long-stay atypical cases, if there are significant and sufficient investments in community resources to provide both transitional care and CCAC services so that patients do not remain in ALC status in the local hospitals. 7. Each hub hospital will provide a Heart Failure Clinic to support the transitional phase of care for CHF patients. GIM or Family Medicine led clinics should be located at all Hubs except HSN. (HSN will be expected to provide telemedicine and telehomecare support to the clinics in the other Hub hospitals when required). It is suggested that consideration should be given to offering a combination Heart Failure/Respiratory Clinic at each Hub hospital. These could be run as a combined clinic using a Chronic Disease Management model but will require appropriate types of staffing with sufficient time to provide appropriate care. The clinics will require more access to and support from community resources to monitor patients and prevent readmissions to hospitals. The hub clinics and the community resources should work in tandem with FHTs to care for these patients. 8. The expertise in the hub sites should be made available to the more remote locations using telemedicine and telehomecare to reduce the burden of travel for patients. 43 For modeling purposes, the Steering Committee has assumed that NE LHIN hospitals can reduce the % of atypical cases to the lowest percentage achieved by hospitals in other LHINs in the province. Page 46

51 5.4 Implications of Proposed Model for CHF Services The following sections and tables present estimates of the implications of implementing the proposed model of care for CHF patients Volumes and Costs The tables following present the implications of the proposed model of care for the number of patients, patient days, HIG weighted cases and cost of inpatient care for each of the NE LHIN hospitals. As can be seen, there will be some movement of patient volume (high intensity patients) from the local hospitals to the hub hospitals. There will also be a decrease in the total number of patient days across all hospitals as hospitals adjust their care processes to achieve: A more consistent ALOS that is less than or equal to the provincial average for typical CHF cases and A reduction in the number of long-stay atypical CHF cases 44. There will also be a reduction in the total case count due to elimination of inpatient transfers from local to hub hospitals 45. Reduction in the number of HIG weighted cases The reduction in the number of atypical cases will also result in a reduction in the total number of HIG weighted cases because each of the long stay atypical CHF cases likely has a higher HIG weight than a typical CHF case Best Practice (i.e. Lowest) % Atypical cases of all Ontario LHINs for each QBP has been applied to NE LHIN hospitals, with cases being converted from Atypical to Typical and then given the target LOS for the QBP and the NE LHIN average weight per Typical case for the QBP. It should be noted that the number of inpatients declines under the proposed CHF model of care because some inter hospital inpatient transfers have been eliminated. In 2012/13, there were 39 CHF patients admitted at a small hospital and then transferred for an inpatient stay at a Hub hospital. For simulation, in accordance with the proposed model of care, we have assumed that these patients will be transferred from small hospital ED directly to Hub hospital (i.e. there will be no inpatient stay in the small hospital prior to transfer). Page 47

52 IP Cases % Atyp. Case IP Days Avg. LOS HIG Wgt. IP Cases % Atyp. Case IP Days Avg. LOS HIG Wgt. IP Cases IP Days HIG Wght. Exhibit 13: Projected Impact on NE LHIN Hospital Activity of Proposed Model of Care for CHF /13 Actual Activity Proposed Activity Change In Activity NE LHIN Hospital Blind River Dist HC 8 25% % Chapleau Hlth Serv 12 42% % Lady Minto 13 38% % St. Jos, Elliot Lk 37 24% % Englehart & District 12 17% % Espanola General 23 35% % Notre Dame 5 20% % Hornepayne 3 33% % Anson General 9 22% % Lady Dunn HC 8 50% % Sensenbrenner 31 10% % Kirkland & District 25 28% % Bingham Memorial 3 67% % Mattawa General 10 20% % Manitoulin HC 38 34% % Smooth Rock Falls 5 0% % West Nipissing 30 23% % Temiskaming 48 29% % Timmins & District % % West Parry Sd HC 69 16% % Health Science N % 4, % 2, , Sault Area % 2, % 1, , Weeneebayko 14 36% % North Bay RHC % 1, % 1, Grand Total 1,386 22% 11, ,103 1,347 14% 6, , , As can be seen, in the following exhibit, these changes will also result in a reduction in the estimated, and likely the real, costs of caring for CHF patients in most NE LHIN hospitals. Across all NE LHIN hospitals the estimated cost of care for CHF patients under the proposed model of care will decline by $689k from $10.95 million to $10.26 million. 46 It should be noted that the hospitals average lengths of stay for CHF patients under the proposed model of care will decline from the current value because the model assumes that all patients stay in acute care for no more than the target length of stay. As a result the modeling reflects a decline in lengths of stay for most patients and thus a (sometimes significant) decrease in the average lengths of stay for all hospitals. Because some CHF patients stay in hospital for shorter periods than the target lengths of stay and the modeling did not increase their lengths of stay, the hospitals resulting average lengths of stay is often less than the target length of stay. Page 48

53 HIG Wtd. Cases HIG Wtd. Cases HIG Wtd. Cases Exhibit 14: Projected Impact on NE LHIN Hospital Costs of Proposed Model of Care for CHF NE LHIN Hospital 2012/13 HBAM QBP Net Unit Cost 2012/13 Activity Proposed Activity Change in Cost Estimated Cost Estimated Cost Estimated Cost Blind River Dist HC $6, $58, $55, $2,307 Chapleau Hlth Serv $7, $79, $100, $20,825 Lady Minto $5, $91, $64, $26,009 St. Joseph's, Elliot Lk $3, $233, $113, $120,135 Englehart & District $4, $75, $68, $7,349 Espanola General $5, $145, $135, $9,700 Notre Dame $5, $83, $34, $49,359 Hornepayne $7, $50, $29, $21,132 Anson General $4, $67, $42, $25,456 Lady Dunn HC $5, $39, $34, $4,813 Sensenbrenner $3, $169, $117, $51,910 Kirkland & District $4, $218, $67, $151,167 Bingham Memorial $7, $36, $27, $8,952 Mattawa General $7, $87, $95, $8,381 Manitoulin HC $5, $182, $231, $49,280 Smooth Rock Falls $3, $18, $25, $6,697 West Nipissing $3, $132, $143, $11,476 Temiskaming $4, $437, $181, $255,648 Timmins & District $4, $739, $823, $84,756 West Parry Sound HC $5, $622, $300, $322,255 Health Science North $5, $3,519, $3,427, $91,555 Sault Area $5, $2,218, $2,074, $143,587 Weeneebayko $5, $96, $95, $1,015 North Bay RHC $6, $1,542, $1,964, $421,825 Grand Total 2,103 $10,945,672 1,940 $10,256, $689, QBP Revenues and Costs Net losses in providing CHF care under QBP funding The application of QBP funding to the proposed model of care would result in a net loss from CHF care for most of those LHIN hospitals that will be included in QBP funding. The estimated cost of caring for CHF patients will be higher than the QBP revenues paid for their care because the hospital s HBAM QBP net unit cost 47 per HIG weighted case is higher than the QBP price per HIG weighted case for CHF cases ($5,110). The estimated magnitude of the hospitals profits 47 The HBAM QBP cost per weighted case is adjusted to remove the impact of the HBAM allowances for teaching, Level of Care and distance. These adjustments for each hospital are presented in an appendix to this report. Page 49

54 IP Cases Total HIG Wgt. and losses from caring for CHF patients under QBP funding is presented in the following table 48. Exhibit 15: Projected QBP Funding Impact on Large NE LHIN Hospitals of Proposed CHF Model of Care NE LHIN Hospital Proposed Activity 2012/13 HBAM QBP Net Unit Cost QBP Price per Wtd. Case Net Profit/Loss Per HIG Wtd. Case Total QBP Volume St. Joseph's, Elliot Lk $3,718 $5,110 $1,392 $42,589 Temiskaming $4,710 $5,110 $400 $15,426 Timmins & District $4,705 $5,110 $405 $70,935 West Parry Sound HC $5,257 $5,110 -$147 -$8,389 Health Science North $5,206 $5,110 -$96 -$63,157 Sault Area $5,302 $5,110 -$192 -$75,110 North Bay RHC $6,113 $5,110 -$1,003 -$322,262 Grand Total 1,143 1,672 -$339, Ambulatory Care The recommended model of care for CHF patients suggests that heart failure clinics should be offered at each hub hospital. A significant percentage of hospital discharges will require the services of this clinic and the cost per visit will be meaningful. If we assume that at least 25% of CHF discharges will require support from the heart failure clinics 49, then we can expect that the hub hospitals in total will need to provide care for approximately 350 CHF patients. We further assume that each of these patients will require 4 clinic visits resulting in a total of 1400 clinic visits. If we assume that the cost of a clinic visit is approximately $250 50, then the hub hospitals will need to dedicate approximately $375,000 of their global funding to support these heart failure clinics. The current QBP price does not reflect nor does QBP funding currently provide for this post discharge service. It is unclear how the It should be noted that implementation of the proposed model of care for CHF patients will result in a reductions in volumes and costs of care for CHF patients in most local hospitals. But, because the smaller of the local hospitals will not be subject to QBP funding, their funding from the LHIN/MHOLTC will not be reduced commensurately. These hospitals will potentially have surplus funds as a result of the reduction in cases, weighted cases and costs. These estimates are suggested only as a basis for estimating the order of magnitude impact of the additional need for outpatient services. Excluding the OHIP fee for the physician. Page 50

55 hospitals will be able to redirect their funds to support these heart failure clinics without securing some additional global budget funding. 5.6 Evaluating the CHF Integration Model The Steering Committee applied its evaluation framework to the recommended CHF Integration Model. The application of the framework is presented in the following tables. As can be seen, the recommended model scores highly on both the integration and the siting criteria. Exhibit 16: Application of Integration Criteria to CHF Model of Care CONGESTIVE HEART FAILURE Criteria Definition Scoring: 0=No; Integration 0.5=Maybe; 1=Yes 1 Maintain/ Improve quality The distribution of clinical services will ensure quality of care standards and practices, clinical outcomes; safety and risk management are optimized 1 Subtotal 2 Appropriate critical mass The distribution of clinical services will be structured to ensure that programs/services have appropriate crticial mass (i.e. volume) to allow for the provision of safe, effective, efficient and timely services while reflecting 1 remote considerations 3 Access to Care Supports access to care requiring multi-system specialized services (e.g. cancer, cardiology). The distribution of services will improve access to care 1 and/or reduce medical, emotional and financial impact on patients. 4 Potential repatriation The distribution of clinical services will enhance the potential to deliver the appropriate services within the north east 0 5 Maintain/ Improve operating efficiency/achieve economies of scale 6 Attract/retain specialized clinical skills The distribution of clinical services will be structured to create a more cost effective and efficient service cost profile in the LHIN and will not result in increased system funding for operations The distribution of clinical services will be structured to enhance the potential of recruiting and/or retaining the specialized skills required for the delivery of the service and will not result in the hospital losing physician or other HHR % Exhibit 17: Application of Siting Criteria to Proposed CHF Model of Care of the service and will not result in the hospital losing physician or other HHR Siting 1 Meets community need The distribution of clinical services will help to minimize variation in health outcomes across the region Improves access to care The distribution of clinical services will be structured to improve patients' access to high quality programs/services closer to home. The distribution of 0.5 services will provide timely access to care 24/7, 365 days/year. 3 Supports clinical The distribution of clinical services will be aligned by site to ensure that interdependencies and clinical clinical interdependencies and patient flow is optimized and efficient 0.5 coherence 4 Meets current & future capacity limitations at site The distribution of clinical services will consider the current capacity of the potential host site and potential future capacity changes at the host site. 1 5 Enhance Regional Capability There is capacity and capability of the site to provide district or regional support to satellites if service is provided as a single program % Page 51

56 6.0 Chronic Obstructive Pulmonary Disease 6.1 QBP Handbook Three COPD patient categories The QBP clinical handbook for Chronic Obstructive Pulmonary Disease (COPD) has suggested that COPD exacerbation hospitalizations can be grouped into three patient categories for purposes of QBP funding: Mild Exacerbation: Patient treated in the ED or in OP settings and discharged home without requiring an inpatient admission. In 2011/12 this category represented 44% of provincial hospital episodes of COPD Moderate Exacerbation: Patient requires admission to inpatient care. In 2011/12 this category represented 51% of provincial hospital episodes of COPD Severe Exacerbation: Patient requires hospitalization, ventilation (either noninvasive or invasive ventilation) and/or admission to an ICU. In 2011/12 this category represented only 4% of provincial hospital episodes of COPD The handbook did not provide length of stay targets for COPD inpatients nor did it comment on current ALOS for these patients in Ontario hospitals. Care pathways and practices for COPD patients are provided in the handbook as a guide. It suggests that these will need to be adapted for implementation to meet local challenges. 6.2 Current Characteristics of COPD Service Delivery in NE LHIN The following table presents the number COPD ED patient visits to each NE LHIN hospital 51 and the percentage of these visits that result in admission to inpatient care. As can be seen, overall, 30% of the COPD ED visits to NE LHIN hospitals are admitted to inpatient acute 51 Note re ED Admission and Inpatient Case Reconciliation: NACRS (ambulatory) data used to identify number of ED patients who present, and are admitted, within a QBP. DAD (inpatient) data used to identify QBP inpatients. But diagnosis groupings in ED data don t exactly match inpatient QBP specifications. As a result there will be some discrepancies between the ED count of admitted patients from the NACRS data and the inpatient count from the DAD data. Another part of the discrepancy is explained by transfers between sites; some of the IP cases reflect the same patient counted twice (i.e. Multiple IP stays). Page 52

57 care; this is less than the province as a whole where 40% of COPD visits across the province are admitted to acute care. Exhibit 18: 2012/13 ED Visits and Admissions for COPD in NE LHIN Hospitals NE LHIN Hospital ED Visits ED Admits % Admit Health Science North % Sault Area Hospital % Timmins & District % North Bay RHC % St. Joseph's, Elliot Lake % West Nipissing General % Sensenbrenner Hospital % Manitoulin HC % West Parry Sound HC % Kirkland & District Hospital % Temiskaming Hospital % Anson General Hospital % Espanola General Hospital % Lady Minto Hospital % Notre Dame Hospital % Englehart & District Hospital % Blind River Dist Hlth Ctr % Mattawa General Hospital % Lady Dunn Health Centre % Chapleau Hlth Serv % Weeneebayko Area HA % Bingham Memorial Hospital % Hornepayne Community % Smooth Rock Falls Hospital % Grand Total 4,832 1,450 30% As can be seen in the following exhibit, the categorization of these ED visits into one of the three patient intensity groups is similar to the provincial average. However, there is a higher percentage of mild exacerbation patient visits to NE LHIN hospitals than in the province Page 53

58 as whole and a correspondingly lower percentage of moderate and severe exacerbation patients 52. Exhibit 19: Comparison of NE LHIN and Ontario COPD Cases by Intensity Hospital Cases by Intensity % Distribution of Cases Low Medium High Total Low Medium High Blind River Dist Hlth Ctr % 19% 0% Chapleau Hlth Serv % 35% 0% Lady Minto Hospital % 15% 2% St. Joseph's, Elliot Lake % 20% 8% Englehart & District Hospital % 41% 0% Espanola General Hospital % 28% 0% Notre Dame Hospital % 21% 0% Hornepayne Community % 30% 0% Anson General Hospital % 22% 0% Lady Dunn Health Centre % 7% 0% Sensenbrenner Hospital % 18% 2% Kirkland & District Hospital % 19% 15% Bingham Memorial Hospital % 21% 0% Mattawa General Hospital % 17% 0% Manitoulin HC % 26% 0% Smooth Rock Falls Hospital % 95% 0% West Nipissing General % 21% 0% Temiskaming Hospital % 16% 9% Timmins & District % 33% 2% West Parry Sound HC % 22% 5% Health Science North % 55% 6% Sault Area Hospital % 49% 5% Weeneebayko Area HA % 33% 0% North Bay RHC % 41% 6% North East LHIN Total 3,402 1, ,570 61% 35% 4% Ontario Total 28,897 21,169 3,508 53,574 54% 40% 7% The following tables present the current (2012/13) volumes and characteristics of COPD inpatients in each hospital in each NE LHIN Hub. 52 The COPD QBP Handbook provided limited guidance on assigning COPD patients to categories. For simplicity if a COPD ED visit was not admitted then the patient was assigned to the Mild Exacerbation COPD category; if a COPD patient was admitted and spent time in a Special Care Unit then the patient was assigned to the Severe Exacerbation COPD category; all other admitted COPD patients were assigned to the Moderate Exacerbation COPD category. Page 54

59 Hub Exhibit 20: 2012/13 NE LHIN COPD Inpatient Activity by Hub and Hospital Hospital COPD IP Cases IP Days Avg. LOS % ALC Days Avg. RIW Avg. HIG Wght. Algoma Blind River Dist Hlth Ctr % Hornepayne Community % Lady Dunn Health Centre % Sault Area Hospital 433 2, % Algoma Total 455 2, % MPSS Espanola General Hospital % Health Science North 555 5, % Manitoulin HC % St. Joseph's, Elliot Lake 81 1, % West Parry Sound HC % MPSS Total 796 7, % Nip-Temisk Englehart & District Hospital % Kirkland & District Hospital % Mattawa General Hospital % North Bay RHC 310 2, % Temiskaming Hospital % West Nipissing General % Nip-Temisk Total 532 4, % Cochrane & Coast Anson General Hospital % Bingham Memorial Hospital % Chapleau Hlth Serv % Lady Minto Hospital % Notre Dame Hospital % Sensenbrenner Hospital % Smooth Rock Falls Hospital % Timmins & District 211 1, % Weeneebayko Area HA % Cochrane & Coast Total 385 3, % Grand Total 2,168 18, % As can be seen, there is significant variation in the number of cases, the ALOS, and Average RIW and HIG weights among the hospitals in each hub and between hubs. 6.3 Proposed Model for Delivery of COPD Services The Hub clinical workshops have developed and the Steering Committee has reviewed, refined and confirmed the following model for the care of COPD patients in NE LHIN hospitals. Page 55

60 A consistent model of care and clinical pathway/order set in caring for COPD patients It is recommended that NE LHIN hospitals should use a consistent model of care and clinical pathway/order set in caring for COPD patients across region. Clinicians should provide leadership in the interpretation of the COPD handbook to develop this model of care and clinical pathway/order set. The LHIN should provide coordination for this initiative. The model and approach to care should incorporate the following key elements: 1. Mild exacerbation patients should be discharged from EDs across the LHIN Moderate exacerbation patients should be admitted and managed at the hospital where the patient first presents. All hospitals with an ED should be able to care for moderate exacerbation COPD patients. However, when required, telemedicine from hub hospitals should be available to support clinicians looking after moderate exacerbation patients in local hospitals. The post discharge follow-up model for these patients should be the same as the follow up for mild exacerbation patients who are discharged from the ED. 3. Severe exacerbation COPD patients should be transferred from the local hospital ED to the appropriate Hub hospitals (SAH, TADH, HSN, NBRHC) for admission at that hospital. However, there should be some ability for some severe exacerbation patients to be cared for with BiPAP for 6-12 hours at the site where they present and then continue to be managed locally for the remainder of their stay. Thus, all severe exacerbation patients may not need to be transferred to a Hub hospital. The NE LHIN model of care for COPD patients assumes that 10% of severe exacerbation patients can be and will be managed locally; with the use of a virtual ICU to facilitate care of severe exacerbation COPD patients at the local hospitals. Thus, the model assumes that only 90% of severe exacerbation COPD ED patients should be and will be transferred to Hub hospitals. 4. It is expected that the hospitals will achieve the provincial average lengths of stay performance (or better) in caring for COPD patients admitted for inpatient care: 53 For modelling purposes, we have used the current NE averages for % of COPD patients in each patient group. Page 56

61 The target maximum average length of stay for moderate exacerbation COPD patients is 5.9 days. The target maximum average length of stay for severe exacerbation COPD patients is 10.2 days. The number of extremely long stay patients will be reduced significantly thus reducing the number of atypical patients Once the severe exacerbation patient is ready for discharge from ICU care, they should be considered for repatriation to the local hospital for the completion of their inpatient episode of care. When repatriated or when discharged to the community the local hospital or the community provider should be provided with a plan for continuing care. 6. Importantly, it is noted that the hospitals in the NE LHIN will only be able to achieve the provincial average lengths of stay and reduce the number of long stay atypical cases if there are significant and sufficient investments in community resources to provide transitional care and CCAC services so that patients do not remain in ALC status in the local hospitals. 7. Each hub hospital should provide a COPD clinic to support the post discharge (from ED or inpatient) community care for COPD patients. This should be a GIM or Family Medicine led clinic at all hubs except HSN. (HSN will be expected to provide telemedicine support to the clinics in the other hub hospitals when required). As has been discussed, it is suggested that consideration should be given to offering a combination Heart Failure/Respiratory Clinic at each Hub hospital. These could be run as a combined clinic using a Chronic Disease Management model but they will require appropriate types of staffing with sufficient time to provide appropriate care. The clinics will require more access to and support from community resources to monitor patients and prevent readmissions to hospitals. The hub clinics and the community resources should work in tandem with FHTs to care for these patients. It is noted that these clinics likely will be a financial burden to the hub hospitals; neither the integration model presented here nor QBP funding will generate sufficient funds to support the operation of the proposed COPD clinic. 54 For modeling purposes, the Steering Committee has assumed that NE LHIN hospitals can reduce the % of atypical cases to the lowest percentage achieved by hospitals in other LHINs in the province. Page 57

62 IP Cases % Atyp. Case IP Days Avg. LOS HIG Wgt. IP Cases % Atyp. Case IP Days Avg. LOS HIG Wgt. IP Cases IP Days HIG Wght. 8. The COPD expertise in the hub sites should be made available to the more remote locations using telemedicine to reduce the burden of travel for patients. 6.4 Implications of Proposed Model for COPD Services The following sections and tables present estimates of the implications of implementing the proposed model of care for COPD patients Volumes and Costs The tables following present the implications of the proposed model of care for the number of patients 55, patient days and total HIG weighted cases for each of the NE LHIN hospitals. Exhibit 21: Projected Impact on NE LHIN Hospital Activity of Proposed Model of Care for COPD /13 Actual Activity Proposed Activity Change In Activity NE LHIN Hospital Blind River Dist HC 15 27% % Chapleau Hlth Serv 14 36% % Lady Minto 20 25% % St. Joseph's, Elliot Lk 81 25% 1, % Englehart & District 37 24% % Espanola General 34 12% % Notre Dame 22 14% % Hornepayne 3 33% % Anson General 28 21% % Lady Dunn HC 4 25% % It should be noted that the number of inpatients declines modestly under the proposed COPD model of care because some inter hospital inpatient transfers have been eliminated. In 2012/13, there were 24 COPD patients admitted at a small hospital and then transferred for an inpatient stay at a Hub hospital. For simulation, assume that these patients will be transferred from small hospital ED directly to Hub hospital (i.e. No inpatient stay in the small hospital prior to transfer). 56 It should be noted that the hospitals average lengths of stay for COPD patients under the proposed model of care will decline from the current value because the model assumes that all patients stay in acute care for no more than the target length of stay. As a result the modeling reflects a decline in lengths of stay for most patients and thus a (sometimes significant) decrease in the average lengths of stay for all hospitals. Because some COPD patients stay in hospital for shorter periods than the target lengths of stay and the modeling did not increase their lengths of stay, the hospitals resulting average lengths of stay is often less than the target length of stay. Page 58

63 IP Cases % Atyp. Case IP Days Avg. LOS HIG Wgt. IP Cases % Atyp. Case IP Days Avg. LOS HIG Wgt. IP Cases IP Days HIG Wght. 2012/13 Actual Activity Proposed Activity Change In Activity NE LHIN Hospital Sensenbrenner 53 19% % Kirkland & District 67 22% % Bingham Memorial 4 0% % Mattawa General 11 36% % Manitoulin HC 70 19% % Smooth Rock Falls 20 25% % West Nipissing 60 27% % Temiskaming 47 15% % Timmins & District % 1, % West Parry Sound HC 56 20% % Health Science North % 5, % 2, , Sault Area % 2, % 1, Weeneebayko 13 31% % North Bay RHC % 2, % 1, Grand Total 2,168 19% 18, ,103 2,144 14% 9, , , As can be seen, there will be some movement of patient volume (high intensity patients) from the local hospitals to the hub hospitals. There will also be a decrease in the total number of patient days across all hospitals as hospitals adjust their care processes to achieve: A more consistent ALOS that is less than or equal to the provincial average for their typical cases and A reduction in the number of long stay atypical COPD cases 57 Small reduction in the total case count due to a reduction in the number of transfers. The reduction in the number of long stay atypical cases will also result in a reduction in the number of HIG weighted cases because each of the long stay atypical COPD cases likely has a higher HIG weight than a typical COPD case. These changes will also result in a reduction in the estimated, and likely the real, costs of caring for COPD patients in NE LHIN hospitals. 57 Best Practice (i.e. Lowest) % Atypical cases of all Ontario LHINs for each QBP has been applied to NE LHIN hospitals, with cases being converted from Atypical to Typical and then given the target LOS for the QBP and the NE LHIN average weight per Typical case for the QBP. Page 59

64 NE LHIN Hospital Exhibit 22: Projected Impact on NE LHIN Hospital Costs of Proposed Model of Care for COPD 2012/13 HBAM QBP Net Unit Cost 2012/13 Activity Proposed Activity Change in Cost HIG Wtd. Cases Estimated Cost HIG Wtd. Cases Estimated Cost HIG Wtd. Cases Estimated Cost Blind River Dist HC $6, $162, $105, $56,438 Chapleau Hlth Serv $7, $133, $114, $18,186 Lady Minto $5, $105, $114, $9,066 St. Joseph's, Elliot Lk $3, $577, $309, $267,530 Englehart & District $4, $272, $190, $81,724 Espanola General $5, $171, $207, $35,928 Notre Dame $5, $235, $133, $102,472 Hornepayne $7, $15, $25, $10,253 Anson General $4, $146, $121, $25,724 Lady Dunn HC $5, $17, $18, $473 Sensenbrenner $3, $335, $213, $122,382 Kirkland & District $4, $578, $238, $340,006 Bingham Memorial $7, $26, $31, $5,380 Mattawa General $7, $73, $84, $11,217 Manitoulin HC $5, $322, $420, $98,544 Smooth Rock Falls $3, $99, $90, $9,385 West Nipissing $3, $284, $240, $44,100 Temiskaming $4, $352, $159, $192,679 Timmins & District $4, $1,186, $1,345, $159,419 West Parry Sound HC $5, $513, $267, $245,409 Health Science North $5, $4,988, $4,385, $603,115 Sault Area $5, $2,750, $3,085, $334,473 Weeneebayko $5, $72, $73, $1,450 North Bay RHC $6, $2,535, $3,463, $928,097 Grand Total 3,103 $15,955,701 2,936 $15,440, $514,853 Net profit for most hospitals from caring for COPD patients The application of QBP funding to the proposed model of care would result in a net profit from COPD care for most of those LHIN hospitals that will be included in QBP funding. The estimated cost of caring for COPD patients will be lower than the QBP revenues paid for their care because the hospital s HBAM QBP net unit cost 58 per HIG weighted case is lower than the QBP price per HIG weighted case for COPD cases ($5,352). The estimated magnitude of the 58 The HBAM QBP cost per weighted case is adjusted to remove the impact of the HBAM allowances for teaching, Level of Care and distance. These adjustments for each hospital are presented in an appendix to this report. Page 60

65 hospitals profits and losses from caring for COPD patients under QBP funding is presented in the following table 59. Exhibit 23: Projected Revenue Impact on Large NE LHIN Hospitals from Proposed Model of Care for COPD NE LHIN Hospital Proposed Activity IP Cases Total HIG Wgt. 2012/13 HBAM QBP Net Unit Cost QBP Price per Wtd. Case Net Profit/Loss Per HIG Wtd. Case Total QBP Volume St. Joseph's, Elliot Lk $3,718 $5,352 $1,634 $136,220 Temiskaming $4,710 $5,352 $642 $21,796 Timmins & District $4,705 $5,352 $647 $185,043 West Parry Sound HC $5,257 $5,352 $95 $4,837 Health Science North $5,206 $5,352 $146 $122,972 Sault Area $5,302 $5,352 $50 $29,083 North Bay RHC $6,113 $5,352 -$761 -$431,219 Grand Total 1,718 2,445 $68, Ambulatory Care The recommended model of care for COPD patients suggests that pulmonary/respiratory clinics should be offered at each hub hospital. A significant percentage of hospital discharges will require the services of this clinic and the cost per visit will be meaningful. If we assume that at least 25% of COPD discharges will require support from the pulmonary/respiratory clinics 60, then we can expect that the hub hospitals in total will need to provide care for approximately 550 COPD patients. We further assume that each of these patients will require 4 clinic visits resulting in a total of 2,200 clinic visits. If we assume that the cost of a clinic visit is approximately $250 61, then the hub hospitals will need to dedicate approximately $550,000 of their global funding to support these pulmonary / respiratory clinics It should be noted that implementation of the proposed model of care for COPD patients will result in a reductions in volumes and costs of care for COPD patients in most local hospitals. But, because the smaller of the local hospitals will not be subject to QBP funding, their funding from the LHIN/MHOLTC will not be reduced commensurately. These hospitals will potentially have surplus funds as a result of the reduction in cases, weighted cases and costs. This estimate is provided only as a basis for estimating the order of magnitude cost of operating COPD clinics. Excluding the OHIP fee for the physician. Page 61

66 The current QBP price does not reflect nor does QBP funding currently provide for this post discharge service. It is unclear how the hospitals will be able to redirect their funds to support these heart failure clinics without securing some additional global budget funding. 6.6 Evaluating the COPD Clinical Integration Model The Steering Committee applied its evaluation framework to the recommended COPD Clinical Integration Model. The application of the framework is presented in the following tables. As can be seen, the recommended model scores highly on both the integration and the siting criteria. Exhibit 24: Application of Integration Criteria to COPD Model of Care CHRONI OBSTRUCTIVE PULMONARY DISEASE Criteria Definition Scoring: 0=No; Integration 0.5=Maybe; 1=Yes 1 Maintain/ Improve quality The distribution of clinical services will ensure quality of care standards and practices, clinical outcomes; safety and risk management are optimized 1 TOTALS 2 Appropriate critical mass The distribution of clinical services will be structured to ensure that programs/services have appropriate crticial mass (i.e. volume) to allow for the provision of safe, effective, efficient and timely services while reflecting 1 remote considerations 3 Access to Care Supports access to care requiring multi-system specialized services (e.g. cancer, cardiology). The distribution of services will improve access to care and/or 1 reduce medical, emotional and financial impact on patients. 4 Potential repatriation The distribution of clinical services will enhance the potential to deliver the appropriate services within the north east 0 5 Maintain/ Improve operating The distribution of clinical services will be structured to create a more cost efficiency/achieve economies effective and efficient service cost profile in the LHIN and will not result in of scale increased system funding for operations 6 Attract/retain specialized clinical skills The distribution of clinical services will be structured to enhance the potential of recruiting and/or retaining the specialized skills required for the delivery of the service and will not result in the hospital losing physician or other HHR % Page 62

67 Exhibit 25: Application of Siting Criteria to Proposed COPD Model of Care the service and will not result in the hospital losing physician or other HHR Siting 1 Meets community need The distribution of clinical services will help to minimize variation in health outcomes across the region Improves access to care The distribution of clinical services will be structured to improve patients' access to high quality programs/services closer to home. The distribution of services 0.5 will provide timely access to care 24/7, 365 days/year. 3 Supports clinical The distribution of clinical services will be aligned by site to ensure that clinical interdependencies and clinical interdependencies and patient flow is optimized and efficient 0.5 coherence 4 Meets current & future capacity limitations at site The distribution of clinical services will consider the current capacity of the potential host site and potential future capacity changes at the host site. 1 5 Enhance Regional Capability There is capacity and capability of the site to provide district or regional support to satellites if service is provided as a single program % Page 63

68 7.0 Stroke 7.1 QBP Handbook The QBP Clinical Handbook for Stroke has suggested that stroke hospitalizations can be grouped into four patient categories 62 for purposes of QBP funding: Transient Ischemic Attack Ischemic Stroke Intracerebral Hemorrhagic Stroke Other, unspecified strokes Care pathways and clinical practices were provided for each of these categories of stroke patients Transient Ischemic Attack (TIA) Majority of TIA patients do not require admission to hospital The QBP Clinical Handbook suggests that the majority of TIA patients do not require admission to hospital and should be referred to an urgent TIA/Stroke Prevention Clinic or comparable ambulatory setting for rapid diagnostic & medical evaluation, ideally within 48 hours of symptom onset/visit to ED. The handbook goes on to suggest that urgent access to community-based services is an integral part of providing high quality care for TIA patients in Ontario Acute Admission Stroke patients should be admitted to an acute stroke unit Stroke patients who require inpatient care should be admitted to a specialized, geographically defined hospital unit dedicated to the management of stroke patients; an acute stroke unit. The handbook also states that the acute stroke unit should be staffed with an Interdisciplinary team with stroke expertise. The Handbook states to optimize outcomes and efficiencies, stroke volumes should be at least 165 ischemic stroke patients per year per organization. Greater volumes are likely to confer additional benefits (based on an analysis of the Discharge Abstract Database, ). The appropriate critical mass for an integrated stroke unit (a 62 It should be noted that there are other neurological conditions that might have been considered strokes that have been excluded from this categorization scheme and from QBP Funding. This includes conditions such as Subarachnoid haemorrhage; Subdural haemorrhage (acute) (nontraumatic); Nontraumatic extradural haemorrhage; Intracranial haemorrhage (nontraumatic), unspecified. Page 64

69 specialized inpatient stroke unit that provides both acute and rehabilitation interventions) has not been determined. While the HQO clinical handbook (and many research articles) do not specify a minimum volume for an integrated stroke unit, there is broad consensus that higher volumes result in better outcomes and that achieving critical mass is essential for the quality of care (and efficiency) on these units. The handbook suggests the following as appropriate lengths of stay for the inpatient acute care of stroke patients: Ischemic - LOS of 5 days is recommended Hemorrhagic LOS of 7 days is recommended A stroke patient should have an assessment by a rehabilitation team 63 and a rehabilitation plan developed within hours of admission Admission to Inpatient Rehabilitation Ontario Stroke Network suggests that 40% of stroke patients should get inpatient stroke rehabilitation The QBP Clinical Handbook Stroke indicates that patients discharged to home will require rehabilitation care for the first 8-12 weeks after discharge from inpatient acute care. Some stroke patients will require inpatient rehabilitation care 64. For those patients requiring admission to inpatient rehabilitation, it will be important to begin rehabilitation as soon as possible. To achieve rapid access to rehabilitation, processes should be established to enable discharge from acute care and admission to rehabilitation 7 days per week. Stroke patients discharged from inpatient rehabilitation 65 will also require rehabilitation care for a period of eight to twelve weeks after discharge Ideally this would be an interdisciplinary core stroke unit team consisting of professionals with stroke expertise in medicine, nursing, occupational therapy, physiotherapy, speech language pathology, social work and clinical nutrition (dietitian). Ontario Stroke Network has suggested that 40% of stroke patients should get inpatient stroke rehabilitation. The Ontario Stroke Network s 2013 Provincial Stroke Report Card highlighted a benchmark of 42.3% of stroke patients should get inpatient stroke rehabilitation. Length of stay for inpatient rehabilitation is dependent on Rehabilitation Practice Group (RPG) ranging from 48.9 days for RPG 1100 to 7.5 days for RPG (page 49 QBP Handbook for Stroke). Page 65

70 7.2 Current Characteristics of Stroke Care in NE LHIN TIA patients NE LHIN hospitals have the highest rate of TIA admissions among Ontario LHINs The following table presents the percentage of ED TIA patient visits to hospitals in the NE LHIN that resulted in admission to inpatient care. As can be seen, overall, 32.2% of the TIA ED visits to NE LHIN hospitals are admitted to inpatient acute care; this is significantly more than the province as a whole. Across the province only 19.8% of TIA visits were admitted to acute care. NE LHIN hospitals have the highest rate of TIA admissions among Ontario LHINs. They are admitting over 50% more TIA patients than the provincial average. Exhibit 26: 2012/13 TIA ED Patient Visits and Admissions by LHIN Hospital LHIN ED Visits ED Admits % Admit Erie St. Clair % South West 1, % Waterloo Well % HNHB 1, % Central West % Miss. Halton % Toronto Central 1, % Central 1, % Central East 1, % South East % Champlain 1, % Nth. Simcoe Musk % North East % North West % Ontario 15,283 3, % Generally high rate of admission for TIA patients at almost all NE LHIN hospitals The following table presents the number ED TIA patient visits to each NE LHIN hospital. 66 As can be seen, there was wide variation among NE LHIN hospitals in their rates of admission of ED TIA patients in 66 Note re ED Admission and Inpatient Case Reconciliation: NACRS (ambulatory) data used to identify number of ED patients who present, and are admitted, within a QBP. DAD (inpatient) data used to identify QBP inpatients. But diagnosis groupings in ED data don t exactly match inpatient QBP specifications. As a result there will be some discrepancies between the ED count of admitted patients from the NACRS data and the inpatient count from the DAD data. Another part of the discrepancy is explained by transfers between sites; some of the IP cases reflect the same patient counted twice (i.e. Multiple IP stays). Page 66

71 2012/13. However, there was a generally high rate of admission for TIA patients at almost all hospitals. North Bay and Sault Area hospitals both had TIA admission rates over 40%; HSN and W. Parry Sound had admission rates approaching 30%. Exceptions are found in several local hospitals that admitted a relatively small percentage of their TIA ED visits. These include: St. Joseph s Elliot Lake (12%); Espanola GH (17%); Kirkland & District (19%) and Chapleau (13%). Exhibit 27: 2012/13 TIA ED Patients and Admissions by NE LHIN Hospital NE LHIN Hospital ED Visits ED Admits % Admit North Bay RHC % Health Science North % Sault Area Hospital % West Parry Sound HC % Timmins & District % Manitoulin HC % Temiskaming Hospital % St. Joseph's, Elliot Lake % West Nipissing General % Espanola General Hospital % Kirkland & District Hospital % Anson General Hospital % Blind River Dist Hlth Ctr % Lady Minto Hospital % Sensenbrenner Hospital % Mattawa General Hospital % Chapleau Hlth Serv % Englehart & District Hospital % Weeneebayko Area HA % Notre Dame Hospital % Lady Dunn Health Centre % Bingham Memorial Hospital % Hornepayne Community % Grand Total % As can be seen in the following exhibit, when TIA patients are admitted, they stay in hospital for varying lengths of time among the NE LHIN hospitals. Page 67

72 Hub Exhibit 28: 2012/13 NE LHIN TIA Inpatient Activity by Hub and Hospital Hospital Stroke TIA IP Cases IP Days Avg. LOS % ALC Days Avg. RIW Avg. HIG Wght. Algoma Blind River Dist Hlth Ctr % Hornepayne Community % Sault Area Hospital % Algoma Total % MPSS Espanola General Hospital % Health Science North % Manitoulin HC % St. Joseph's, Elliot Lake % West Parry Sound HC % MPSS Total % Nip-Temisk Englehart & District Hospital % Kirkland & District Hospital % Mattawa General Hospital % North Bay RHC % Temiskaming Hospital % West Nipissing General % Nip-Temisk Total % Cochrane & Coast Anson General Hospital % Lady Minto Hospital % Notre Dame Hospital % Sensenbrenner Hospital % Timmins & District % Weeneebayko Area HA % Cochrane & Coast Total % Grand Total 286 1, % Ischemic and Haemorrhagic Stroke Patients 84% of Ischemic and Haemorrhagic Stroke ED patients are admitted to inpatient acute care in NE LHIN hospitals As can be seen from the following exhibit, 84% of Ischemic and Haemorrhagic Stroke ED patients are admitted to inpatient acute care in NE LHIN hospitals 67. This is comparable to the provincial average of 80%. With the exception of Temiskaming, all of the higher volume hospitals (more than 20 stroke ED Visits) are admitting more than 80% of their stroke ED visits to inpatient care. 67 Note re ED Admission and Inpatient Case Reconciliation: NACRS (ambulatory) data used to identify number of ED patients who present, and are admitted, within a QBP. DAD (inpatient) data used to identify QBP inpatients. But diagnosis groupings in ED data don t exactly match inpatient QBP specifications. As a result there will be some discrepancies between the ED count of admitted patients from the NACRS data and the inpatient count from the DAD data. Another part of the discrepancy is explained by transfers between sites; some of the IP cases reflect the same patient counted twice (i.e. Multiple IP stays). Page 68

73 Exhibit 29: 2012/13 NE LHIN ED Stroke Patients and Admissions NE LHIN Hospital ED Visits ED Admits % Admit Health Science North % Sault Area Hospital % North Bay RHC % Timmins & District % West Parry Sound HC % Temiskaming Hospital % West Nipissing General % St. Joseph's, Elliot Lake % Manitoulin HC % Espanola General Hospital % Kirkland & District Hospital % Sensenbrenner Hospital % Anson General Hospital % Blind River Dist Hlth Ctr % Mattawa General Hospital % Weeneebayko Area HA % Chapleau Hlth Serv % Notre Dame Hospital % Englehart & District Hospital % Lady Dunn Health Centre % Hornepayne Community % Lady Minto Hospital % Bingham Memorial Hospital % Smooth Rock Falls Hospital % Grand Total 1, % Most Ischemic Stroke patients are being admitted to the hub hospitals As can be seen in the following exhibit, most Ischemic (and unspecified) Stroke patients are being admitted to the hub hospitals rather than to the local hospitals 68. However, the lengths of stay for these patients vary among the NE LHIN hub hospitals. 68 Note re ED Admission and Inpatient Case Reconciliation: NACRS (ambulatory) data used to identify number of ED patients who present, and are admitted, within a QBP. DAD (inpatient) data used to identify QBP inpatients. But diagnosis groupings in ED data don t exactly match inpatient QBP specifications. As a result there will be some discrepancies between the ED count of admitted patients from the NACRS data and the inpatient count from the DAD data. Another part of the discrepancy is explained by transfers between sites; some of the IP cases reflect the same patient counted twice (i.e. Multiple IP stays). Page 69

74 Exhibit 30: 2012/13 NE LHIN Ischemic and Unspecified Stroke Inpatient Activity by Hub and Hospital Hub Hospital IP Cases IP Days Avg. LOS % ALC Days Avg. RIW Avg. HIG Wght. Algoma Blind River Dist Hlth Ctr % Hornepayne Community % Lady Dunn Health Centre % Sault Area Hospital % Algoma Total % MPSS Espanola General Hospital % Health Science North 171 2, % Manitoulin HC % St. Joseph's, Elliot Lake % West Parry Sound HC % MPSS Total 247 3, % Nip-Temisk Englehart & District Hospital % Kirkland & District Hospital % Mattawa General Hospital % North Bay RHC % Temiskaming Hospital % West Nipissing General % Nip-Temisk Total 146 1, % Cochrane & Coast Anson General Hospital % Bingham Memorial Hospital % Chapleau Hlth Serv % Lady Minto Hospital % Notre Dame Hospital % Sensenbrenner Hospital % Timmins & District % Weeneebayko Area HA % Cochrane & Coast Total 96 1, % Grand Total 623 7, % Most Haemorrhagic Stroke patients are being admitted to the hub hospitals As can be seen in the following exhibit, most Haemorrhagic Stroke patients are also being admitted to the hub hospitals. Again, the lengths of stay for these patients vary among the NE LHIN hub hospitals. Page 70

75 Exhibit 31: 2012/13 NE LHIN Haemorrhagic Stroke Inpatient Activity by Hub and Hospital Hub Hospital IP Cases IP Days Avg. LOS % ALC Days Avg. RIW Avg. HIG Wght. Algoma Hornepayne Community % Sault Area Hospital % Algoma Total % MPSS Espanola General Hospital % Health Science North % Manitoulin HC % St. Joseph's, Elliot Lake % West Parry Sound HC % MPSS Total % Nip-Temisk Englehart & District Hospital % North Bay RHC % Temiskaming Hospital % Nip-Temisk Total % Cochrane & Coast Smooth Rock Falls Hospital % Timmins & District % Cochrane & Coast Total % Grand Total 64 1, % Stroke Rehabilitation Only 27.5% of all NE hospital inpatient stroke patients were discharged to IP rehab The following table presents the percentage of inpatient stroke patients that received inpatient rehabilitation in 2012/13. As can be seen only 27.5% of all NE hospital inpatient stroke patients were discharged to IP rehab. Exhibit 32: Discharge of NE LHIN Hospital Inpatient Stroke Patients to IP Rehabilitation Stroke Type IP Discharges % of Patients to IP Rehab % of Survivors to IP Rehab Stroke Hemorrhage % 34.1% Stroke Ischemic % 40.8% Stroke Unspecified % 7.7% Grand Total % 32.9% The following table present the percentage of inpatient stroke patients in each NE LHIN hospital that were discharged to inpatient rehabilitation. It is interesting to note that more than 36% of stroke patients cared for in the hub hospitals were discharged from acute care to inpatient rehabilitation. This is already very close to the 40% target suggested by the Ontario Stroke Network. Page 71

76 Exhibit 33: Discharge of NE LHIN Hospital Inpatient Stroke Patients to IP Rehabilitation by Hospital 69 Hospital IP Disch. % of Patients to IP Rehab % of Survivors to IP Rehab Health Science North % 49.0% Sault Area Hospital % 38.7% North Bay RHC % 36.8% Timmins & District % 37.9% West Parry Sound HC % 25.0% St. Joseph's, Elliot Lake % 0.0% Temiskaming Hospital % 0.0% Manitoulin HC % 7.1% West Nipissing General % 0.0% Espanola General Hospital % 0.0% Sensenbrenner Hospital % 0.0% Kirkland & District Hospital % 25.0% Mattawa General Hospital 7 0.0% 0.0% Weeneebayko Area HA 5 0.0% 0.0% Hornepayne Community 4 0.0% 0.0% Blind River Dist Hlth Ctr 4 0.0% 0.0% Englehart & District Hospital 4 0.0% 0.0% Chapleau Hlth Serv 4 0.0% 0.0% Lady Minto Hospital 3 0.0% 0.0% Anson General Hospital 3 0.0% 0.0% Notre Dame Hospital 3 0.0% 0.0% Lady Dunn Health Centre 2 0.0% 0.0% Bingham Memorial Hospital 2 0.0% 0.0% Smooth Rock Falls Hospital 1 0.0% Grand Total % 32.9% 7.3 Proposed Model for Delivery of Stroke Services The Hub clinical workshops have developed and the Steering Committee has reviewed, refined and confirmed the following clinical integration model for the care of TIA and Stroke patients in NE LHIN hospitals. 69 These are based on coding by acute care hospitals of the numbers that were discharged to inpatient rehabilitation. This may differ slightly from NRS records of stroke patients admitted to inpatient rehabilitation. Also, it is important to note that the RPG or RCG categories for stroke in the NRS don t correspond directly to the QBP stroke definition; the NRS treats a broader range of patients as stroke. Page 72

77 Consistent models of care and clinical pathways/order sets in caring for TIA and stroke patients It is recommended that NE LHIN hospitals should use consistent models of care and clinical pathways/order sets in caring for TIA and stroke patients across region. Clinicians should provide leadership in the interpretation of the QBP Clinical Handbook for Stroke to develop these models of care and clinical pathways/order sets. The LHIN should provide coordination for this initiative. The model and approach to care should incorporate the following key elements: 1. Continue with the model of regional and hub/district stroke centres as proposed by the Northeastern Ontario (NEO) Stroke Network. 70 Regional Stroke Centre - Health Science North District Stroke Centre at Sault Area Hospital, Timmins and District Hospital and North Bay Regional Health Centre for each of other hubs 2. Inpatient acute and rehabilitative stroke care should be consolidated at regional and district stroke centres. 3. Ensure that inter-professional stroke teams are established and functioning in each hub/district stroke centre. 4. Target to reduce admissions of ED TIA patients to the provincial average rate of admission When a stroke patient (TIA, Ischemic, Haemorrhagic) requires admission to inpatient care they should be transferred from the ED where they present for admission to the specialized, geographically defined hospital unit dedicated to the management of stroke patients at the appropriate designated stroke centre Current provincial ALOS will be the target length of stay for TIA patients that are admitted to inpatient care admits. 7. QBP average length of stay targets for Ischemic and Hemorrhagic stroke care will be achieved by NE LHIN acute stroke units: Ischemic Stroke Target ALOS: 5 days See NE LHIN Hospital Based Stroke Care: Impact of Consolidating Care. This can be achieved through enhancement of the existing Regional Stroke Prevention Clinic model. For many hospitals this will be a change in practice. Protocols and formal agreements among hospitals to facilitate these transfers will need to be developed. Page 73

78 Haemorrhagic Stroke Target ALOS: 7 days 8. The number of extremely long stay patients should be reduced significantly thus reducing the number of atypical patients Stroke patients requiring inpatient rehabilitation should stay at regional/district stroke centers to receive this care. Upon completion their inpatient rehabilitation; they should be discharged to home Use QBP targets for inpatient rehabilitation: Approximately 40% of Stroke patients should receive inpatient rehabilitation after completing their inpatient acute care. Inpatient Rehabilitation Lengths of Stay should conform to the recommended LOS per RPG as outlined in QBP Clinical Handbook for Stroke. For modeling purposes we have assumed an ALOS of 30 days for all strokes for all RPGs. 11. If a patient is designated ALC-LTC Placement at any time during the patient s acute or rehabilitation care stay then the patient should be repatriated to her/his home hospital. 12. It is recognized that these clinical performance targets will only be achieved if: The existing Stroke Prevention Clinics (SPCs) at each Hub hospital are enhanced to ensure that TIA patients who are not admitted to inpatient care 75 can receive diagnostic and therapeutic care within 48 hours of presentation to an Emergency Department in the North East For modeling purposes, the Steering Committee has assumed that NE LHIN hospitals can reduce the % of atypical cases to the lowest percentage achieved by hospitals in other LHINs in the province. This is a significant and important change from current practice. Majority of TIA patients do not require admission to hospital and should be referred to an urgent TIA/Stroke Prevention Clinic or comparable ambulatory setting for rapid diagnostic and medical evaluation, within 48 hours of symptom onset/visit to ED. Page 74

79 The Outpatient Stroke Clinics at the hub hospitals are enabled to provide for the post discharge needs of stroke patients who are discharged from acute and inpatient rehabilitation Implications of Proposed Model for Stroke Services The following tables present estimates of the implications of implementing the proposed model of care for Stroke patients in the NE LHIN TIA Volumes, Costs and Revenues Implications of the proposed model of care for TIA patients The table following presents the implications of the proposed model of care for the number of TIA patients 77, patient days and cost of inpatient care for each of the NE LHIN hospitals. As can be seen, there will be some movement of patient volume from the local hospitals to the acute stroke units at the hub hospitals. There will also be a decrease in the total number of patients and patient days across all hospitals as hospitals adjust their care processes for TIA patients to achieve: Almost 40% reduction in the number of ED TIA patients admitted to inpatient care A reduction in the total case count due to elimination of inter hospital transfers from inpatient units It has been suggested by NEOSN that a regional Stroke Re-Check Clinic model should be established (with clinics located at each Hub hospital) to ensure stroke patients discharged home are followed by an interdisciplinary team for a minimum of one year following their discharge. These clinics will address the medical and rehabilitation needs of stroke patients and assist in decreasing hospital readmissions for post-stroke complications. Telemedicine should be used when possible and appropriate to provide this service to patients living in rural communities. Additionally, a regional Stroke Outpatient Services model should be established to ensure stroke patient that do not qualify for CCAC services, can access stroke-specific outpatient services within a 45 minute drive of their home. These clinics would also be connected with the Northern Ontario Independent Living Association (NILA) Regional Post-Stroke Program to assist with stroke community navigation well beyond hospital discharge. It should be noted that the number of inpatients declines under the proposed Stroke model of care because some inter hospital inpatient transfers have been eliminated. In 2012/13, there were 2 TIA patients admitted at a small hospital and then transferred for an inpatient stay at a Hub hospital. For simulation, we have assumed that these patients will be transferred from small hospital ED directly to Hub hospital (i.e. No inpatient stay in the small hospital prior to transfer). Also, application of the target provincial % TIA admission rate from ED would have resulted in 105 fewer TIA admissions. For simulation, the 105 shortest stay IP TIA cases have been removed. Page 75

80 IP Cases % Atyp. Case IP Days Avg. LOS HIG Wgt. IP Cases % Atyp. Case IP Days Avg. LOS HIG Wgt. IP Cases IP Days HIG Wght. A more consistent ALOS for TIA patients that is equal to the provincial average for typical cases of 3.64 days A reduction in the number of atypical cases. 78 The reduction in the number of atypical cases will also result in a reduction in the number of HIG weighted cases because each of the long stay atypical TIA cases likely has a higher HIG weight than a typical TIA case. The reduction in the number of cases, patient days and HIG weighted cases will also result in a reduction in the cost of caring for TIA patients. Exhibit 34: Projected Impact on NE LHIN Hospital Activity of Proposed Model of Care for TIA 2012/13 Actual Activity Proposed Activity Change In Activity NE LHIN Hospital Blind River Dist HC 3 0% Chapleau Hlth Serv Lady Minto 5 20% St. Joseph's, Elliot Lk 5 20% Englehart & District 3 0% Espanola General 3 33% Notre Dame 2 0% Hornepayne 1 0% Anson General 3 0% Lady Dunn HC Sensenbrenner 3 33% Kirkland & District 3 33% Bingham Memorial Mattawa General 4 0% Manitoulin HC 13 8% Smooth Rock Falls West Nipissing 14 7% Temiskaming 7 0% Timmins & District 17 0% % West Parry Sound HC 6 17% Health Science North 57 9% % Sault Area 54 11% % Weeneebayko 1 100% North Bay RHC 82 9% % Grand Total 286 9% 1, % Best Practice (i.e. Lowest) % Atypical cases of all Ontario LHINs for each QBP has been applied to NE LHIN hospitals, with cases being converted from Atypical to Typical and then given the target LOS for the QBP and the NE LHIN average weight per Typical case for the QBP. Page 76

81 NE LHIN Hospital Exhibit 35: Projected Impact on NE LHIN Hospital Costs of Proposed Model of Care for TIA 2012/13 HBAM QBP Net Unit Cost 2012/13 Activity Proposed Activity Change in Cost HIG Wtd. Cases Estimated Cost HIG Wtd. Cases Estimated Cost HIG Wtd. Cases Estimated Cost Blind River Dist HC $6, $11,139 - $ $11,139 Chapleau Hlth Serv $7,812 - $- - $- - $- Lady Minto $5, $31,646 - $ $31,646 St. Joseph's, Elliot Lk $3, $21,218 - $ $21,218 Englehart & District $4, $7,795 - $ $7,795 Espanola General $5, $7,343 - $ $7,343 Notre Dame $5, $6,709 - $ $6,709 Hornepayne $7, $4,724 - $ $4,724 Anson General $4, $7,020 - $ $7,020 Lady Dunn HC $5,426 - $- - $- - $- Sensenbrenner $3, $6,493 - $ $6,493 Kirkland & District $4, $18,768 - $ $18,768 Bingham Memorial $7,044 - $- - $- - $- Mattawa General $7, $16,094 - $ $16,094 Manitoulin HC $5, $40,582 - $ $40,582 Smooth Rock Falls $3,977 - $- - $- - $- West Nipissing $3, $34,849 - $ $34,849 Temiskaming $4, $19,417 - $ $19,417 Timmins & District $4, $47, $76, $29,122 West Parry Sound HC $5, $23,446 - $ $23,446 Health Science North $5, $217, $170, $47,450 Sault Area $5, $200, $97, $103,354 Weeneebayko $5, $13,211 - $ $13,211 North Bay RHC $6, $377, $303, $74,158 Grand Total 207 $1,114, $647, $466,295 Net profits from TIA care The application of QBP funding to the proposed model of care would result in a net profit from TIA acute care for most of those LHIN hospitals that will be included in QBP funding, with the exception of North Bay RHC. The estimated cost of caring for TIA patients will be lower than the QBP revenues paid for their care because the hospital s HBAM QBP net unit cost 79 per HIG weighted case is lower than the QBP price per HIG weighted case for TIA cases ($5,513). The estimated magnitude of the hospitals profits and losses 79 The HBAM QBP cost per weighted case is adjusted to remove the impact of the HBAM allowances for teaching, Level of Care and distance. These adjustments for each hospital are presented in an appendix to this report. Page 77

82 from caring for TIA patients under QBP funding is presented in the following table 80. Exhibit 36: NE LHIN Hospital Projected Revenue Impact on Large NE LHIN Hospitals from Proposed Model of Care for TIA Proposed Activity 2012/13 IP Cases Total HIG Wgt. HBAM QBP Net Unit Cost QBP Price per Wtd. Case Net Profit/Loss Per HIG Wtd. Case Total QBP Volume St. Joseph's, Elliot Lk - - $3,718 $5,513 $1,795 $- Temiskaming - - $4,710 $5,513 $803 $- Timmins & District $4,705 $5,513 $808 $13,207 West Parry Sound HC - - $5,257 $5,513 $256 $- Health Science North $5,206 $5,513 $307 $10,041 Sault Area $5,302 $5,513 $211 $3,866 North Bay RHC $6,113 $5,513 -$600 -$29,794 Grand Total $2, Ischemic (and Unspecified) Stroke Volumes, Costs and Revenues A decrease in the total number of stroke patient days The table following presents the implications of the proposed model of care for the number of ischemic (and unspecified) stroke patients 81, patient days and cost of inpatient care for each of the NE LHIN hospitals. As can be seen, because patients will be transferred directly from the ED for admission at a hub hospital, there will be some movement of patient volume from the local hospitals to the acute stroke units at the hub hospitals. There will also be a decrease in the total number of patient days across all hospitals as hospitals adjust their care processes to achieve: It should be noted that implementation of the proposed model of care for TIA patients will result in a reductions in volumes and costs of care for CHF patients in local hospitals. But, because the smaller of the local hospitals will not be subject to QBP funding, their funding from the LHIN/MHOLTC will not be reduced commensurately. These hospitals will potentially have surplus funds as a result of the reduction in cases, weighted cases and costs. It should be noted that the number of inpatients declines under the proposed Stroke model of care because some inter hospital inpatient transfers have been eliminated. In 2012/13, there were 22 Ischemic and Unspecified Stroke patients admitted at a small hospital and then transferred to another hospital for inpatient care (all to Hub hospital, except 1). Additionally, there were 6 Stroke patients admitted to small hospital after IP stay in Hub hospital. For simulation, we have assumed that these patients will be transferred from small hospital ED directly to Hub hospital (i.e. No inpatient stay in the small hospital prior to transfer) and that patients repatriated to local acute care from Hub hospital will go to IP rehab or community care instead. Page 78

83 IP Cases % Atyp. Case IP Days Avg. LOS HIG Wgt. IP Cases % Atyp. Case IP Days Avg. LOS HIG Wgt. IP Cases IP Days HIG Wght. A more consistent ALOS that is equal to the QBP target LOS of 5 days and A reduction in the number of atypical cases 82. The reduction in the number of atypical cases will also result in a reduction in the number of HIG weighted cases because each of the long stay atypical stroke cases likely has a higher HIG weight than a typical ischemic stroke case. The reduction in the number of cases, patient days and HIG weighted cases will also result in a reduction in the cost of caring for stroke patients. NE LHIN Hospital Exhibit 37: Projected Impact on NE LHIN Hospital Activity of Proposed Model of Care for Ischemic and Unspecified Stroke 2012/13 Actual Activity Proposed Activity Change In Activity Blind River Dist HC 4 50% Chapleau Hlth Serv 4 75% Lady Minto 3 33% St. Joseph's, Elliot Lk 24 29% Englehart & District 3 33% Espanola General 10 40% Notre Dame 3 0% Hornepayne 3 67% Anson General 3 33% Lady Dunn HC 2 50% Sensenbrenner 10 30% Kirkland & District 8 25% Bingham Memorial 2 50% Mattawa General 7 29% Manitoulin HC 13 23% Smooth Rock Falls West Nipissing 13 46% Temiskaming 17 47% Timmins & District 66 45% % West Parry Sound HC 29 10% Health Science North % 2, % 1, , Sault Area % % Weeneebayko 5 40% North Bay RHC 98 11% % Grand Total % 7, , % 2, , , Best Practice (i.e. Lowest) % Atypical cases of all Ontario LHINs for each QBP has been applied to NE LHIN hospitals, with cases being converted from Atypical to Typical and then given the target LOS for the QBP and the NE LHIN average weight per Typical case for the QBP. Page 79

84 NE LHIN Hospital Exhibit 38: Projected Impact on NE LHIN Hospital Costs of Proposed Model of Care for Ischemic and Unspecified Stroke 2012/13 HBAM QBP Net Unit Cost 2012/13 Activity Proposed Activity Change in Cost HIG Wtd. Cases Estimated Cost HIG Wtd. Cases Estimated Cost HIG Wtd. Cases Estimated Cost Blind River Dist HC $6, $31,279 - $ $31,279 Chapleau Hlth Serv $7, $19,998 - $ $19,998 Lady Minto $5, $48,778 - $ $48,778 St. Joseph's, Elliot Lk $3, $249,615 - $ $249,615 Englehart & District $4, $19,971 - $ $19,971 Espanola General $5, $68,410 - $ $68,410 Notre Dame $5, $19,670 - $ $19,670 Hornepayne $7, $13,437 - $ $13,437 Anson General $4, $30,155 - $ $30,155 Lady Dunn HC $5, $7,596 - $ $7,596 Sensenbrenner $3, $127,100 - $ $127,100 Kirkland & District $4, $59,426 - $ $59,426 Bingham Memorial $7, $38,182 - $ $38,182 Mattawa General $7, $115,193 - $ $115,193 Manitoulin HC $5, $72,484 - $ $72,484 Smooth Rock Falls $3,977 - $- - $- - $- West Nipissing $3, $115,989 - $ $115,989 Temiskaming $4, $271,083 - $ $271,083 Timmins & District $4, $563, $836, $273,278 West Parry Sound HC $5, $713,220 - $ $713,220 Health Science North $5, $2,095, $2,469, $374,178 Sault Area $5, $1,013, $1,383, $369,407 Weeneebayko $5, $35,113 - $ $35,113 North Bay RHC $6, $985, $1,606, $621,236 Grand Total 1,300 $6,715,064 1,176 $6,296, $418,601 Net losses from caring for Ischemic Stroke patients The application of QBP funding to the proposed model of care would result in a net loss from acute care of Ischemic Stroke patients for most of those LHIN hospitals that will be included in QBP funding. The estimated cost of caring for Ischemic Stroke patients will be higher than the QBP revenues paid for their care because the hospital s HBAM QBP net unit cost 83 per HIG weighted case is higher than the QBP price per HIG weighted case for Ischemic Stroke cases ($4,970). The estimated magnitude of the hospitals profits and losses from caring for Ischemic Stroke patients under QBP funding is presented in the following table. 83 The HBAM QBP cost per weighted case is adjusted to remove the impact of the HBAM allowances for teaching, Level of Care and distance. These adjustments for each hospital are presented in an appendix to this report. Page 80

85 Exhibit 39: Projected Funding Impact on Large NE LHIN Hospitals from Proposed Model of Care for Ischemic Stroke NE LHIN Hospital Proposed Activity 2012/13 IP Cases Total HIG Wgt. HBAM QBP Net Unit Cost QBP Price per Wtd. Case Net Profit/Loss Per HIG Wtd. Case Total QBP Volume St. Joseph's, Elliot Lk - - $3,718 $4,970 $1,252 $- Temiskaming - - $4,710 $4,970 $260 $- Timmins & District $4,705 $4,970 $265 $47,201 West Parry Sound HC - - $5,257 $4,970 -$287 $- Health Science North $5,206 $4,970 -$236 -$111,775 Sault Area $5,302 $4,970 -$332 -$86,522 North Bay RHC $6,113 $4,970 -$1,143 -$300,360 Grand Total 595 1,176 -$451, Haemorrhagic Stroke Volumes, Costs and Revenues A decrease in the total number of patient days and weighted cases The table following presents the implications of the proposed model of care for the number of haemorrhagic stroke patients, patient days and cost of inpatient care for each of the NE LHIN hospitals. As can be seen, there will be some movement of patient volume from the local hospitals to the acute stroke units at the hub hospitals. There will also be a decrease in the total number of patient days and weighted cases across all hospitals as hospitals adjust their care processes to achieve: A more consistent ALOS that is equal to the QBP target LOS of 7 days and A reduction in the number of atypical cases 84. The reduction in the number of atypical cases will also result in a reduction in the number of HIG weighted cases because each of the long stay atypical stroke cases likely has a higher HIG weight than a typical haemorrhagic stroke case. The reduction in the number of cases, patient days and HIG weighted cases will also result in a reduction in the cost of caring for haemorrhagic stroke patients. 84 Best Practice (i.e. Lowest) % Atypical cases of all Ontario LHINs for each QBP has been applied to NE LHIN hospitals, with cases being converted from Atypical to Typical and then given the target LOS for the QBP and the NE LHIN average weight per Typical case for the QBP. Page 81

86 HIG Wtd. Cases HIG Wtd. Cases HIG Wtd. Cases IP Cases % Atyp. Case IP Days Avg. LOS HIG Wgt. IP Cases % Atyp. Case IP Days Avg. LOS HIG Wgt. IP Cases IP Days HIG Wght. Exhibit 40: Projected Impact on NE LHIN Hospital Activity of Proposed Model of Care for Haemorrhagic Stroke 2012/13 Actual Activity Proposed Activity Change In Activity NE LHIN Hospital Blind River Dist HC Chapleau Hlth Serv Lady Minto St. Joseph's, Elliot Lk 1 0% Englehart & District 1 0% Espanola General 1 0% Notre Dame Hornepayne 1 100% Anson General Lady Dunn HC Sensenbrenner Kirkland & District Bingham Memorial Mattawa General Manitoulin HC 1 0% Smooth Rock Falls 1 100% West Nipissing Temiskaming 3 33% Timmins & District 4 25% % West Parry Sound HC 2 50% Health Science North 29 31% % Sault Area 12 50% % Weeneebayko North Bay RHC 8 13% % Grand Total 64 33% 1, % Exhibit 41: Projected Impact on NE LHIN Hospital Costs of Proposed Model of Care for Haemorrhagic Stroke NE LHIN Hospital 2012/13 HBAM QBP Net Unit Cost 2012/13 Activity Proposed Activity Change in Cost Estimated Cost Estimated Cost Estimated Cost Blind River Dist HC $6,219 - $- - $- - $- Chapleau Hlth Serv $7,812 - $- - $- - $- Lady Minto $5,057 - $- - $- - $- St. Joseph's, Elliot Lk $3, $5,807 - $ $5,807 Englehart & District $4, $5,554 - $ $5,554 Espanola General $5, $6,398 - $ $6,398 Notre Dame $5,362 - $- - $- - $- Hornepayne $7, $3,021 - $ $3,021 Anson General $4,116 - $- - $- - $- Lady Dunn HC $5,426 - $- - $- - $- Page 82

87 IP Cases Total HIG Wgt. HIG Wtd. Cases HIG Wtd. Cases HIG Wtd. Cases NE LHIN Hospital 2012/13 HBAM QBP Net Unit Cost 2012/13 Activity Proposed Activity Change in Cost Estimated Cost Estimated Cost Estimated Cost Sensenbrenner $3,770 - $- - $- - $- Kirkland & District $4,797 - $- - $- - $- Bingham Memorial $7,044 - $- - $- - $- Mattawa General $7,451 - $- - $- - $- Manitoulin HC $5, $6,311 - $ $6,311 Smooth Rock Falls $3, $193,621 - $ $193,621 West Nipissing $3,862 - $- - $- - $- Temiskaming $4, $16,248 - $ $16,248 Timmins & District $4, $20, $48, $28,237 West Parry Sound HC $5, $13,446 - $ $13,446 Health Science North $5, $240, $367, $127,149 Sault Area $5, $141, $142, $1,284 Weeneebayko $5,000 - $- - $- - $- North Bay RHC $6, $81, $152, $70,622 Grand Total 151 $734, $711, $23,115 Net profits from caring for Hemorrhagic stroke patients The application of QBP funding to the proposed model of care would result in a net profit from the acute care of Hemorrhagic stroke patients for most of those LHIN hospitals that will be included in QBP funding, except for North Bay RHC. The estimated cost of caring for Hemorrhagic Stroke patients will be lower than the QBP revenues paid for their care because the hospital s HBAM QBP net unit cost 85 per HIG weighted case is lower than the QBP price per HIG weighted case for Hemorrhagic Stroke cases ($5,452). The estimated magnitude of the hospitals profits and losses from caring for Hemorrhagic Stroke patients under QBP funding is presented in the following table. Exhibit 42: Projected Revenue Impact on Large NE LHIN Hospitals from Proposed Model of Care NE LHIN Hospital Proposed Activity 2012/13 HBAM QBP Net Unit Cost QBP Price per Wtd. Case Net Profit/Loss Per HIG Wtd. Case Total QBP Volume St. Joseph's, Elliot Lk - - $3,718 $5,452 $1,734 $- Temiskaming - - $4,710 $5,452 $742 $- Timmins & District $4,705 $5,452 $747 $7, The HBAM QBP cost per weighted case is adjusted to remove the impact of the HBAM allowances for teaching, Level of Care and distance. These adjustments for each hospital are presented in an appendix to this report. Page 83

88 IP Cases Total HIG Wgt. NE LHIN Hospital Proposed Activity 2012/13 HBAM QBP Net Unit Cost QBP Price per Wtd. Case Net Profit/Loss Per HIG Wtd. Case Total QBP Volume West Parry Sound HC - - $5,257 $5,452 $195 $- Health Science North $5,206 $5,452 $246 $17,349 Sault Area $5,302 $5,452 $150 $4,044 North Bay RHC $6,113 $5,452 -$661 -$16,456 Grand Total $12, Rehabilitation 40% of stroke patients should be discharged to inpatient rehabilitation The recommended model of care suggests that 40% of stroke patients should be discharged to inpatient rehabilitation with an ALOS of approximately 32 days. This would be a modest increase from current practice wherein 36% of stroke patients at hub hospitals are currently being discharged to inpatient rehabilitation. Under the recommended model of care, there would be 264 cases discharged to inpatient rehabilitation. This would be an increase of 75 cases from the 189 acute care stroke patients coded in the acute care data as having been discharged to inpatient rehabilitation. If the average length of stay in inpatient rehabilitation is 32 days, then this would require 8,435 patient days and 25.7 beds 86 in total devoted to stroke rehabilitation. If the LHIN hospitals achieve these targets, then each hub will require the following number of rehabilitation beds for stroke rehabilitation. Exhibit 43: Acute Care Hospital Projected Inpatient Rehabilitation Bed Requirement for Stroke Patients Proposed IP Stroke Cases Tgt. IP Rehab Cases IP Rehab 32 day ALOS Stroke IP 90% Health Science North , North Bay RHC , Sault Area , Timmins & District , Total , An increase in the number of inpatient stroke rehabilitation cases and an associated increase in the need for beds and care This clearly represents an increase in the volume of inpatient rehabilitation cases and an associated increase in the need for beds and care. As of now, QBP funding for stroke rehabilitation will not be introduced until the second year. It is unclear therefore how the 86 Assuming 90% occupancy for rehabilitation beds. Page 84

89 LHIN will fund the extra volume of inpatient rehabilitation during the first year of QBP funding for strokes. It is also unknown whether the QBP price and funding for stroke rehabilitation will be sufficient to support the inpatient rehabilitation component of the care for stroke patients. If there is insufficient QBP funding, the LHIN will be challenged to provide the rehabilitation aspect of the best practice model of care for stroke patients. 7.6 Ambulatory Care Ensure that TIA patients can access stroke prevention clinic care within 48 hours of their ED visit The recommended model of care for stroke patients suggests that the existing TIA/Stroke Prevention Clinics operating at each of the hub hospitals should be expanded to ensure that TIA patients can access this care within 48 hours of their ED visit and can continue to be cared for as outpatients thereafter. If we assume 87 that at least 80% of TIA ED visits will require support from the stroke prevention clinics, then we can expect that the hub hospitals in total will need to provide care for approximately 660 TIA patients discharged from an ED at a North East LHIN hospital. Each of these patients will require an initial diagnostic visit within 48 hours of their ED visit and approximately 1-2 clinic visits thereafter resulting in a total of approximately (2.5* 660 = ) 1,650 clinic visits. If we assume that the cost of a clinic visit is approximately $300, then the hub hospitals will need to dedicate approximately $500,000 of their global funding to support these stroke prevention clinics. Stroke hospital discharges will require support from a stroke follow up clinic Additionally if we assume 88 that at least 75% of stroke hospital discharges will require support from a stroke follow up clinic, then we can expect that the hub hospitals in total will need to provide care for approximately 446 post discharge stroke patients and each of these patients will require approximately 3 clinic visits resulting in a total of 1,338 clinic visits. Again, if we assume that the cost of a clinic visit is approximately $200, then the hub hospitals will need to dedicate an additional $270,000 of their global funding to support the care of post acute care stroke patients in these stroke clinics. In total, the stroke prevention and follow up clinics will require approximately $750,000 in additional hospital resources to ensure that proper outpatient services are available to decrease TIA admissions These estimates are provided to demonstrate the order of magnitude cost of providing ambulatory care for TIA patients. These estimates are provided to demonstrate the order of magnitude cost of providing ambulatory care for stroke patients. Page 85

90 and decrease readmissions for post-stroke complications. It is unclear how the hospitals will be able to redirect their funds to support these stroke clinics without securing some additional global budget funding. 7.7 Evaluating the QBP Integration Model Recommended model for stroke care scores highly on both the integration and the siting criteria The Steering Committee applied its evaluation framework to the recommended Stroke Clinical Integration Model. The application of the framework is presented in the following tables. As can be seen, the recommended model scores highly on both the integration and the siting criteria. Exhibit 44: Application of Integration Criteria to Stroke Model of Care Criteria Definition Scoring: 0=No; Integration 0.5=Maybe; 1=Yes 1 Maintain/ Improve quality The distribution of clinical services will ensure quality of care standards and practices, clinical outcomes; safety and risk management are optimized 1 TOTALS 2 Appropriate critical mass The distribution of clinical services will be structured to ensure that programs/services have appropriate crticial mass (i.e. volume) to allow for the provision of safe, effective, efficient and timely services while reflecting 1 remote considerations 3 Access to Care Supports access to care requiring multi-system specialized services (e.g. cancer, cardiology). The distribution of services will improve access to care and/or reduce medical, emotional and financial impact on patients. 4 Potential repatriation The distribution of clinical services will enhance the potential to deliver the appropriate services within the north east Maintain/ Improve operating The distribution of clinical services will be structured to create a more cost efficiency/achieve economies effective and efficient service cost profile in the LHIN and will not result in of scale increased system funding for operations 6 Attract/retain specialized clinical skills The distribution of clinical services will be structured to enhance the potential of recruiting and/or retaining the specialized skills required for the delivery of the service and will not result in the hospital losing physician or other HHR % Exhibit 45: Application of Siting Criteria to Proposed Stroke Model of Care the service and will not result in the hospital losing physician or other HHR Siting 1 Meets community need The distribution of clinical services will help to minimize variation in health outcomes across the region 1 2 Improves access to care The distribution of clinical services will be structured to improve patients' access to high quality programs/services closer to home. The distribution of services will provide timely access to care 24/7, 365 days/year. 3 Supports clinical The distribution of clinical services will be aligned by site to ensure that clinical interdependencies and clinical interdependencies and patient flow is optimized and efficient 1 coherence 4 Meets current & future capacity limitations at site 0.5 The distribution of clinical services will consider the current capacity of the potential host site and potential future capacity changes at the host site. 0 5 Enhance Regional Capability There is capacity and capability of the site to provide district or regional support to satellites if service is provided as a single program % Page 86

91 8.0 Cataracts 8.1 QBP Handbook Cataract surgery can be grouped into 8 categories The QBP clinical handbook for cataracts has suggested that cataract surgery can be grouped into 8 categories for purposes of developing clinical pathways and QBP funding. The categories are: Corrected vision nearing the threshold required to maintain driving or occupational requirements Simultaneous bilateral surgery Procedures on the second eye Combined pathology Removal to facilitate other disease management Pediatric cataract removal Complex cataracts Visual impairment secondary to cataracts Each of these are to be provided as outpatient procedures. 8.2 Current Characteristics of Cataract Service Delivery in NE LHIN The following table presents the number of cataract surgery procedures provided in each NE LHIN hospital. As can be seen 7,003 cataract procedures were performed in NE LHIN hospitals in 2012/13. Exhibit 46: 2012/13 NE LHIN Cataract Activity by Hub and Hospital Hub Hospital Visits Wtd. Avg. Cases Wght. Algoma Sault Area Hospital 1, Algoma Total 1, MPSS Health Science North 2, St. Joseph's, Elliot Lake West Parry Sound HC MPSS Total 2, Nip.-Temisk. Kirkland & District Hospital North Bay RHC 2, Temiskaming Hospital Nip.-Temisk. Total 2, Cochrane & Coast Timmins & District Cochrane & Coast Total Grand Total 7,003 1, Page 87

92 8.3 Proposed Model for Delivery of Cataract Surgery The Hub clinical workshops have developed and the Steering Committee has reviewed, refined and confirmed the following model for the provision of cataract procedures in NE LHIN hospitals. A single, integrated clinical program for cataract surgery should be established for each hub It is recommended that NE LHIN hospitals should use a consistent model of care and clinical pathway/order sets in the provision of cataract surgery across the region. Standardization of model of care should result in utilization rates that will be standardized across the LHIN so that populations in each hub have equivalent access to care. Clinicians should provide leadership in the interpretation of the QBP Clinical Handbook for cataract surgery to develop and implement these models of care and clinical pathways/order sets 89. The LHIN should provide coordination for this initiative. Additionally, it is recommended that a single, integrated clinical program for cataract surgery should be established for each hub for the provision and oversight of cataract surgery. Within this program, within each hub: Cataract surgery procedures should be consolidated at the Hub hospitals. Specialist diagnostic and follow up clinics should be provided at local hospitals. Simple procedures will be provided at local hospitals at the discretion of the hub clinical program for cataract surgery All cataract surgery should be provided within the hub where the patient lives. 8.4 Implications of Proposed Model for Cataract Surgery The table following presents the implications of the proposed model of care for the number of procedures and the costs of cataract surgery for each of the NE LHIN hospitals. The projections assume that: All cataracts will be consolidated in the 4 Hub hospitals 89 It should be noted that concurrent with the work of the Clinical Services Review Steering Committee, work has begun in the LHIN to interpret and implement the findings and recommendations of A Vision for Ontario, Strategic Recommendations for Ophthalmology in Ontario. The Provincial Vision Strategy Task Force. The development of models for the delivery of cataract surgery should take into account this broader work related to the delivery of all ophthalmology services in the LHIN. Page 88

93 RIW Wtd. Cases RIW Wtd. Cases All patients will receive their cataract surgery within the LHIN where they live Cataracts will be repatriated from out of LHIN hospitals The estimated cost of care and the QBP price 90 based on direct costs only. As can be seen, the modeling suggests that QBP funding will be less than the cost of providing cataract surgery in NE LHIN hospitals since all of the Hub hospitals have higher HBAM QBP net direct unit cost rates than the QBP price per weighted case. It should be noted that the overall hospital direct cost per weighted case may or may not reflect the actual costs incurred by a hospital in providing cataract surgery procedures; but it is the basis for carving out costs for QBP funding. It is likely that this construct overstates the amount of money that hospitals in the northeast are currently spending on cataract surgery. Exhibit 47: Projected Revenue Impact on Large NE LHIN Hospitals from Proposed Cataract Model of Care 91 Hospital 2012/13 Actual Activity Proposed Activity Net Estim. Cost at Estimated Case HBAM Net Cost Unit Cost Case HBAM Direct Unit Cost Estimated Marginal Cost QBP Price QBP Revenue Impact on Revenue Health Science North 2, $2,071,407 3, $2,592,754 $4,168 $1,658,265 $3,533 $1,759,547 $101,282 North Bay RHC 2, $1,952,285 2, $2,349,239 $4,494 $1,435,122 $3,533 $1,357,739 -$77,382 Sault Area Hospital 1, $883,753 1, $903,933 $3,999 $666,501 $3,533 $602,338 -$64,163 Timmins & District $390, $453,045 $3,677 $304,952 $3,533 $340,193 $35,242 St. Joseph's, Elliot Lake $130, $- $2,789 $97,646 $3,533 $- -$97,646 West Parry Sound HC $165, $- $3,834 $120,600 $3,533 $- -$120,600 Kirkland & District $136, $- $3,507 $100,007 $3,533 $- -$100,007 Temiskaming Hospital $75, $- $3,352 $54,054 $3,533 $- -$54,054 Total 7,003 1,078 $5,805,901 7,426 1,149 $6,298,971 $4,437,146 $4,059,817 -$377, The cataract QBP price is the provincial avg. DIRECT cost per HIG weighted case after adjusting for HBAM cost modifiers including teaching, tertiary and distance at the case level. It is based on 2011/12 Ontario Case Costing Initiative (OCCI) datasets. While a carve out and QBP revenue is shown for Kirkland Lake, as a small hospital, Kirkland Lake will not be subject to either the carve out or the QBP payment approach. Page 89

94 8.5 Evaluating the Cataract Surgery Clinical Integration Model Recommended model for cataract surgery scores highly on both the integration and the siting criteria The Steering Committee applied its evaluation framework to the recommended Cataract Clinical Integration Model. The application of the framework is presented in the following tables. As can be seen, the recommended model scores highly on both the integration and the siting criteria. Exhibit 48: Application of Integration Criteria to Cataract Model of Care Criteria Definition Scoring: 0=No; Integration 0.5=Maybe; 1=Yes 1 Maintain/ Improve quality The distribution of clinical services will ensure quality of care standards and practices, clinical outcomes; safety and risk management are optimized 1 TOTALS 2 Appropriate critical mass The distribution of clinical services will be structured to ensure that programs/services have appropriate crticial mass (i.e. volume) to allow for the provision of safe, effective, efficient and timely services while reflecting 1 remote considerations 3 Access to Care Supports access to care requiring multi-system specialized services (e.g. cancer, cardiology). The distribution of services will improve access to care and/or 1 reduce medical, emotional and financial impact on patients. 4 Potential repatriation The distribution of clinical services will enhance the potential to deliver the appropriate services within the north east Maintain/ Improve operating The distribution of clinical services will be structured to create a more cost efficiency/achieve economies effective and efficient service cost profile in the LHIN and will not result in of scale increased system funding for operations 6 Attract/retain specialized clinical skills The distribution of clinical services will be structured to enhance the potential of recruiting and/or retaining the specialized skills required for the delivery of the service and will not result in the hospital losing physician or other HHR % Exhibit 49: Application of Siting Criteria to Proposed Cataract Model of Care Siting 1 Meets community need The distribution of clinical services will help to minimize variation in health outcomes across the region 1 2 Improves access to care The distribution of clinical services will be structured to improve patients' access to high quality programs/services closer to home. The distribution of services 0.5 will provide timely access to care 24/7, 365 days/year. 3 Supports clinical The distribution of clinical services will be aligned by site to ensure that clinical interdependencies and clinical interdependencies and patient flow is optimized and efficient 0.5 coherence 4 Meets current & future capacity limitations at site The distribution of clinical services will consider the current capacity of the potential host site and potential future capacity changes at the host site. 1 5 Enhance Regional Capability There is capacity and capability of the site to provide district or regional support to satellites if service is provided as a single program % Page 90

95 9.0 Total Joint Replacements The Total Joint Replacement QBPs include primary, unilateral knee replacement and primary, unilateral hip replacements. 9.1 QBP Handbook QBP clinical handbook for Total Joint Replacements has provided specific targets for care processes The QBP clinical handbook for Total Joint Replacements (TJR) has provided the following guidance: Clinical practice targets for Primary Unilateral Knee Replacement are: 4.4 day post-operative acute LOS 90% of patients discharged to home 10% of patients discharged to inpatient rehabilitation Wait time for surgery should be less than182 days Clinical practice targets for Primary Unilateral Hip Replacement are: 4.4 days post-operative acute LOS 90% of patients discharged to home 10% of patients discharged to inpatient rehabilitation Wait time for surgery should be less than 182 days Hub 9.2 Current Characteristics of TJR Service Delivery in NE LHIN The following tables present the current (2012/13) volumes and characteristics of TJR inpatients in each hospital in each NE LHIN Hub. Exhibit 50: 2012/13 Hip Replacement Patients in NE LHIN Hospitals Hospital IP Cases IP Days Avg. LOS % ALC Days Avg. RIW Avg. HIG Wght. Algoma Sault Area Hospital % Algoma Total % MPSS Health Science North 258 1, % West Parry Sound HC % MPSS Total 344 1, % Nip-Temisk North Bay RHC % Nip-Temisk Total % Cochrane & Coast Timmins & District % Cochrane & Coast Total % Grand Total 625 2, % Page 91

96 Hub Exhibit 51: 2012/13 Knee Replacement Patients in NE LHIN Hospitals Hospital IP Cases IP Days Avg. LOS % ALC Days Avg. RIW Avg. HIG Wght. Algoma Sault Area Hospital % Algoma Total % MPSS Health Science North 475 2, % West Parry Sound HC % MPSS Total 565 2, % Nip-Temisk North Bay RHC 462 1, % Nip-Temisk Total 462 1, % Cochrane & Coast Timmins & District % Cochrane & Coast Total % Grand Total 1,337 5, % As can be seen, overall, the NE LHIN hospitals are close to the ALOS target for hip replacements and better than the ALOS targets for Knee Replacements. Only 0.5% of TJR patients are gaining access to inpatient rehabilitation after care in a NE LHIN hospital Currently, very few TJR patients are being discharged to inpatient rehabilitation. As can be seen in the following table, only 0.5% of patients are gaining access to inpatient rehabilitation after care in a NE LHIN hospital. This compares quite unfavorably to the QBP Clinical Handbook target of 10%. Patients in the NE LHIN are being disadvantaged relative to best practice and, likely, relative to patients in other parts of the province. Exhibit 52: 2012/13 Percent of TJR Patients Discharged to Inpatient Rehabilitation in NE LHIN Hospital IP Disch. % of Patients to IP Rehab % of Survivors to IP Rehab Health Science North % 0.0% North Bay RHC % 0.2% Sault Area Hospital % 1.5% West Parry Sound HC % 0.0% Timmins & District % 2.8% Grand Total 1, % 0.5% 9.3 Proposed Model for Delivery of TJR Services The Hub clinical workshops have developed and the Steering Committee has reviewed, refined and confirmed the following model for the care of Primary Unilateral Total Joint Replacement patients in NE LHIN hospitals. Page 92

97 A single, integrated, hub wide orthopaedic surgery program in each hub It is recommended that NE LHIN hospitals should use a consistent model of care and clinical pathway/order sets in caring for primary, unilateral hip and knee replacement patients across region. Clinicians should provide leadership in the interpretation of the QBP Clinical Handbook for Total Joint Replacements to develop this model of care and clinical pathway/order set. The LHIN should provide coordination for this initiative. The model and approach to care should incorporate the following key elements: 1. TJRs should be provided as part of a single, integrated, hub wide orthopaedic surgery program in each hub. Within this program if a hospital/surgeon is providing major orthopaedic surgery, it/he should also provide hip fracture treatment and should provide for hip fracture treatment 7 days per week. 2. Each hospital providing TJRs, should maintain a Joint Assessment Centres (JACs) as the only route of access to TJR. It is hoped that this will assure appropriate and equitable access to TJRs. 3. For modeling purposes, assume that the current NE LHIN population utilization rates for TJR are appropriate. 4. TJRs should be provided by a hospital in the LHIN where the patient resides. In the future 100% of TJR for NE LHIN residents will be provided within the NE LHIN The wait time target for TJRs should be the QBP target of 182 days. However, achieving the target will require sufficient funding to achieve and maintain performance at that target. 6. NE LHIN orthopaedic surgery programs should adopt the QBP targets for ALOS of 4.4 days. 7. The number of extremely long stay patients should be reduced significantly thus reducing the number of atypical patients NE LHIN orthopaedic surgery program should adopt the QBP targets for discharge disposition with 90% of patients discharged to home; and 10% discharged to inpatient rehabilitation Both primary TJRs and revisions will be provided within the LHIN. For modeling purposes, the Steering Committee has assumed that NE LHIN hospitals can reduce the % of atypical cases to the lowest percentage achieved by hospitals in other LHINs in the province. This would be a significant increase from current practice wherein only approximately 1% of TJR patients are discharged to inpatient rehabilitation. Page 93

98 9. Patients can and should be repatriated from acute care to their local hospitals for inpatient rehabilitation with a plan of rehabilitative care and access to telemedicine for rehabilitation support. Enhanced rehabilitation resourcing and support in smaller communities will be needed to facilitate effective repatriation. Cross-training of RN s, RPN s and PSWs in hip fracture rehabilitation in smaller communities will facilitate effective repatriation. 10. TJR patients should have enhanced access to physiotherapy in the community with initial therapy provided by the CCAC as appropriate to the needs of the patient and continuing therapy provided in group sessions by hospitals as ambulatory care. 9.4 Implications of Proposed Acute Care Model for TJR Services The following tables present estimates of the implications of implementing the proposed model of care for TJR patients Volumes and Costs Repatriation will provide a significant increase in TJR volumes in NE LHIN hospitals The tables following present the implications of the proposed model of care for the number of patients, patient days and cost of inpatient care for each of the NE LHIN hospitals. As can be seen, there will be repatriation of significant patient volume from out of LHIN hospitals that will cause an increase in cases within the LHIN. There will also be a decrease in the total number of patient days across all hospitals as hospitals adjust their care processes to achieve: A more consistent and shorter ALOS that is less than or equal to the provincial average for their typical cases and A reduction in the number of atypical cases. 95 Although patient days will decline, costs will increase significantly as the increased number of cases will increase the number of surgical procedures and the number of prosthetics used. The modeling assumes that TJR surgery will continue in the 5 hospitals currently providing this surgery. TJR surgery will be provided in the hub where the resident lives and TJR surgery will be repatriated from out of LHIN hospitals to the patients hub hospital. 95 Best Practice (i.e. Lowest) % Atypical cases of all Ontario LHINs for each QBP has been applied to NE LHIN hospitals, with cases being converted from Atypical to Typical and then given the target LOS for the QBP and the NE LHIN average weight per Typical case for the QBP. Page 94

99 HIG Wtd. Cases HIG Wtd. Cases HIG Wtd. Cases IP Cases % Atyp. Case IP Days Avg. LOS HIG Wgt. IP Cases % Atyp. Case IP Days Avg. LOS HIG Wgt. IP Cases IP Days HIG Wght. IP Cases % Atyp. Case IP Days Avg. LOS HIG Wgt. IP Cases % Atyp. Case IP Days Avg. LOS HIG Wgt. IP Cases IP Days HIG Wght. Exhibit 53: Projected Impact on NE LHIN Hospital Activity of Proposed Model of Care for THR /13 Actual Activity Proposed Activity Change In Activity NE LHIN Hospital Timmins & District 21 19% % West Parry Sound HC 86 0% % Health Science North 258 6% 1, % 1, Sault Area 116 5% % North Bay RHC 144 4% % Grand Total 625 5% 2, , % 2, , Exhibit 54: Projected Impact on NE LHIN Hospital Activity of Proposed Model of Care for TKR 2012/13 Actual Activity Proposed Activity Change In Activity NE LHIN Hospital Timmins & District 88 25% % West Parry Sound HC 90 1% % Health Science North 475 3% 2, % 2, Sault Area 222 4% % North Bay RHC 462 2% 1, % 1, Grand Total 1,337 4% 5, ,059 1,585 1% 5, , Exhibit 55: Projected Impact on NE LHIN Hospital Costs of Proposed Model of Care for THR NE LHIN Hospital 2012/13 HBAM QBP Net Unit Cost 2012/13 Activity Proposed Activity Change in Cost Estimated Cost Estimated Cost Estimated Cost Timmins & District $4, $154, $472, $317,884 West Parry Sound HC $5, $747, $316, $431,249 Health Science North $5, $2,300, $2,995, $695,033 Sault Area $5, $1,130, $1,268, $137,855 North Bay RHC $6, $1,493, $2,044, $551,007 Grand Total 1,074 $5,826,413 1,310 $7,096, $1,270, It should be noted that the hospitals average lengths of stay for TJR patients under the proposed model of care will decline from the current value because the model assumes that all patients (except for the residual atypical patients) stay in acute care for no more than the target length of stay. As a result the modeling reflects a decline in lengths of stay for most patients and thus a (sometimes significant) decrease in the average lengths of stay for all hospitals. Because some TJR patients stay in hospital for shorter periods than the target lengths of stay and the modeling did not increase their lengths of stay, the hospitals resulting average lengths of stay is often less than the target length of stay. Page 95

100 HIG Wtd. Cases HIG Wtd. Cases HIG Wtd. Cases Exhibit 56: Projected Impact on NE LHIN Hospital Costs of Proposed Model of Care for TKR NE LHIN Hospital 2012/13 HBAM QBP Net Unit Cost 2012/13 Activity Proposed Activity Change in Cost Estimated Cost Estimated Cost Estimated Cost Timmins & District $4, $644, $1,499, $855,417 West Parry Sound HC $5, $717, $371, $346,191 Health Science North $5, $3,898, $5,040, $1,141,890 Sault Area $5, $1,761, $1,817, $55,802 North Bay RHC $6, $4,306, $4,172, $133,939 Grand Total 2,059 $11,328,263 2,383 $12,901, $1,572, QBP Revenues and Costs The application of QBP funding to the proposed model of care would result in a net loss from TJR care for most of those LHIN hospitals that will be included in QBP funding. The estimated cost of caring for TJR patients will be higher than the QBP revenues paid for their care because the hospital s HBAM QBP net unit cost 97 per HIG weighted case is higher than the QBP price per HIG weighted case for TJR cases ($5,214 for THR and $5,188 for TKR). Significant increase in revenues for TJR activity in NE LHIN hospitals It should be noted, however, that repatriation of TJR cases from hospitals outside the LHIN, together with the introduction of QBP funding has the potential to provide in a significant increase in revenues for those LHIN hospitals that will be included in QBP funding. (But these will not be profitable additional revenues if the hospitals are unable to reduce their marginal cost of caring for these additional TJR patients to less than the QBP price for their care) The estimated magnitude of the hospitals profits and losses from caring for TJR patients under QBP funding is presented in the following tables. 97 In calculating the HBAM QBP net unit cost, the HBAM cost per weighted case is adjusted to remove the impact of the HBAM allowances for teaching, Level of Care and distance. These adjustments for each hospital are presented in an appendix to this report. Page 96

101 IP Cases Total HIG Wgt. IP Cases Total HIG Wgt. Exhibit 57: Projected Revenue Impact on Large NE LHIN Hospitals from Proposed Model of Care for THR NE LHIN Hospital Proposed Activity 2012/13 HBAM QBP Net Unit Cost QBP Price per Wtd. Case Net Profit/Loss Per HIG Wtd. Case Total QBP Volume Timmins & District $4,705 $5,214 $509 $51,102 West Parry Sound HC $5,257 $5,214 -$43 -$2,575 Health Science North $5,206 $5,214 $8 $4,733 Sault Area $5,302 $5,214 -$88 -$20,993 North Bay RHC $6,113 $5,214 -$899 -$300,648 Grand Total 783 1,310 -$268,381 Exhibit 58: Projected Revenue Impact on Large NE LHIN Hospitals from Proposed Model of Care for TKR NE LHIN Hospital Proposed Activity 2012/13 HBAM QBP Net Unit Cost QBP Price per Wtd. Case Net Profit/Loss Per HIG Wtd. Case Total QBP Volume Timmins & District $4,705 $5,188 $483 $153,828 West Parry Sound HC $5,257 $5,188 -$69 -$4,901 Health Science North $5,206 $5,188 -$18 -$17,774 Sault Area $5,302 $5,188 -$114 -$39,199 North Bay RHC $6,113 $5,188 -$925 -$631,598 Grand Total 1,585 2,383 -$539, Implications of TJR Model of Care for Inpatient Rehabilitation Very few NE LHIN knee replacements are currently discharged to IP rehab (0.5%). The proposed model suggests that the provincial target of 10% should be applied, particularly after repatriation of (possibly more complex) cases from hospitals outside NE LHIN. If there is no QBP funding, how will the LHIN provide for the rehabilitation aspect of the best practice model of care for TJR patients? The proposed model of TJR care for NE LHIN suggests that 10% of TJR inpatients should be discharged directly from acute care to inpatient rehabilitation with an estimated average length of stay of 14 days. This represents a 20 fold increase over the current use of inpatient rehabilitation by NE LHIN TJR patients. If the LHIN hospitals achieve these targets then each hub will require the following number of rehabilitation beds for TJR patients. Page 97

102 Exhibit 59: Projected Requirement for Inpatient Rehabilitation Beds for Total Joint Replacement Patients Hub Proposed IP TJR Cases Tgt. IP Rehab Cases IP Rehab 14 day ALOS TJR IP 90% Algoma Cochrane & Coast MPSS 1, , Nip-Temisk , Grand Total 2, , This will be a significant increase in the volume of inpatient rehabilitation cases and the associated need for beds and care. As of now, there is no indication that there will be QBP funding to support the inpatient rehabilitation component of the care for TJR patients. If there is no QBP funding, how will the LHIN provide for the rehabilitation aspect of the best practice model of care for TJR patients? Will the surpluses achieved in acute care need to be used to fund inpatient rehabilitation? Will the surpluses be sufficient initially and into the future? 9.6 Ambulatory Care If there is no QBP funding for ambulatory rehabilitation, then how will hospitals be able to fund the necessary additional outpatient rehabilitation? TJR patients that do not get inpatient rehabilitation will need continuing rehabilitation either in their homes or in a clinic setting. Currently there is very limited homecare or hospital based ambulatory rehabilitation care for TJR patients. As of now, there is no indication that there will be QBP funding to support the outpatient rehabilitation component of the care for TJR patients. If there is no QBP funding for ambulatory rehabilitation, then how will hospitals be able to fund this additional outpatient rehabilitation? Will the surpluses achieved in acute care need to be used to fund outpatient rehabilitation? Will the surpluses be sufficient initially and into the future? 9.7 Evaluating the QBP Integration Model Recommended model for TJR care scores highly on both the integration and the siting criteria The Steering Committee applied its evaluation framework to the recommended TJR Clinical Integration Model. The application of the framework is presented in the following tables. As can be seen, the recommended model scores highly on both the integration and the siting criteria. Page 98

103 Exhibit 60: Application of Integration and Siting Criteria to TJR Model of Care TOTAL JOINT REPLACEMENT Criteria Definition Scoring: 0=No; Integration 0.5=Maybe; 1=Yes 1 Maintain/ Improve quality The distribution of clinical services will ensure quality of care standards and practices, clinical outcomes; safety and risk management are optimized 1 TOTALS 2 Appropriate critical mass The distribution of clinical services will be structured to ensure that programs/services have appropriate crticial mass (i.e. volume) to allow for the provision of safe, effective, efficient and timely services while reflecting 1 remote considerations 3 Access to Care Supports access to care requiring multi-system specialized services (e.g. cancer, cardiology). The distribution of services will improve access to care and/or reduce medical, emotional and financial impact on patients. 4 Potential repatriation The distribution of clinical services will enhance the potential to deliver the appropriate services within the north east 1 5 Maintain/ Improve operating The distribution of clinical services will be structured to create a more cost efficiency/achieve economies effective and efficient service cost profile in the LHIN and will not result in of scale increased system funding for operations 6 Attract/retain specialized clinical skills The distribution of clinical services will be structured to enhance the potential of recruiting and/or retaining the specialized skills required for the delivery of the service and will not result in the hospital losing physician or other HHR Siting 1 Meets community need The distribution of clinical services will help to minimize variation in health outcomes across the region 1 2 Improves access to care The distribution of clinical services will be structured to improve patients' access to high quality programs/services closer to home. The distribution of services 1 will provide timely access to care 24/7, 365 days/year. 3 Supports clinical The distribution of clinical services will be aligned by site to ensure that clinical interdependencies and clinical interdependencies and patient flow is optimized and efficient 1 coherence 4 Meets current & future capacity limitations at site The distribution of clinical services will consider the current capacity of the potential host site and potential future capacity changes at the host site % 5 Enhance Regional Capability There is capacity and capability of the site to provide district or regional support to satellites if service is provided as a single program % Page 99

104 10.0 Hip Fractures Although not a QBP for 2013/14, it is planned that Hip Fractures will be a QBP for 2014/15. Further, caring for hip fracture patients is directly related to the provision of Total Joint Replacements QBP Handbook Guidance from the Ontario Orthopaedic Expert Panel Although there is not yet a QBP Handbook for Hip Fractures, the project took guidance from work of the Ontario Orthopaedic Expert Panel related to care for hip fractures. The Expert Panel has suggested: The inpatient length of stay for hip fracture patients should average at 7 days with 90% of all hip fracture patients being discharged from acute care within 7 days of admission. 80 % of hip fracture patients should be discharged from acute care directly to inpatient rehabilitation. The inpatient length of stay for hip fracture patients in rehabilitation should average at 28 days with 90% of all hip fracture patients being discharged from inpatient rehabilitation care within 28 days of admission and 10% staying longer than 28 days Current Characteristics of Hip Fracture Service Delivery in NE LHIN Current NE LHIN hip fracture ALOS is longer than provincial target The following tables present the current (2012/13) volumes and characteristics of hip fracture inpatients in each hospital in each NE LHIN Hub. As can be seen, the average length of stay for hip fracture patients in NE LHIN hospitals is 15.4 days, which is significantly longer than the recommended 7 days For modelling purposes we have assumed a mean LOS of 28 days for 90% of HF IP rehab patients and an overall LOS of 32 days, including 10% long-stay patients. 99 It has been suggested that the paucity of rehabilitation beds in the NE LHIN is forcing patients to extend their acute lengths of stay so as to receive their inpatient rehabilitation in acute care beds. Page 100

105 Hub Exhibit 61: 2012/13 NE LHIN Hip Fracture Activity by Hub and Hospital Hospital IP Cases IP Days Avg. LOS % ALC Days Avg. RIW Avg. HIG Wght. Algoma Blind River Dist Hlth Ctr % Lady Dunn Health Centre % Sault Area Hospital 130 1, % Algoma Total 133 1, % MPSS Espanola General Hospital % Health Science North 207 3, % Manitoulin HC % St. Joseph's, Elliot Lake % West Parry Sound HC 37 1, % MPSS Total 267 5, % Nip-Temisk Englehart & District Hospital % Kirkland & District Hospital % Mattawa General Hospital % North Bay RHC 128 1, % Temiskaming Hospital % West Nipissing General % Nip-Temisk Total 155 1, % Cochrane & Coast Anson General Hospital % Bingham Memorial Hospital % Lady Minto Hospital % Notre Dame Hospital % Sensenbrenner Hospital % Timmins & District % Weeneebayko Area HA % Cochrane & Coast Total % Grand Total , % Only 13% of NE LHIN hip fracture patients were discharged directly to inpatient rehabilitation As can be seen in the following table, only 13% of NE LHIN hip fracture patients are currently being discharged directly to inpatient rehabilitation; the Ontario Hip Fracture Model of Care suggests a target of 80% It has been suggested that the paucity of rehabilitation beds in the NE LHIN is forcing patients to receive their inpatient rehabilitation in acute care beds and also to be discharged to home with or without homecare before it is clinically appropriate. Page 101

106 Exhibit 62: 2012/13 Percent of NE LHIN Hospital Hip Fracture Patients Discharged Directly to Inpatient Rehabilitation % of % of Hospital IP Patients Survivors Disch. to IP to IP Rehab Rehab Health Science North % 9.5% North Bay RHC % 17.2% Sault Area Hospital % 25.0% Timmins & District % 5.7% West Parry Sound HC % 30.8% St. Joseph's, Elliot Lake % 0.0% Temiskaming Hospital % 0.0% Manitoulin HC % 4.5% Sensenbrenner Hospital % 0.0% West Nipissing General % 0.0% Kirkland & District Hospital % 0.0% Espanola General Hospital 9 0.0% 0.0% Mattawa General Hospital 9 0.0% 0.0% Weeneebayko Area HA 4 0.0% 0.0% Lady Minto Hospital 4 0.0% 0.0% Englehart & District Hospital 4 0.0% 0.0% Anson General Hospital 4 0.0% 0.0% Notre Dame Hospital 4 0.0% 0.0% Hornepayne Community 3 0.0% 0.0% Blind River Dist Hlth Ctr 3 0.0% 0.0% Lady Dunn Health Centre 2 0.0% 0.0% Bingham Memorial Hospital 2 0.0% 0.0% Chapleau Hlth Serv 1 0.0% 0.0% Grand Total % 12.6% 10.3 Proposed Model for Delivery of Hip Fracture Services The Hub clinical workshops have developed and the Steering Committee has reviewed, refined and confirmed the following model for the care of Hip Fracture patients in NE LHIN hospitals. A consistent model of care and clinical pathway/order set in caring for Hip Fracture patients across region It is recommended that NE LHIN hospitals should use a consistent model of care and clinical pathway/order set in caring for Hip Fracture patients across region. Clinicians should provide leadership in the interpretation of the Orthopaedic Expert Panel s Hip Fracture Model of Care to develop this model of care and clinical pathway/order set. The LHIN should provide coordination for this Page 102

107 initiative. The model and approach to care should incorporate the following key elements: 1. Assume that the current NE LHIN average percentage of ED Hip Fractures being admitted to inpatient care is appropriate. 2. Assume that current hospital specific Hip Fracture transfer out rate is appropriate (i.e. assume that minor hip fractures are appropriately being treated locally by general surgeons; with more significant fractures being transferred out to a site with orthopaedic surgery capability). All transfers should be from the local ED to inpatient care at the TJR hospital. Hip fracture patients should not be forced to wait as inpatients in a referring hospital; they should be transferred from the referring hospital ED to inpatient or pre operative status in the receiving hospital Hip Fracture Repair should be provided as part of an integrated hub wide orthopaedic surgery program. Within this program if a hospital/surgeon is providing major orthopaedic surgery, it should also provide hip fracture treatment and should provide for hip fracture treatment 7 days per week. 4. Hospitals treating hip fracture should achieve the provincial median ALOS performance (or better) for inpatient acute care. 5. The number of extremely long stay patients will be reduced significantly thus reducing the number of atypical patients % of Hip Fracture patients discharged from acute care in a NE LHIH hospital should be discharged directly to inpatient rehabilitation. 7. Patients can and should be repatriated from acute care to their local hospitals for inpatient rehabilitation with a plan of rehabilitative care and access to telemedicine for rehabilitation support. Enhanced rehabilitation resourcing and support in smaller communities will be needed to facilitate effective repatriation. Cross-training of RN s, RPN s and PSWs in hip fracture rehabilitation in smaller communities will facilitate effective repatriation. 101 For many hospitals this will be a change in practice. Protocols and formal agreements among hospitals to facilitate these transfers will need to be developed 102 For modeling purposes, the Steering Committee has assumed that NE LHIN hospitals can reduce the % of atypical cases to the lowest percentage achieved by hospitals in other LHINs in the province. Page 103

108 9. Hospitals providing rehabilitation care for hip fracture patients should achieve the provincial median ALOS performance for inpatient rehabilitation for hip fracture patients Implications of Proposed Model for QBP Services The following tables present estimates of the implications of implementing the proposed model of care for hip fracture patients Volumes and Costs A very large reduction in patient days (6,405) and costs The table following presents the implications of the proposed model of care for the number of patients 103, patient days and cost of inpatient care for each of the NE LHIN hospitals. As can be seen, there will be some movement of patient volume from the local hospitals to the hub hospitals. There will also be a decrease in the total number of patient days across all hospitals as hospitals adjust their care processes to achieve: A more consistent ALOS that is less than or equal to the provincial average LOS of 8.71 days and A reduction in the number of atypical cases 104. As can be seen, there will be a very large reduction in patient days (6,126) and costs in caring for hip fracture patients in the NE LHIN using the proposed model of care 103 It should be noted that the number of inpatients declines under the proposed Hip Fx model of care because some inter hospital inpatient transfers have been eliminated. In 2012/13, there were 50 Hip Fracture inpatients in small hospitals transferred for inpatient care in a Hub hospital. For simulation, we have assumed that these patients would be transferred directly from small hospital ED to inpatient care in Hub hospital. 104 Best Practice (i.e. Lowest) % Atypical cases of all Ontario LHINs for each QBP has been applied to NE LHIN hospitals, with cases being converted from Atypical to Typical and then given the target LOS for the QBP and the NE LHIN average weight per Typical case for the QBP. Page 104

109 IP Cases % Atyp. Case IP Days Avg. LOS HIG Wgt. IP Cases % Atyp. Case IP Days Avg. LOS HIG Wgt. IP Cases IP Days HIG Wght. Exhibit 63: Projected Impact on NE LHIN Hospital Activity of Proposed Model of Care for Hip Fracture /13 Actual Activity Proposed Activity Change In Activity NE LHIN Hospital Blind River Dist HC 2 100% Chapleau Hlth Serv Lady Minto 3 100% St. Joseph's, Elliot Lk 12 58% % Englehart & District 3 100% % Espanola General 2 50% % Notre Dame 1 100% Hornepayne Anson General 1 100% Lady Dunn HC 1 100% Sensenbrenner 6 83% % Kirkland & District 7 86% % Bingham Memorial 2 50% Mattawa General 2 100% Manitoulin HC 9 89% % Smooth Rock Falls West Nipissing 2 100% Temiskaming % Timmins & District 88 55% % West Parry Sound HC 37 24% 1, % , Health Science North % 3, % 1, , Sault Area % 1, % Weeneebayko 2 50% % North Bay RHC % 1, % Grand Total % 10, , % 3, , , It should be noted that the hospitals average lengths of stay for Hip Fx patients under the proposed model of care will decline from the current value because the model assumes that all patients (except for the residual atypical patients) stay in acute care for no more than the target length of stay. As a result the modeling reflects a decline in lengths of stay for most patients and thus a (sometimes significant) decrease in the average lengths of stay for all hospitals. Because some Hip Fx patients stay in hospital for shorter periods than the target lengths of stay and the modeling did not increase their lengths of stay, the hospitals resulting average lengths of stay is often less than the target length of stay. Page 105

110 HIG Wtd. Cases HIG Wtd. Cases HIG Wtd. Cases NE LHIN Hospital Exhibit 64: Projected Impact on NE LHIN Hospital Costs of Proposed Model of Care for Hip Fracture 2012/13 HBAM QBP Net Unit Cost 2012/13 Activity Proposed Activity Change in Cost Estimated Cost Estimated Cost Estimated Cost Blind River Dist HC $6, $3,583 - $ $3,583 Chapleau Hlth Serv $7,812 - $- - $- - $- Lady Minto $5, $4,314 - $ $4,314 St. Joseph's, Elliot Lk $3, $112, $61, $50,748 Englehart & District $4, $121, $34, $87,223 Espanola General $5, $10, $13, $2,899 Notre Dame $5, $3,209 - $ $3,209 Hornepayne $7,551 - $- - $- - $- Anson General $4, $1,232 - $ $1,232 Lady Dunn HC $5, $3,247 - $ $3,247 Sensenbrenner $3, $11, $17, $6,748 Kirkland & District $4, $13, $11, $2,349 Bingham Memorial $7, $10,422 - $ $10,422 Mattawa General $7, $4,293 - $ $4,293 Manitoulin HC $5, $21, $25, $4,878 Smooth Rock Falls $3,977 - $- - $- - $- West Nipissing $3, $8,666 - $ $8,666 Temiskaming $4, $26,040 - $ $26,040 Timmins & District $4, $856, $983, $126,303 West Parry Sound HC $5, $1,770, $461, $1,308,469 Health Science North $5, $3,358, $2,558, $799,723 Sault Area $5, $1,707, $1,636, $71,017 Weeneebayko $5, $7, $23, $16,347 North Bay RHC $6, $1,891, $1,857, $33,319 Grand Total 1,877 $9,947,250 1,444 $7,686, $2,260, QBP Revenues and Costs Net losses from caring for hip fracture patients The application of QBP funding to the proposed model of care would result in a net loss from Hip Fracture acute care for most of those LHIN hospitals that will be included in QBP funding. The estimated cost of caring for Hip Fracture patients will be higher than the QBP revenues paid for their care because many hospital s HBAM QBP net unit cost 106 per HIG weighted case is higher than the QBP price per HIG weighted case for Hip Fracture cases ($5,200). 106 In calculating the HBAM QBP net unit cost, the HBAM cost per weighted case is adjusted to remove the impact of the HBAM allowances for teaching, Level of Care and distance. These adjustments for each hospital are presented in an appendix to this report. Page 106

111 IP Cases Total HIG Wgt. The estimated magnitude of the hospitals profits and losses from caring for Hip Fracture patients under QBP funding is presented in the following table. Exhibit 65: Projected Revenue Impact on Large NE LHIN Hospitals from Proposed Model of Care NE LHIN Hospital Proposed Activity 2012/13 HBAM QBP Net Unit Cost QBP Price per Wtd. Case Net Profit/Loss Per HIG Wtd. Case Total QBP Volume St. Joseph's, Elliot Lake $3,718 $5,200 $1,482 $24,633 Temiskaming - - $4,710 $5,200 $490 $- Timmins & District $4,705 $5,200 $495 $103,431 West Parry Sound HC $5,257 $5,200 -$57 -$5,008 Health Science North $5,206 $5,200 -$6 -$2,949 Sault Area $5,302 $5,200 -$102 -$31,485 North Bay RHC $6,113 $5,200 -$913 -$277,489 Grand Total 597 1,418 -$188, Inpatient Rehabilitation If there is no QBP funding, how will the LHIN provide for the rehabilitation aspect of the best practice model of care for hip fracture patients? The proposed model of care for NE LHIN suggests that 80% of hip fracture inpatients should be discharged directly from acute care to inpatient rehabilitation with an estimated average length of stay of 32 days, including 10% long-stay patients. If the LHIN hospitals achieve these targets than each hub will require the following number of rehabilitation beds. Exhibit 66: Projected Inpatient Rehabilitation Bed Requirement for Hip Fracture Patients Hub Proposed IP HF Cases Tgt. IP Rehab Cases IP Rehab 32 day ALOS HF IP 90% Algoma , Cochrane & Coast , MPSS , Nip-Temisk , Grand Total , This will be a significant increase in the volume of inpatient rehabilitation cases and the associated need for beds and care. As of now, there is no indication that there will be QBP funding to support the inpatient rehabilitation component of the care for hip fracture patients. If there is no QBP funding, how will the LHIN provide for Page 107

112 the rehabilitation aspect of the best practice model of care for hip fracture patients? 10.6 Ambulatory Care If hospitals suffer a net reduction in funding for inpatient care as a result of the introduction of QBP funding, and there is no QBP funding for ambulatory rehabilitation, then how will hospitals be able to fund this additional outpatient rehabilitation Both hip fracture patients that do not get inpatient rehabilitation and hip fracture patients that do receive inpatient rehabilitation will need continuing rehabilitation either in their homes or in a clinic setting. Currently there is very limited homecare or hospital based ambulatory rehabilitation care for hip fracture patients. As of now, there is no indication that there will be QBP funding to support the outpatient rehabilitation component of the care for hip fracture patients. If hospitals suffer a net reduction in funding for inpatient care as a result of the introduction of QBP funding, and there is no QBP funding for ambulatory rehabilitation, then how will hospitals be able to fund this additional outpatient rehabilitation? 10.7 Evaluating the QBP Integration Model The Steering Committee applied its evaluation framework to the recommended Hip Fracture Clinical Integration Model. The application of the framework is presented in the following tables. As can be seen, the recommended model scores highly on both the integration and the siting criteria. Page 108

113 Exhibit 67: Application of Integration and Siting Criteria to Hip Fracture Model of Care Criteria Definition Scoring: 0=No; Integration 0.5=Maybe; 1=Yes 1 Maintain/ Improve quality The distribution of clinical services will ensure quality of care standards and practices, clinical outcomes; safety and risk management are optimized 1 TOTALS 2 Appropriate critical mass The distribution of clinical services will be structured to ensure that programs/services have appropriate crticial mass (i.e. volume) to allow for the provision of safe, effective, efficient and timely services while reflecting 0.5 remote considerations 3 Access to Care Supports access to care requiring multi-system specialized services (e.g. cancer, cardiology). The distribution of services will improve access to care and/or 1 reduce medical, emotional and financial impact on patients. 4 Potential repatriation The distribution of clinical services will enhance the potential to deliver the appropriate services within the north east Maintain/ Improve operating The distribution of clinical services will be structured to create a more cost efficiency/achieve economies effective and efficient service cost profile in the LHIN and will not result in of scale increased system funding for operations 6 Attract/retain specialized clinical skills The distribution of clinical services will be structured to enhance the potential of recruiting and/or retaining the specialized skills required for the delivery of the service and will not result in the hospital losing physician or other HHR Siting 1 Meets community need The distribution of clinical services will help to minimize variation in health outcomes across the region 1 2 Improves access to care The distribution of clinical services will be structured to improve patients' access to high quality programs/services closer to home. The distribution of services 0.5 will provide timely access to care 24/7, 365 days/year. 3 Supports clinical The distribution of clinical services will be aligned by site to ensure that clinical interdependencies and clinical interdependencies and patient flow is optimized and efficient 0.5 coherence 4 Meets current & future The distribution of clinical services will consider the current capacity of the capacity limitations at site potential host site and potential future capacity changes at the host site. 1 5 Enhance Regional Capability There is capacity and capability of the site to provide district or regional support % to satellites if service is provided as a single program % Page 109

114 11.0 Vascular Surgery Narrow definition of vascular surgery for QBP funding QBP funding for vascular surgery will be applied only to very narrowly defined Elective Aortic Aneurysm Repairs and Repairs for Lower Extremity Occlusive Disease QBP Handbook The QBP clinical handbook for Vascular Surgery 107 has reported that there is a large body of literature indicating that improved clinical outcomes of elective Aortic Aneurysm (AA) repair can be achieved when the procedures are done in high-volume dedicated vascular centers. The handbook also reported on the current lengths of stay for the vascular surgery procedures that will be initially addressed through QBP funding. For AA repair in 2010/11, the handbook has reported significant variation in ALOS across province: Open AAA repairs: Mean ALOS = 10.2 days (range days) Open TAA repairs: Mean ALOS = 11.6 days (range days) EVAR for AAA: Mean ALOS = 7.3 days (range days) EVAR for TAA: Mean ALOS = 9.4 days (range 3-14 days) For Lower Extremity revascularization in 2010/11, at hospitals with case volumes >5, the handbook has reported even more significant variation in ALOS across the province: Open revascularization (aortoiliac): Mean ALOS = 11.2 days (range days) EVAR revascularization (aortoiliac): Mean ALOS = 7.8 days (range 2-68 days) Open revascularization (infra-inguinal): Mean ALOS = 10.0 days (range 1-20 days) EVAR revascularization (infra-inguinal): Mean ALOS = 9.5 days (range 1-53 days) 107 In addition to the HQO QBP Handbook, there is also a recent expert panel report from the Cardiac Care Network of Ontario entitled A Vascular Services Quality Strategy for Ontario: Observations and Recommendations which was published in May 2012 which provides recommendations to improve access to vascular care and the quality of vascular outcomes in Ontario. Page 110

115 11.2 Current Characteristics of QBP Vascular Surgery in NE LHIN The following table presents the number the QBP Vascular Surgery (Non Cardiac) Procedures provided by each NE LHIN hospital in 2012/13. Exhibit 68: 2012/13 Non-Cardiac Vascular, Lower Extremity Procedures Hub Hospital IP Cases IP Days Avg. LOS % ALC Days Avg. RIW Avg. HIG Wght. Algoma Sault Area Hospital % Algoma Total % MPSS Health Science North % MPSS Total % Nip-Temisk North Bay RHC % Nip-Temisk Total % Grand Total % Hub The following tables present the characteristics of the QBP Aortic Aneurysm Repair procedures provided by NE LHIN hospitals in 2012/13. Exhibit 69: 2012/13 Non-Cardiac Vascular, AA Repair Procedures Non-Cardiac Vascular AA Repair - EVAR Hospital IP Cases IP Days Avg. LOS % ALC Days Avg. RIW Avg. HIG Wght. MPSS Health Science North % Hub Non-Cardiac Vascular AA Repair - Open Hospital IP Cases IP Days Avg. LOS % ALC Days Avg. RIW Avg. HIG Wght. Algoma Sault Area Hospital % Algoma Total % MPSS Health Science North % MPSS Total % Grand Total % As can be seen, the QBP vascular procedures are being provided primarily in the Sault Area Hospital and Health Sciences North. EVARs are only provided at Health Sciences North. There are three vascular surgeons located at HSN and one vascular surgeon at SAH. Page 111

116 11.3 Proposed Model for Delivery of Vascular Surgery The Hub clinical workshops have developed and the Steering Committee has reviewed, refined and confirmed the following approach to organizing and delivering the care of QBP Vascular Surgery patients in NE LHIN hospitals. QBP vascular surgery procedures should be provided as part of an integrated LHIN wide vascular surgery program It is recommended that: 1. NE LHIN hospitals should use a consistent model of care and clinical pathways/order sets in caring for vascular surgery patients across region. 2. QBP vascular surgery procedures should be provided as part of a single, integrated LHIN wide vascular surgery program. 3. The LHIN wide vascular surgery program should operate under an integrated clinical governance and management model. The clinicians involved in vascular surgery working with a small task force should provide leadership in the interpretation of the QBP Clinical Handbook for Vascular Surgery (and the recent and continuing work of the Cardiac Care Network) to fully develop a definitive model of care for the delivery of vascular surgery in the NE LHIN and to determine how best to operationalize the LHIN wide vascular surgery program Implications of QBP Model for Vascular Surgery Services The following tables present estimates of the potential implications of implementing a model of care for the QBP vascular surgery procedures that more closely reflects the QBP Clinical Handbook for Vascular Surgery and the CCN Guidelines Volumes and Costs The tables following present the potential implications of the QBP model of care for the number of patients, patient days and cost of inpatient care for each of the participating NE LHIN hospitals for the QBP funded Aortic Aneurysm Repairs. As can be seen there will be a decrease in the total number of patient days across the two hospitals as hospitals adjust their care processes to achieve: 108 A model that can be used to guide this process is provided in section 15.3 of this report. Page 112

117 HIG Wtd. Cases HIG Wtd. Cases HIG Wtd. Cases IP Cases % Atyp. Case IP Days Avg. LOS HIG Wgt. IP Cases % Atyp. Case IP Days Avg. LOS HIG Wgt. IP Cases IP Days HIG Wght. A more consistent ALOS that is less than or equal to the provincial average acute length of stay and A reduction in the number of atypical cases 109. Exhibit 70: Projected Impact on NE LHIN Hospital Activity of Proposed Model of Care for Aortic Aneurysm Repair 2012/13 Actual Activity Proposed Activity Change In Activity NE LHIN Hospital Health Science North 89 40% % Sault Area 5 0% % Grand Total 94 38% % Exhibit 71: Projected Impact on NE LHIN Hospital Costs of Proposed Model of Care for Aortic Aneurysm Repair NE LHIN Hospital 2012/13 HBAM QBP Net Unit Cost 2012/13 Activity Proposed Activity Change in Cost Estimated Cost Estimated Cost Estimated Cost Health Science North $5, $1,695, $1,650, $45,405 Sault Area $5, $135, $112, $22,924 Grand Total 351 $1,831, $1,763, $68,329 A decrease in patient days The tables following present the potential implications of the QBP model of care for the number of patients, patient days and cost of inpatient care for each of the participating NE LHIN hospitals for the QBP funded Non-Cardiac Vascular Surgery for Lower Extremity Occlusive Disease. As can be seen, there will be a decrease in the total number of patient days across the two hospitals as hospitals adjust their care processes to achieve: A more consistent ALOS that is less than or equal to the provincial average acute LOS and A reduction in the number of atypical cases Best Practice (i.e. Lowest) % Atypical cases of all Ontario LHINs for each QBP has been applied to NE LHIN hospitals, with cases being converted from Atypical to Typical and then given the target LOS for the QBP and the NE LHIN average weight per Typical case for the QBP. 110 Best Practice (i.e. Lowest) % Atypical cases of all Ontario LHINs for each QBP has been applied to NE LHIN hospitals, with cases being converted from Atypical to Typical and then given the target LOS for the QBP and the NE LHIN average weight per Typical case for the QBP. Page 113

118 HIG Wtd. Cases HIG Wtd. Cases HIG Wtd. Cases IP Cases % Atyp. Case IP Days Avg. LOS HIG Wgt. IP Cases % Atyp. Case IP Days Avg. LOS HIG Wgt. IP Cases IP Days HIG Wght. Exhibit 72: Projected Impact on NE LHIN Hospital Activity of Proposed Model of Care for Non-Cardiac Vascular Surgery for Lower Extremity Occlusive Disease 2012/13 Actual Activity Proposed Activity Change In Activity NE LHIN Hospital Health Science North 93 14% % Sault Area 26 0% % North Bay RHC 1 0% Grand Total % % Exhibit 73: Projected Impact on NE LHIN Hospital Costs of Proposed Model of Care for Non-Cardiac Vascular Surgery for Lower Extremity Occlusive Disease NE LHIN Hospital 2012/13 HBAM QBP Net Unit Cost 2012/13 Activity Proposed Activity Change in Cost Estimated Cost Estimated Cost Estimated Cost Health Science North $5, $1,044, $874, $170,028 Sault Area $5, $240, $246, $6,057 North Bay RHC $6, $9,119 - $ $9,119 Grand Total 247 $1,293, $1,120, $173, QBP Revenues and Costs The application of QBP funding to the proposed model of care would result in a net loss from Vascular Surgery care for the two LHIN hospitals that will continue to provide this care. The MOHLTC has established QBP prices per weighted case of $5,334 for AA repair and $4,896 for lower extremity occlusive disease. Using the proposed model of care, the introduction of QBP funding will result in modest losses for the two participating LHIN hospitals. The estimated magnitude of the hospitals profits and losses from caring for Vascular Surgery patients under QBP funding is discussed and presented in the following paragraphs. For Aortic Aneurysm Repair there will be modest profits of $40,717 at HSN, and $689 at SAH). Page 114

119 IP Cases Total HIG Wgt. IP Cases Total HIG Wgt. Exhibit 74: Projected Revenue Impact on Large NE LHIN Hospitals from Proposed Model of Care for Aortic Aneurysm Repair NE LHIN Hospital Proposed Activity 2012/13 HBAM QBP Net Unit Cost QBP Price per Wtd. Case Net Profit/Loss Per HIG Wtd. Case Total QBP Volume Health Science North $5,206 $5,334 $128 $40,717 Sault Area $5,302 $5,334 $32 $688 Grand Total $41,405 The profits for AA repair will be negated by the estimated losses for Lower Extremity Occlusive Disease. For LEOD vascular surgery the losses will be. -$52,133 for HSN and $18,880 for SAH. Exhibit 75: Projected Revenue Impact on Large NE LHIN Hospitals from Proposed Model of Care for Non-Cardiac Vascular Surgery for Lower Extremity Occlusive Disease NE LHIN Hospital Proposed Activity 2012/13 HBAM QBP Net Unit Cost QBP Price per Wtd. Case Net Profit/Loss Per HIG Wtd. Case Total QBP Volume Health Science North $5,206 $4,896 -$310 -$52,133 Sault Area $5,302 $4,896 -$406 -$18,880 North Bay RHC - - $6,113 $4,896 -$1,217 $- Grand Total $71,013 Page 115

120 12.0 Endoscopy 12.1 QBP Handbook Colonoscopy has been chosen to be the first endoscopic procedure to be funded under the QBP funding. Colonoscopy has been chosen by the MOHLTC and CCO to be the first endoscopic procedure to be funded under the QBP funding framework. It is expected that other endoscopic procedures will follow 111. The QBP handbook suggests that a large number of colonoscopies are currently being performed at out-of-hospital premises (OHPs) across the province. The handbook also reports that preliminary analysis suggests significant savings when certain colonoscopy procedures are delivered in an OHP. The Handbook recommends that the same performance and quality standards should apply to the provision of colonoscopies in both OHPs and hospitals. The QBP handbook also indicates that physicians practicing in an OHP will need to maintain hospital privileges and will need to provide coverage support to the hospital for either or both inpatients and emergency patients Current Characteristics of QBP Service Delivery in NE LHIN The following table presents the current (2012/13) volume of Day Surgery Colonoscopies provided by NE LHIN hospitals. Exhibit 76: 2012/13 Day Surgery Colonoscopy Activity in NE LHIN Hospitals Hub Hospital Visits Wtd. Cases Avg. Wght. Algoma Blind River Dist Hlth Ctr Lady Dunn Health Centre Sault Area Hospital 1, Algoma Total 2, MPSS Health Science North 5, Manitoulin HC St. Joseph's, Elliot Lake 1, West Parry Sound HC MPSS Total 8, Nip.-Temisk. Kirkland & District Hospital North Bay RHC 2, Temiskaming Hospital West Nipissing General It should be noted that CCO has recently indicated that all GI endoscopic procedures will be included in QBP funding. Page 116

121 Hub Hospital Visits Wtd. Cases Avg. Wght. Nip.-Temisk. Total 4, Cochrane & Coast Anson General Hospital Lady Minto Hospital Notre Dame Hospital Sensenbrenner Hospital Timmins & District 2, Weeneebayko Area HA Cochrane & Coast Total 4, Grand Total 18,782 1, In considering the current cost of outpatient colonoscopies, we have estimated the current costs using the current costs per CIHI RIW Weighted Case and the estimated percentage of hospital costs related to direct care. These estimates are provided in the following table for each NE LHIN hospital that reports colonoscopy procedures. Exhibit 77: 2012/13 NE LHIN Hospitals Estimated Day Surgery Colonoscopy Costs 2012/13 Actual Hospital RIW Cases Wtd. Estim. Cost Cases Health Science North 5, $ 3,105,313 Timmins & District 2, $ 1,555,928 North Bay RHC 2, $ 1,627,787 Sault Area Hospital 1, $ 1,325,541 St. Joseph's, Elliot Lake 1, $ 547,313 West Parry Sound HC $ 435,263 Temiskaming Hospital $ 404,732 West Nipissing General $ 307,195 Kirkland & District Hospital $ 290,021 Sensenbrenner Hospital $ 262,059 Manitoulin HC $ 216,227 Anson General Hospital $ 230,546 Lady Minto Hospital $ 244,327 Notre Dame Hospital $ 154,673 Lady Dunn Health Centre $ 85,630 Blind River Dist Hlth Ctr $ 49,930 Weeneebayko Area HA $ 22,513 Total 18,782 1,966.4 $ 10,864,999 Page 117

122 12.3 Proposed Model for Delivery of Endoscopy Services The Hub clinical workshops have developed and the Steering Committee has reviewed, refined and confirmed the following model for the care of colonoscopy patients in NE LHIN hospitals. Unless there are significant clinical and economic advantages to providing colonoscopies in out-ofhospital premises, colonoscopies in the NE LHIN should be provided in hospitals It is recommended that NE LHIN hospitals should use a consistent model of care in performing colonoscopies across region. Clinicians should provide leadership in the interpretation of the QBP Clinical Handbook for colonoscopies to develop this model of care and clinical pathway/order set. Led by Cancer Care Ontario, the Regional Cancer Program should provide coordination for this initiative. The model and approach to care should incorporate the following key elements: As a general rule, QBP colonoscopies should be provided in hospitals. Unless there are significant clinical and economic advantages to providing colonoscopies in out-of-hospital premises 112, in the NE LHIN, QBP funded colonoscopies should be restricted to hospital facilities Implications of Proposed Model for QBP Services Colonoscopies will continue to be provided by hospitals and the single OHP provider in Sault Ste Marie Given that, under the proposed model of care, colonoscopies will continue to be provided by hospitals and the single OHP provider in Sault Ste Marie, the proposed clinical integration model of car should not result in any significant change in the volumes of procedures provided or the cost per procedure at each site. Based on the currently available data, we have been unable to estimate the revenues that can be expected for colonoscopies to be funded under the QBP model. What is known is that: QBP funding will not include the cost of pathology, and correspondingly the carve out will also not include the cost of pathology. 112 If QBP funded colonoscopies are to be provided in OHPs, then binding covenants must be provided to ensure that physicians participating in these OHPs continue to be meaningfully involved in supporting the clinical activities of the hospital. 113 The only exception is in Sault Ste Marie where the existing OHP provider of colonoscopies should be allowed to continue, and depending on the emerging policy for Community Based Specialty Clinics, it should be considered for QBP funding for the colonoscopies that it is providing. Page 118

123 The QBP funding will only cover the direct costs of the procedure, and correspondingly, the carve out will also only include the direct costs of the procedure. Unfortunately, specific carve-out amounts and the QBP price for colonoscopies are not yet available to this project. More detailed information will be required to support estimates of hospital QBP colonoscopy revenues and the resulting profits and/or losses from the provision of endoscopy procedures Evaluating the QBP Integration Model The Steering Committee applied its evaluation framework to the recommended Endoscopy Clinical Integration Model. The application of the framework is presented in the following tables. As can be seen, the recommended model scores highly on both the integration and the siting criteria. Exhibit 78: Application of Integration and Siting Criteria to Colonoscopy Model of Care Criteria Definition Scoring: 0=No; Integration 0.5=Maybe; 1=Yes 1 Maintain/ Improve quality The distribution of clinical services will ensure quality of care standards and practices, clinical outcomes; safety and risk management are optimized 1.0 TOTALS 2 Appropriate critical mass The distribution of clinical services will be structured to ensure that programs/services have appropriate crticial mass (i.e. volume) to allow for the provision of safe, effective, efficient and timely services while reflecting 1.0 remote considerations 3 Access to Care Supports access to care requiring multi-system specialized services (e.g. cancer, cardiology). The distribution of services will improve access to care and/or 0.5 reduce medical, emotional and financial impact on patients. 4 Potential repatriation The distribution of clinical services will enhance the potential to deliver the appropriate services within the north east Maintain/ Improve operating The distribution of clinical services will be structured to create a more cost efficiency/achieve economies effective and efficient service cost profile in the LHIN and will not result in of scale increased system funding for operations 6 Attract/retain specialized clinical skills The distribution of clinical services will be structured to enhance the potential of recruiting and/or retaining the specialized skills required for the delivery of the service and will not result in the hospital losing physician or other HHR % Page 119

124 Siting 1 Meets community need The distribution of clinical services will help to minimize variation in health outcomes across the region Improves access to care The distribution of clinical services will be structured to improve patients' access to high quality programs/services closer to home. The distribution of services 1.0 will provide timely access to care 24/7, 365 days/year. 3 Supports clinical The distribution of clinical services will be aligned by site to ensure that clinical interdependencies and clinical interdependencies and patient flow is optimized and efficient 1.0 coherence 4 Meets current & future capacity limitations at site The distribution of clinical services will consider the current capacity of the potential host site and potential future capacity changes at the host site Enhance Regional Capability There is capacity and capability of the site to provide district or regional support to satellites if service is provided as a single program % Page 120

125 13.0 Chemotherapy 13.1 QBP Handbook The QBP clinical handbook for Chemotherapy has suggested that QBP funding will be developed for 2 phases of cancer care. Phase 1 Will focus on the bundle of services included in the consultation for systemic treatment in the current phase of QBP funding. A subsequent activity will focus on the bundle of activities related to diagnosis and staging. Phase 2 Will include the bundle of services related to parenteral treatment (for adjuvant, neo-adjuvant, curative intent). The bundle of services starts with a medical oncologist consultation and ends 28 days later. It consists of 2 patient visits initial consult and activities related to patient education. It is expected that 85% of patients should start treatment within 28 days of consulting with a medical oncologist Current Characteristics of Chemotherapy Service Delivery in NE LHIN The following table presents the current volume of chemotherapy treatment in the NE LHIN. Exhibit 79: 2012/13 Chemotherapy Activity in NE LHIN Hospitals Hub Hospital Visits Wtd. Avg. Cases Wght. Algoma Blind River Dist Hlth Ctr Hornepayne Community Lady Dunn Health Centre Sault Area Hospital 2, Algoma Total 2, MPSS Health Science North 6,530 1, Manitoulin HC St. Joseph's, Elliot Lake West Parry Sound HC MPSS Total 7,553 1, Nip.-Temisk. Kirkland & District Hospital North Bay RHC 1, Temiskaming Hospital West Nipissing General Nip.-Temisk. Total 3, Cochrane & Coast Lady Minto Hospital Sensenbrenner Hospital Timmins & District 1, Cochrane & Coast Total 1, Grand Total 14,622 2, Page 121

126 13.3 Proposed Model for Delivery of Systemic Therapy Services The Hub clinical workshops have developed and the Steering Committee has reviewed, refined and confirmed the following model for the systemic therapy in NE LHIN hospitals. The process has recommended that the NE LHIN should continue the current consolidated model as defined by CCO. This includes the following key elements: A network of Community Oncology Clinics comprised of the Northeastern Ontario community hospitals that work closely with the North East Regional Cancer Program to provide drug treatments closer to patients homes. Sault Area Hospital Algoma District Cancer Program. An extensive regional ambulatory oncology information system that supports Computerized Physician Order Entry in Sudbury with remote use for 90% of satellite chemotherapy treatments across the region. Given the nature of the proposed model of care, there is no volume or revenue projection required Evaluating the Chemotherapy Integration Model The Steering Committee applied its evaluation framework to the recommended Chemotherapy Clinical Integration Model. The application of the framework is presented in the following tables. As can be seen, the recommended model scores highly on both the integration and the siting criteria. Page 122

127 Exhibit 80: Application of Integration and Siting Criteria to Chemotherapy Model of Care CHEMOTHERAPY Criteria Definition Scoring: 0=No-N/A; Integration 0.5=Maybe; 1=Yes 1 Maintain/ Improve quality The distribution of clinical services will ensure quality of care standards and practices, clinical outcomes; safety and risk management are optimized 1.0 TOTALS 2 Appropriate critical mass The distribution of clinical services will be structured to ensure that programs/services have appropriate crticial mass (i.e. volume) to allow for the provision of safe, effective, efficient and timely services while reflecting 1.0 remote considerations 3 Access to Care Supports access to care requiring multi-system specialized services (e.g. cancer, cardiology). The distribution of services will improve access to care and/or 0.5 reduce medical, emotional and financial impact on patients. 4 Potential repatriation The distribution of clinical services will enhance the potential to deliver the appropriate services within the north east Maintain/ Improve operating The distribution of clinical services will be structured to create a more cost efficiency/achieve economies effective and efficient service cost profile in the LHIN and will not result in of scale increased system funding for operations 6 Attract/retain specialized clinical skills clinical skills The distribution of clinical services will be structured to enhance the potential of recruiting and/or retaining the specialized skills required for the delivery of the of recruiting service and and/or will not retaining result the in the specialized hospital losing skills required physician for or the other delivery HHR of the service and will not result in the hospital losing physician or other HHR Siting 1 Meets community need The distribution of clinical services will help to minimize variation in health outcomes across the region Improves access to care The distribution of clinical services will be structured to improve patients' access to high quality programs/services closer to home. The distribution of services 1.0 will provide timely access to care 24/7, 365 days/year. 3 Supports clinical The distribution of clinical services will be aligned by site to ensure that clinical interdependencies and clinical interdependencies and patient flow is optimized and efficient 1.0 coherence 4 Meets current & future capacity limitations at site 1.0 The distribution of clinical services will consider the current capacity of the potential host site and potential future capacity changes at the host site % % 5 Enhance Regional Capability There is capacity and capability of the site to provide district or regional support to satellites if service is provided as a single program % Page 123

128 14.0 Summary of Implications of QBP Clinical Integration Models of Care Ensuring timely and equitable patient access to high quality care Implementation of the proposed clinical integration models for each inpatient QBP will have a significant and positive impact the care provided to QBP patients in all the hospitals in the North East LHIN. The most significant impacts will come from changes in clinical practices to ensure timely and equitable patient access to high quality care. These most significant of these changes are: There will be consistent clinical models of care, pathways and order sets for all QBPs across all LHIN hospitals. Local hospitals will transfer all stroke cases directly to hub hospitals rather than admitting and treating these patients locally. Local hospitals will transfer higher acuity CHF, COPD and Hip Fracture cases from their Emergency Departments directly to hub hospitals rather than first admitting, stabilizing and then transferring. Local hospitals will focus on lower and moderate acuity CHF COPD cases; these will all be admitted and cared for locally. Lengths of stay for stroke patients will be reduced so as to achieve an average length of stay equivalent to the QBP target lengths of stay; lengths of stay for all other QBPs will be reduced to be no more than the provincial average length of stay for that QBP. The percentage of atypical patients for a QBP will be reduced to the lowest percentage of Ontario LHINs. Once a QBP patient s condition is stabilized at a hub hospital, the patient will be transferred to his/her local hospital for the completion of his/her acute care and/or for rehabilitation. However, stroke patients will complete both their acute and rehabilitation care at the hub hospital. There will be an increase in the percentage of stroke, hip fracture and TJR patients transferred to inpatient rehabilitation both at hub hospitals and at local hospitals. Hub hospitals will offer outpatient clinics to provide post acute and chronic disease management care for CHF, COPD, TIA and Stroke patients. There will be integrated clinical programs across each hub to provide care for hip fracture and TJR patients and for cataract Page 124

129 IP Cases % Atyp. Case IP Days Avg. LOS HIG Wtd Cases. IP Cases % Atyp. Case IP Days Avg. LOS HIG Wtd Cases. IP Cases IP Days HIG Wtd Cases. patients. There will be an integrated, LHIN wide clinical program to provide care for vascular surgery patients Inpatient Acute Care The following table presents the impact on inpatient acute care patient volume, patient days and weighted cases across all of the LHIN hospitals of the implementation of the proposed clinical integration models for each inpatient QBP. As can be seen there will be a significant reduction in patient days resulting from both more consistent QBP lengths of stay that are less than or equal to the provincial average for the typical cases in the QBP and a reduction in the number of atypical cases. As a result of the reduction in the number of atypical cases there will also be a significant reduction in the number of weighted cases. Exhibit 81: Projected Impact on NE LHIN IP Hospital Activity of Proposed Models of QBP Care 2012/13 Actual Activity Proposed Activity Change In Activity Inpatient QBP CHF 1,386 22% 11, ,103 1,347 14% 6, , , COPD 2,168 19% 18, ,103 2,144 14% 9, , , TIA 286 9% 1, % Ischemic Stroke % 7, , % 2, , , Haem Stroke 64 33% 1, % THR 625 5% 2, , % 2, , TKR 1,337 4% 5, ,059 1,585 1% 5, , Hip Fracture % 10, , % 3, , , AAA Repair 94 38% % LEOD % % Total 7,361 59, ,473 7,519 33, , , Page 125

130 IP Cases % Atyp. Case IP Days Avg. LOS HIG Wgt. IP Cases % Atyp. Case IP Days Avg. LOS HIG Wgt. IP Cases IP Days HIG Wght. The following tables show the impact on each hospital of each QBP. Exhibit 82: Projected Impact on NE LHIN Hospital Activity of Proposed Model of Care for CHF /13 Actual Activity Proposed Activity Change In Activity NE LHIN Hospital Blind River Dist HC 8 25% % Chapleau Hlth Serv 12 42% % Lady Minto 13 38% % St. Jos, Elliot Lk 37 24% % Englehart & District 12 17% % Espanola General 23 35% % Notre Dame 5 20% % Hornepayne 3 33% % Anson General 9 22% % Lady Dunn HC 8 50% % Sensenbrenner 31 10% % Kirkland & District 25 28% % Bingham Memorial 3 67% % Mattawa General 10 20% % Manitoulin HC 38 34% % Smooth Rock Falls 5 0% % West Nipissing 30 23% % Temiskaming 48 29% % Timmins & District % % West Parry Sd HC 69 16% % Health Science N % 4, % 2, , Sault Area % 2, % 1, , Weeneebayko 14 36% % North Bay RHC % 1, % 1, Grand Total 1,386 22% 11, ,103 1,347 14% 6, , , It should be noted that the hospitals average lengths of stay for CHF patients under the proposed model of care will decline from the current value because the model assumes that all patients (except for the residual atypical patients) stay in acute care for no more than the target length of stay. As a result the modeling reflects a decline in lengths of stay for most patients and thus a (sometimes significant) decrease in the average lengths of stay for all hospitals. Because some CHF patients stay in hospital for shorter periods than the target lengths of stay and the modeling did not increase their lengths of stay, the hospitals resulting average lengths of stay is often less than the target length of stay. Page 126

131 IP Cases % Atyp. Case IP Days Avg. LOS HIG Wgt. IP Cases % Atyp. Case IP Days Avg. LOS HIG Wgt. IP Cases IP Days HIG Wght. Exhibit 83: Projected Impact on NE LHIN Hospital Activity of Proposed Model of Care for COPD /13 Actual Activity Proposed Activity Change In Activity NE LHIN Hospital Blind River Dist HC 15 27% % Chapleau Hlth Serv 14 36% % Lady Minto 20 25% % St. Joseph's, Elliot Lk 81 25% 1, % Englehart & District 37 24% % Espanola General 34 12% % Notre Dame 22 14% % Hornepayne 3 33% % Anson General 28 21% % Lady Dunn HC 4 25% % Sensenbrenner 53 19% % Kirkland & District 67 22% % Bingham Memorial 4 0% % Mattawa General 11 36% % Manitoulin HC 70 19% % Smooth Rock Falls 20 25% % West Nipissing 60 27% % Temiskaming 47 15% % Timmins & District % 1, % West Parry Sound HC 56 20% % Health Science North % 5, % 2, , Sault Area % 2, % 1, Weeneebayko 13 31% % North Bay RHC % 2, % 1, Grand Total 2,168 19% 18, ,103 2,144 14% 9, , , It should be noted that the hospitals average lengths of stay for COPD patients under the proposed model of care will decline from the current value because the model assumes that all patients (except for the residual atypical patients) stay in acute care for no more than the target length of stay. As a result the modeling reflects a decline in lengths of stay for most patients and thus a (sometimes significant) decrease in the average lengths of stay for all hospitals. Because some COPD patients stay in hospital for shorter periods than the target lengths of stay and the modeling did not increase their lengths of stay, the hospitals resulting average lengths of stay is often less than the target length of stay. Page 127

132 IP Cases % Atyp. Case IP Days Avg. LOS HIG Wgt. IP Cases % Atyp. Case IP Days Avg. LOS HIG Wgt. IP Cases IP Days HIG Wght. IP Cases % Atyp. Case IP Days Avg. LOS HIG Wgt. IP Cases % Atyp. Case IP Days Avg. LOS HIG Wgt. IP Cases IP Days HIG Wght. Exhibit 84: Projected Impact on NE LHIN Hospital Activity of Proposed Model of Care for TIA 2012/13 Actual Activity Proposed Activity Change In Activity NE LHIN Hospital Blind River Dist HC 3 0% Chapleau Hlth Serv Lady Minto 5 20% St. Joseph's, Elliot Lk 5 20% Englehart & District 3 0% Espanola General 3 33% Notre Dame 2 0% Hornepayne 1 0% Anson General 3 0% Lady Dunn HC Sensenbrenner 3 33% Kirkland & District 3 33% Bingham Memorial Mattawa General 4 0% Manitoulin HC 13 8% Smooth Rock Falls West Nipissing 14 7% Temiskaming 7 0% Timmins & District 17 0% % West Parry Sound HC 6 17% Health Science North 57 9% % Sault Area 54 11% % Weeneebayko 1 100% North Bay RHC 82 9% % Grand Total 286 9% 1, % Exhibit 85: Projected Impact on NE LHIN Hospital Activity of Proposed Model of Care for Ischemic and Unspecified Stroke 2012/13 Actual Activity Proposed Activity Change In Activity NE LHIN Hospital Blind River Dist HC 4 50% Chapleau Hlth Serv 4 75% Lady Minto 3 33% St. Joseph's, Elliot Lk 24 29% Englehart & District 3 33% Espanola General 10 40% Notre Dame 3 0% Hornepayne 3 67% Anson General 3 33% Lady Dunn HC 2 50% Sensenbrenner 10 30% Page 128

133 IP Cases % Atyp. Case IP Days Avg. LOS HIG Wgt. IP Cases % Atyp. Case IP Days Avg. LOS HIG Wgt. IP Cases IP Days HIG Wght. IP Cases % Atyp. Case IP Days Avg. LOS HIG Wgt. IP Cases % Atyp. Case IP Days Avg. LOS HIG Wgt. IP Cases IP Days HIG Wght. 2012/13 Actual Activity Proposed Activity Change In Activity NE LHIN Hospital Kirkland & District 8 25% Bingham Memorial 2 50% Mattawa General 7 29% Manitoulin HC 13 23% Smooth Rock Falls West Nipissing 13 46% Temiskaming 17 47% Timmins & District 66 45% % West Parry Sound HC 29 10% Health Science North % 2, % 1, , Sault Area % % Weeneebayko 5 40% North Bay RHC 98 11% % Grand Total % 7, , % 2, , , Exhibit 86: Projected Impact on NE LHIN Hospital Activity of Proposed Model of Care for Haemorrhagic Stroke 2012/13 Actual Activity Proposed Activity Change In Activity NE LHIN Hospital Blind River Dist HC Chapleau Hlth Serv Lady Minto St. Joseph's, Elliot Lk 1 0% Englehart & District 1 0% Espanola General 1 0% Notre Dame Hornepayne 1 100% Anson General Lady Dunn HC Sensenbrenner Kirkland & District Bingham Memorial Mattawa General Manitoulin HC 1 0% Smooth Rock Falls 1 100% West Nipissing Temiskaming 3 33% Timmins & District 4 25% % West Parry Sound HC 2 50% Health Science North 29 31% % Sault Area 12 50% % Weeneebayko North Bay RHC 8 13% % Grand Total 64 33% 1, % Page 129

134 IP Cases % Atyp. Case IP Days Avg. LOS HIG Wgt. IP Cases % Atyp. Case IP Days Avg. LOS HIG Wgt. IP Cases IP Days HIG Wght. IP Cases % Atyp. Case IP Days Avg. LOS HIG Wgt. IP Cases % Atyp. Case IP Days Avg. LOS HIG Wgt. IP Cases IP Days HIG Wght. Exhibit 87: Projected Impact on NE LHIN Hospital Activity of Proposed Model of Care for THR /13 Actual Activity Proposed Activity Change In Activity NE LHIN Hospital Timmins & District 21 19% % West Parry Sound HC 86 0% % Health Science North 258 6% 1, % 1, Sault Area 116 5% % North Bay RHC 144 4% % Grand Total 625 5% 2, , % 2, , Exhibit 88: NE LHIN Hospital Projected Impact on NE LHIN Hospital Activity of Proposed Model of Care for TKR 2012/13 Actual Activity Proposed Activity Change In Activity Timmins & District 88 25% % West Parry Sound HC 90 1% % Health Science North 475 3% 2, % 1, Sault Area 222 4% % North Bay RHC 462 2% 1, % 1, Grand Total 1,337 4% 5, ,059 1,585 1% 5, , It should be noted that the hospitals average lengths of stay for TJR patients under the proposed model of care will decline from the current value because the model assumes that all patients (except for the residual atypical patients) stay in acute care for no more than the target length of stay. As a result the modeling reflects a decline in lengths of stay for most patients and thus a (sometimes significant) decrease in the average lengths of stay for all hospitals. Because some TJR patients stay in hospital for shorter periods than the target lengths of stay and the modeling did not increase their lengths of stay, the hospitals resulting average lengths of stay is often less than the target length of stay. Page 130

135 IP Cases % Atyp. Case IP Days Avg. LOS HIG Wgt. IP Cases % Atyp. Case IP Days Avg. LOS HIG Wgt. IP Cases IP Days HIG Wght. Exhibit 89: Projected Impact on NE LHIN Hospital Activity of Proposed Model of Care for Hip Fracture /13 Actual Activity Proposed Activity Change In Activity NE LHIN Hospital Blind River Dist HC 2 100% Chapleau Hlth Serv Lady Minto 3 100% St. Joseph's, Elliot Lk 12 58% % Englehart & District 3 100% % Espanola General 2 50% % Notre Dame 1 100% Hornepayne Anson General 1 100% Lady Dunn HC 1 100% Sensenbrenner 6 83% % Kirkland & District 7 86% % Bingham Memorial 2 50% Mattawa General 2 100% Manitoulin HC 9 89% % Smooth Rock Falls West Nipissing 2 100% Temiskaming % Timmins & District 88 55% % West Parry Sound HC 37 24% 1, % , Health Science North % 3, % 1, , Sault Area % 1, % Weeneebayko 2 50% % North Bay RHC % 1, % Grand Total % 10, , % 3, , , It should be noted that the hospitals average lengths of stay for Hip Fx patients under the proposed model of care will decline from the current value because the model assumes that all patients (except for the residual atypical patients) stay in acute care for no more than the target length of stay. As a result the modeling reflects a decline in lengths of stay for most patients and thus a (sometimes significant) decrease in the average lengths of stay for all hospitals. Because some Hip Fx patients stay in hospital for shorter periods than the target lengths of stay and the modeling did not increase their lengths of stay, the hospitals resulting average lengths of stay is often less than the target length of stay. Page 131

136 IP Cases % Atyp. Case IP Days Avg. LOS HIG Wgt. IP Cases % Atyp. Case IP Days Avg. LOS HIG Wgt. IP Cases IP Days HIG Wght. IP Cases % Atyp. Case IP Days Avg. LOS HIG Wgt. IP Cases % Atyp. Case IP Days Avg. LOS HIG Wgt. IP Cases IP Days HIG Wght. Exhibit 90: Projected Impact on NE LHIN Hospital Activity of Proposed Model of Care for Aortic Aneurysm Repair 2012/13 Actual Activity Proposed Activity Change In Activity NE LHIN Hospital Health Science North 89 40% % Sault Area 5 0% % Grand Total 94 38% % Exhibit 91: Projected Impact on NE LHIN Hospital Activity of Proposed Model of Care for Non-Cardiac Vascular Surgery for Lower Extremity Occlusive Disease 2012/13 Actual Activity Proposed Activity Change In Activity NE LHIN Hospital Health Science North 93 14% % Sault Area 26 0% % North Bay RHC 1 0% Grand Total % % Inpatient Rehabilitation More than triple the number of patients being discharged to inpatient rehabilitation Implementation of the proposed clinical models of care for Stroke, TJR and Hip Fracture will dramatically change the current approach to the organization and delivery of rehabilitation services in the North East LHIN. Currently (2012/13) there are only 312 of these QBP patients being discharged from acute care 118. The proposed models of care suggest that 987 of these patients should have been discharged to inpatient rehabilitation; this would more than triple the number of patients being discharged to inpatient rehabilitation. Given the suggested ALOS for these patients in rehabilitation, these patients would require 26,352 patient days of care and, at 90% occupancy, would require 80.2 inpatient rehabilitation beds. The inpatient rehabilitation for stroke patients is to be provided in the hub hospitals. The inpatient rehabilitation for TJR and Hip Fracture patients can be provided in the patients local hospitals, in a CCC/Rehabilitation hospital or in the hub hospital. This increase in the use of rehabilitation beds will require significant planning and potential repurposing of beds that are no longer required for acute care because of the significant reduction in the need for acute care patient days under the proposed models of care. 118 As reflected in the hospitals CIHI DAD data. Page 132

137 HIG Wtd. Cases QBP Current Discharge to IP Rehabilitation Proposed Models of Care % Number % Number Pat. Days Beds Stroke 36.0% % 264 8, TJR 1.7% % 237 3, Hip Fx 12.6% % , Totals , Outpatient Care Enhanced and/or expanded medical and rehabilitation outpatient care The medical and surgical QBP models of care will require enhanced and/or expanded medical and rehabilitation outpatient care as part of the continuum care. These services will be delivered and/or supported by clinicians at the hub hospitals. To improve access to care, telemedicine and/or telehomecare will be used to support care provided by local hospitals and/or home care providers in patients home communities Acute Care Costs and Revenues Based on their current cost per weighted case, the projected QBP revenue for the large hospitals will be approximately $1.7 million less than the estimated cost of care for QBP patients Reductions in the number of atypical cases and the associated weighted cases along with reductions in the lengths of stay in acute care for these QBP patients will result in a reduction in the estimated cost of care in the larger/qbp funded hospitals of approximately $1.8 million. Exhibit 92: Projected Inpatient Acute Care Activity and Profit/Loss for QBP Care of in Large NE LHIN Hospitals Inpatient QBP Proposed Activity Estimated Cost QBP Revenue Net Profit/ Loss for Large Hospitals CHF 1,672 $8,886,456 $8,546,489 -$339,967 COPD 2,445 $13,017,867 $13,086,600 $68,733 TIA 117 $647,732 $645,051 -$2,681 Ischemic Stroke 1,176 $6,296,462 $5,845,007 -$451,456 Haem Stroke 133 $711,168 $723,854 $12,685 THR 1,310 $7,096,942 $6,828,561 -$268,381 TKR 2,383 $12,901,242 $12,361,599 -$539,643 Hip Fracture 1,418 $7,560,130 $7,371,263 -$188,867 AAA Repair 338 $1,763,134 $1,804,539 $41,405 LEOD 214 $1,120,826 $1,049,813 -$71,013 Total 11,206 $60,001,960 $58,262,776 -$1,739,184 Page 133

138 However, it should be noted that, based on the current cost per weighted case of care in these hospitals, the projected QBP revenue for the larger hospitals will be approximately $1.7 million less than the estimated cost of caring for QBP patients. If these hospitals are successful in reducing the lengths of stay for typical cases, they may be able to reduce their cost of caring for these patients to be less than the price being paid and thus move from a loss to a profit position in caring for QBP patients 119. This should be an immediate objective for these QBP funded hospitals. Currently QBP funding does not provide for inpatient and outpatient rehabilitation and outpatient clinic services that are critical to the success of the QBP models of care It also should be noted that these projections do not include the additional costs of additional inpatient rehabilitation that will be required for several of the QBP models of care nor do they include the additional costs related to outpatient clinics and rehabilitation services that will also be required. There will be significant increased costs, but currently the QBP funding does not provide any additional funding to support these services that are critical to the success of the QBP models of care. The following tables present summary information by QBP for each of the large NE LHIN hospitals that will be affected by QBP funding. Exhibit 93: St. Joseph s Change in Activity and Net Revenue Impact of QBP Clinical Integration Models QBP Summary by QBP for Hospital: St. Joseph's, Elliot Lake 2012/13 Actual Proposed Model 2012/13 QBP HBAM Price HIG IP Estimated IP Estimated QBP per Wtd. Cases Cost Cases Cost Net Unit Wtd. Cases Cost Case Net Profit/Loss Per HIG Wtd. Case Total QBP Volume AA Repair - $- - - $- $3,718 $5,334 $1,616 $- Non-Cardiac Vasc. LEOD - $- - - $- $3,718 $4,896 $1,178 $- CHF 37 $233, $113,748 $3,718 $5,110 $1,392 $42,589 COPD 81 $577, $309,958 $3,718 $5,352 $1,634 $136,220 Hip Fracture 12 $112, $61,798 $3,718 $5,200 $1,482 $24,633 Hip Replacement - $- - - $- $3,718 $5,214 $1,496 $- Knee Replacement - $- - - $- $3,718 $5,188 $1,470 $- 119 The hospitals cost per weighted case is based on the cost of caring for all patients; not just QBP patients. As a result, we have not modelled the impact on the hospitals cost per HIG wtd case of reducing lengths of stay for QBP patients. It should be significant and may result in the hospitals achieving a notional profit on QBP patients. The actual cost of caring for QBP patients under the proposed models of care and lengths of stay, as opposed to the implied cost as reflected in the attribution of costs through the use of costs per weighted cases, will likely be much less than the current QBP price. The current QBP price is based on the provincial average cost per HIG wtd case; not the actual current cost per case of caring for QBP patients in Ontario hospitals nor the cost per case under the QBP best practice models of care. Page 134

139 QBP Summary by QBP for Hospital: St. Joseph's, Elliot Lake 2012/13 Actual Proposed Model 2012/13 QBP HBAM Price HIG IP Estimated IP Estimated QBP per Wtd. Cases Cost Cases Cost Net Unit Wtd. Cases Cost Case Net Profit/Loss Per HIG Wtd. Case Total QBP Volume Stroke Hemorrhage 1 $5, $- $3,718 $5,452 $1,734 $- Stroke Ischemic 24 $249, $- $3,718 $4,970 $1,252 $- Stroke TIA 5 $21, $- $3,718 $5,513 $1,795 $- Grand Total 160 $1,200, $485,504 $203,442 Exhibit 94: Temiskaming Change in Activity and Net Revenue Impact of QBP Clinical Integration Models QBP Summary by QBP for Hospital: Temiskaming 2012/13 Actual Proposed Model 2012/13 HBAM HIG IP Estimated IP Estimated QBP Wtd. Cases Cost Cases Cost Net Unit Cases Cost QBP Price per Wtd. Case Net Profit/Loss Per HIG Wtd. Case Total QBP Volume AA Repair - $- - - $- $4,710 $5,334 $624 $- Non-Cardiac Vasc. LEOD - $- - - $- $4,710 $4,896 $186 $- CHF 48 $437, $181,610 $4,710 $5,110 $400 $15,426 COPD 47 $352, $159,914 $4,710 $5,352 $642 $21,796 Hip Fracture 13 $26, $- $4,710 $5,200 $490 $- Hip Replacement - $- - - $- $4,710 $5,214 $504 $- Knee Replacement - $- - - $- $4,710 $5,188 $478 $- Stroke Hemorrhage 3 $16, $- $4,710 $5,452 $742 $- Stroke Ischemic 17 $271, $- $4,710 $4,970 $260 $- Stroke TIA 7 $19, $- $4,710 $5,513 $803 $- Grand Total 135 $1,122, $341,524 $37,223 Exhibit 95: Timmins & District Change in Activity and Net Revenue Impact of QBP Clinical Integration Models QBP Summary by QBP for Hospital: Timmins & District 2012/13 Actual Proposed Model 2012/13 HBAM IP HIG IP Estimated Estimated QBP Case Wtd. Cases Cost Cost Net Unit s Cases Cost QBP Price per Wtd. Case Net Profit/Loss Per HIG Wtd. Case Total QBP Volume AA Repair - $- - - $- $4,705 $5,334 $629 $- Non-Cardiac Vasc. LEOD - $- - - $- $4,705 $4,896 $191 $- CHF 117 $739, $823,916 $4,705 $5,110 $405 $70,935 COPD 211 $1,186, $1,345,683 $4,705 $5,352 $647 $185,043 Hip Fracture 88 $856, $983,120 $4,705 $5,200 $495 $103,431 Hip Replacement 21 $154, $472,159 $4,705 $5,214 $509 $51,102 Knee Replacement 88 $644, $1,499,584 $4,705 $5,188 $483 $153,828 Stroke Hemorrhage 4 $20, $48,803 $4,705 $5,452 $747 $7,748 Stroke Ischemic 66 $563, $836,917 $4,705 $4,970 $265 $47,201 Stroke TIA 17 $47, $76,884 $4,705 $5,513 $808 $13,207 Grand Total 612 $4,212, ,294 $6,087,067 $632,497 Page 135

140 Exhibit 96: W. Parry Sound HC Change in Activity and Net Revenue Impact of QBP Clinical Integration Models QBP Summary by QBP for Hospital: West Parry Sound HC 2012/13 Actual Proposed Model 2012/13 HBAM HIG IP Estimated IP Estimated QBP Wtd. Cases Cost Cases Cost Net Unit Cases Cost QBP Price per Wtd. Case Net Profit/Loss Per HIG Wtd. Case Total QBP Volume AA Repair - $- - - $- $5,257 $5,334 $77 $- Non-Cardiac Vasc. LEOD - $- - - $- $5,257 $4,896 -$361 $- CHF 69 $622, $300,178 $5,257 $5,110 -$147 -$8,389 COPD 56 $513, $267,728 $5,257 $5,352 $95 $4,837 Hip Fracture 37 $1,770, $461,853 $5,257 $5,200 -$57 -$5,008 Hip Replacement 86 $747, $316,532 $5,257 $5,214 -$43 -$2,575 Knee Replacement 90 $717, $371,459 $5,257 $5,188 -$69 -$4,901 Stroke Hemorrhage 2 $13, $- $5,257 $5,452 $195 $- Stroke Ischemic 29 $713, $- $5,257 $4,970 -$287 $- Stroke TIA 6 $23, $- $5,257 $5,513 $256 $- Grand Total 375 $5,121, $1,717,751 -$16,036 QBP Exhibit 97: Health Sciences North Change in Activity and Net Revenue Impact of QBP Clinical Integration Models Summary by QBP for Hospital: Health Science North 2012/13 Actual Proposed Model 2012/13 HBAM HIG IP Estimated IP Estimated QBP Wtd. Cases Cost Cases Cost Net Unit Cases Cost QBP Price per Wtd. Case Net Profit/Loss Per HIG Wtd. Case Total QBP Volume AA Repair 89 $1,695, $1,650,572 $5,206 $5,334 $128 $40,717 Non-Cardiac Vasc. LEOD 93 $1,044, $874,486 $5,206 $4,896 -$310 -$52,133 CHF 406 $3,519, $3,427,768 $5,206 $5,110 -$96 -$63,157 COPD 555 $4,988, $4,385,505 $5,206 $5,352 $146 $122,972 Hip Fracture 207 $3,358, $2,558,814 $5,206 $5,200 -$6 -$2,949 Hip Replacement 258 $2,300, $2,995,299 $5,206 $5,214 $8 $4,733 Knee Replacement 475 $3,898, $5,040,404 $5,206 $5,188 -$18 -$17,774 Stroke Hemorrhage 29 $240, $367,198 $5,206 $5,452 $246 $17,349 Stroke Ischemic 171 $2,095, $2,469,425 $5,206 $4,970 -$236 -$111,775 Stroke TIA 57 $217, $170,141 $5,206 $5,513 $307 $10,041 Grand Total 2,340 $23,358,640 2,728 4,598 $23,939,614 -$51,976 Page 136

141 Exhibit 98: SAH Change in Activity and Net Revenue Impact of QBP Clinical Integration Models QBP Summary by QBP for Hospital: Sault Area 2012/13 Actual Proposed Model 2012/13 HBAM HIG IP Estimated IP Estimated QBP Wtd. Cases Cost Cases Cost Net Unit Cases Cost QBP Price per Wtd. Case Net Profit/Loss Per HIG Wtd. Case Total QBP Volume AA Repair 5 $135, $112,562 $5,302 $5,334 $32 $688 Non-Cardiac Vasc. LEOD 26 $240, $246,340 $5,302 $4,896 -$406 -$18,880 CHF 282 $2,218, $2,074,987 $5,302 $5,110 -$192 -$75,110 COPD 433 $2,750, $3,085,250 $5,302 $5,352 $50 $29,083 Hip Fracture 130 $1,707, $1,636,618 $5,302 $5,200 -$102 -$31,485 Hip Replacement 116 $1,130, $1,268,099 $5,302 $5,214 -$88 -$20,993 Knee Replacement 222 $1,761, $1,817,397 $5,302 $5,188 -$114 -$39,199 Stroke Hemorrhage 12 $141, $142,988 $5,302 $5,452 $150 $4,044 Stroke Ischemic 125 $1,013, $1,383,229 $5,302 $4,970 -$332 -$86,522 Stroke TIA 54 $200, $97,036 $5,302 $5,513 $211 $3,866 Grand Total 1,405 $11,300,511 1,420 2,238 $11,864,507 -$234,508 Exhibit 99: North Bay Change in Activity and Net Revenue Impact of QBP Clinical Integration Models QBP Summary by QBP for Hospital: North Bay RHC 2012/13 Actual Proposed Model 2012/13 HBAM HIG IP Estimated IP Estimated QBP Wtd. Cases Cost Cases Cost Net Unit Cases Cost QBP Price per Wtd. Case Net Profit/Loss Per HIG Wtd. Case Total QBP Volume AA Repair - $- - - $- $6,113 $5,334 -$779 $- Non-Cardiac Vasc. LEOD 1 $9, $- $6,113 $4,896 -$1,217 $- CHF 178 $1,542, $1,964,248 $6,113 $5,110 -$1,003 -$322,262 COPD 310 $2,535, $3,463,828 $6,113 $5,352 -$761 -$431,219 Hip Fracture 128 $1,891, $1,857,927 $6,113 $5,200 -$913 -$277,489 Hip Replacement 144 $1,493, $2,044,852 $6,113 $5,214 -$899 -$300,648 Knee Replacement 462 $4,306, $4,172,397 $6,113 $5,188 -$925 -$631,598 Stroke Hemorrhage 8 $81, $152,179 $6,113 $5,452 -$661 -$16,456 Stroke Ischemic 98 $985, $1,606,891 $6,113 $4,970 -$1,143 -$300,360 Stroke TIA 82 $377, $303,671 $6,113 $5,513 -$600 -$29,794 Grand Total 1,411 $13,223,742 1,552 2,546 $15,565,993 -$2,309,826 Page 137

142 15.0 Implementation Plan: Staging and Phasing The Steering Committee developed a plan to guide the implementation of the recommended changes in the organization and delivery of QBP services. The following paragraphs provide the key elements of the implementation plan. Steering Committee A Steering Committee to oversee the implementation of the clinical integration models The NE LHIN hospitals and the LHIN should appoint a Steering Committee 120 to guide the review and approval of the recommended clinical integration models, to develop and oversee a communication plan in support of the integration models and then to oversee the implementation of the clinical integration models. Communication Communication strategy and plan The Steering Committee should develop a communication strategy and plan that focuses on the interests and potential concerns of key stakeholders. The communication should consider stakeholders in the following order: Hospitals, CCAC and LHIN MOHLTC Provincial and local politicians Physicians that will be affected Patients that will be affected and their advocacy groups Community agencies that will be affected Physicians in LHIN hospitals Community physicians Community agencies Communities served by NE LHIN hospitals Hospital and LHIN Review Distribute report to hospitals for comment This report, and more importantly the recommended clinical integration models for the QBP services should be distributed by the Steering Committee for comment by the NE LHIN hospitals. After considering the comments by the hospitals, the report (with any 120 These responsibilities might also be assigned to an already existing structure or committee within the LHIN. Page 138

143 necessary revisions) should be recommended to the NE LHIN for implementation. Refinement of Clinical Integration Models Clinicians provide leadership in the interpretation of the NE LHIN Clinical Integration Models The Steering Committee should initiate a process wherein clinicians can provide leadership in the interpretation of the NE LHIN Clinical Integration Models and the QBP Clinical Handbooks to further develop and refine these models of care. Development and Implementation of Clinical Governance and Management Structures and Processes As described in the following chapter, the hospitals with support from the LHIN should develop and implement the governance and management structures necessary to implement the models of care and manage the delivery of care related to each QBP service. 1. The first structure and process would provide for the development and implementation of a single model of care and consistent clinical pathways/order sets across the LHIN. This will be required for all QBPs. 2. The second set of structures and process would provide for the development and implementation of operating policies to facilitate the implementation of the QBP models of care within each hub grouping of hospitals. This will be required for the medical QBPs (CHF, COPD and Strokes) where care will have to be coordinated within each Hub grouping of hospitals. 3. The third set of structure and process would provide for the development and implementation of operating policies to facilitate delivery of surgical QBP services as one integrated program on multiple sites within a hub or across the LHIN. This will be required for cataracts, Hip Fractures and TJRs where there will be one program for each Hub and for vascular surgery where there will be one program across the LHIN. Resolution of QBP Funding Issues for NE LHIN Funding for post acute care services The LHIN should work with the MOHLTC, with the support of the hospitals in the LHIN, to clarify and resolve the special issues in care delivery in the north, the current paucity of post acute care services related to the QBP services and the need for additional funding to address these issues. Page 139

144 Resolution Transitional Funding Issues Accommodating the transitional discordance between costs and funding The LHIN, in concert with other similarly affected LHINs should work with the MOHLTC to clarify and address the transitional funding issues that hospitals will have in the year that they absorb volumes from across the LHIN and from other LHINs. QBP volume targets and related funding should be set so as to allow for and accommodate the realignment of volumes among hospitals. It should be noted, that these transitional problems will likely resolve themselves over time as care delivery practices stabilize to reflect the better practice models of care. Similarly, the LHIN should work with the MOHLTC to address the transitional funding issues that hospitals may have as they reduce the number of atypical cases to reflect the better practice models of care. Although costs will decline with the reduction in patient days (and weighted cases), they may not decline as quickly as will be required to accommodate the potentially dramatic reduction in QBP funding. Again, it should be noted, that as care delivery practices stabilize, these problems will likely resolve themselves over time. Develop Process for Resolving QBP Funding Issues The LHIN should use this experience to develop a process for identifying and resolving future issues related to QBP funding. Develop Performance Reporting and Monitoring Mechanisms Monitoring implementation of QBP models of care The LHIN should develop measures and mechanisms to measure and monitor the success of the hospitals in implementing the QBP Clinical Integration Models of Care. The LHIN should provide regular reports to the hospitals on LHIN wide progress. Implementation of Clinical Integration Models Ensuring implementation of the NE LHIN QBP Clinical Integration Models The clinical governance and management structures proposed here should be established and charged with responsibility for ensuring that the NE LHIN QBP Clinical Integration Models are implemented. Implementation of QBP Funding Support for Clinical Integration Models Set target volumes for QBP services The LHIN, as part of its role as the funding agent for the hospitals, should specify target volumes for QBP services for the hospitals and allocate appropriate QBP funding for the assigned volumes of service. Adjustments will of course be made to reflect actual volumes of service up to the specified amounts. Page 140

145 16.0 Governance of QBP Services As noted earlier, there are three models of governance / management that should be established to guide the introduction of the NE LHIN clinical integration models for QBP services. These are: 1. The first model would provide for development and implementation of a single model of care and consistent clinical pathways/order sets across the LHIN. This will be required for all QBPs. 2. The second model would provide for the development and implementation of operating policies to facilitate the implementation of the QBP models of care within each hub grouping of hospitals. This will be required for the medical QBPs (CHF, COPD and Strokes) where care will have to be coordinated across each Hub grouping of hospitals. 3. The third model would provide for the development and implementation of operating policies to facilitate delivery of surgical QBP services as a one integrated program on multiple sites within a hub or across the LHIN. This will be required cataracts, Hips and TJRs where there will be one program for each Hub and for vascular surgery where there will be one program across the LHIN. These governance/management models are discussed briefly in the following paragraphs Single Model of Care for QBP Services Formalizing agreement by hospitals to implement QBP models of care The governance/management process that should be followed in developing and implementing a single model of care across the LHIN for each QBP service should include the following sequentially dependent steps: 1. The Board of each hospital should seek advice from its MAC and, based on that advice, the Board should review and accept, in principle, the recommended models of care for QBP services presented in this report. The Board should then direct its management and its MAC to work with the LHIN and other hospitals in the LHIN to refine the models of care for QBP services presented in this report (as appropriate) and to develop a clinical pathway/order set to support this model of care. Page 141

146 2. The LHIN should facilitate a process that will result in a LHIN clinical lead being appointed for each QBP service whose role will be to lead the process for refining the model of care and developing a clinical pathway/order set for services related to that QBP. 3. The LHIN Clinical Lead for each QBP should then invite representatives from LHIN hospitals to participate on a QBP clinical panel that will be responsible for the refinement the QBP model of care and development of the QBP clinical pathway/order sets. 4. The QBP clinical panel will convene and meet as many times as necessary to reach consensus on the QBP model of care and clinical pathway/order sets The QBP clinical panel should then recommend its consensus QBP model of care and clinical pathway/order set for adoption by each LHIN hospital. 6. The MAC in each hospital should review the consensus model of care and clinical pathway/order set and recommend them to the hospital board for implementation at the hospital. 7. The Board of each hospital should direct its management and MAC to implement the consensus model of care in the hospital and to work with the other hospitals in their hub and, as necessary, across all the hospitals in the hub to implement any inter hospital elements of the consensus model of care Implementing the QBP Models of Care within a Hub Agreements among hospitals to operationalize QBP models of care within a Hub Once the hospitals in a hub have accepted a QBP model of care, they will then need to develop the operating policies necessary to facilitate the implementation of the model of care. The governance/management model that should be followed in the development and implementation of these operating policies within each hub grouping of hospitals should include the following steps: 1. The LHIN should facilitate a process that will result in a hub clinical lead being appointed for each QBP service whose role 121 As a starting point for the development of the clinical pathway/order sets, it is advisable for the QBP Clinical Panels to obtain one or more sample order sets from one of its member hospitals, a hospital from another LHIN or a commercial provider of pathways and order sets such as Patient Order Sets.Com. Page 142

147 will be to lead the process for defining how the QBP model of care should be implemented by the hub hospitals. A Hub Clinical Lead for each QBP 2. The Hub Clinical Lead for each QBP should invite representatives from each hub hospital to participate on a QBP clinical panel that will be responsible for defining how the QBP model of care should be implemented by the hub hospitals. 3. The QBP clinical panel will convene and meet as many times as necessary to reach consensus on the best approach to implementing the QBP model of care. This will include: a) Formal intra hub agreements on transfer and acceptance of ED patients as required for the QBP model. b) Formal intra hub agreements on patient repatriation as required for the QBP model. c) Formal intra hub agreements describing how support will be provided by the hub hospital and its medical staff to other hospitals in the hub and their medical staff as necessary to care for inpatients and outpatients as required for the QBP model. d) Consideration of creating of a single, hub wide clinical program related to each QBP service and/or QBP related services to facilitate achievement of consistent care practices and to facilitate interaction among hospitals and clinicians. e) Formal inter hub agreements among hub hospitals for acceptance of ED transfers when one of the hub hospitals can no longer accept emergent transfers from one of the hospitals in its hub. f) Written protocols emanating from and providing the detail of these agreements should be distributed to all hub/lhin hospitals. g) The LHIN should facilitate this process by developing and providing templates that can be used as a starting point for intra and inter hub agreements related to patient transfers and inter hospital support. 4. The hub QBP clinical panel should then recommend its consensus approach to implementing the QBP model of care for adoption by each LHIN hospital. 5. The MAC in each hospital should review the consensus approach to implementing each QBP model of care and recommend them to the hospital board for implementation at the hospital. Page 143

148 6. The Board of the hospital should review and accept the MAC recommendation and direct its management and MAC to work with the other hospitals in their hub to use the consensus approach to implementing each QBP model of care in the hospital and across all the hospitals in the hub. 7. Hospital management should negotiate appropriate agreements among the hub hospitals necessary for the consensus approach to implementing the QBP models of care and recommend and refer these agreements to their hospital board for ratification. 8. Each hospital board should ratify the intra-hub hospital agreements and the hub hospital board should ratify the inter-hub agreements Single QBP Program Across Multiple Sites Considering special requirements for Hub wide program for surgical QBPs and LHIN wide program in Vascular Surgery The governance/management model that should be followed in the development and implementation of a single program for the provision of services related to a QBP across all hospitals in a hub (Orthopaedics for TJR and Hip Fracture and for Cataracts) or across the LHIN (Vascular Surgery) should include the following steps. 1. The LHIN should facilitate a process that will result in the appointment of a LHIN wide or hub clinical lead for each QBP service whose role will be to lead the process for defining how the QBP model of care should be implemented by the hospitals participating in the delivery of the QBP services. 2. The LHIN or Hub Clinical Lead for each relevant QBP should invite clinical representatives from each hospital in the LHIN or hub that will be participating in any aspect of the delivery of the QBP service to participate on a QBP program management committee. 3. The QBP program management committee will convene and meet as many times as necessary to reach consensus on the best approach to managing the delivery of QBP services consistently and equitably across the participating hospital sites. This will include: a) Identifying the initial clinical leader for the program b) Determining the scope of the clinical program beyond the specific QBP services c) An approach to monitoring and managing delivery of care across sites Page 144

149 d) Formal agreements that ensure appropriate and timely access to diagnostic and therapeutic services and technology across sites e) Formal agreements that ensure appropriate and timely transfer and acceptance patients among program sites as required for the QBP model of care f) Formal agreements among hospitals participating in the program for acceptance of ED transfers when one of the participating hospitals can no longer accept emergent patients either from its own ED or transfers from one of the hospitals in its hub. Specifically the agreements should include: i) Agreement on the types of cases requiring immediate transfer and attention ii) Agreement on the types of cases where transfer and/or consultation can be deferred without compromising patient safety and outcomes iii) Agreement on maximum deferral periods g) Formal agreements on approach to coverage across sites and on the development of coverage schedules among clinicians participating in the program h) Formal agreements for ongoing management of the QBP program across the sites including, but not necessarily limited to: i) Program management structure Clinical Lead Administrative Lead Program Management Committee ii) Role and Responsibilities of Program Leaders iii) Approach to appointing program leadership iv) Term of Program Leadership v) Role and Responsibilities of Program Management Committee vi) Membership on Program Management Committee vii) Frequency of Meetings of Program Management Committee i) The LHIN should facilitate this process by developing and providing templates that can be used as a starting point for Page 145

150 intra and inter hub agreements related to patient transfers, inter hospital support and program management. 4. The QBP program management committee should then recommend its consensus approach to QBP program management for adoption by each participating hospital. 5. The MAC in each participating hospital should review the consensus approach to QBP program management and recommend it to the hospital board for implementation at the hospital. 6. The Board of the hospital should review and accept the MAC recommendation on QBP program management and direct its management and MAC to work with the other participating hospitals to implementing the prescribed approach to QBP program management in the hospital and across all the participating hospitals in the hub and/or the LHIN. 7. Hospital management should negotiate appropriate agreements among the participating hospitals necessary to for the consensus approach to QBP program management and recommend and refer these agreements to their hospital board for ratification. 8. Each hospital board should ratify the inter-hospital program management agreements. 9. Once ratified, copies of these agreements should be circulated to appropriate administrative and clinical staff within each hospital. Page 146

151 Appendix A: Proposed Models of Care for QBP Services Page 147

152 Proposed Models of Care for QBP Services The Hub workshops have developed and the Project Steering Committee has confirmed the following models of care for the delivery of QBP services in the North East LHIN. Proposed Model for Delivery of CHF Services It is recommended that NE LHIN hospitals should use a consistent model of care and clinical pathway/order set across the region in caring for CHF patients. Clinicians should provide leadership in the interpretation of the CHF handbook to develop this model of care and clinical pathway/order set. The LHIN should provide coordination for this initiative. The model and approach to care should incorporate the following elements: 1. Low intensity patients should be discharged from EDs across the LHIN Average intensity patients should be admitted and managed at the hospital where the patient first presents. All hospitals with an ED should be able to care for average intensity CHF patients. However, when required, telemedicine should be available from hub hospitals to clinicians looking after average intensity patients in local hospitals. 3. In general high intensity patients should be transferred to and admitted to Hub hospitals (SAH, TADH, HSN, and NBRHC). However, there should be some ability for some high intensity patients to be cared for with BiPAP for 6-12 hours at the site where they present and then continue to be managed locally for the remainder of their stay. Thus, all high intensity patients may not need to be transferred to a Hub hospital. The NE LHIN model of care for CHF patients assumes that 10% of high intensity patients can be and will be managed locally; with the use of a virtual ICU to facilitate care of high intensity CHF patients at the local hospitals. Thus, the model assumes that only 90% of high intensity CHF ED patients should be and will be transferred to Hub hospitals. 4. It is expected that the hospitals will achieve provincial average length of stay performance (or better) in caring for each CHF patient admitted to inpatient care. 122 For modeling purposes we have used current NE averages for % of CHF patients in each patient group. Page 148

153 The target maximum length of stay for medium intensity patients is 7.2 days. The target maximum length of stay for high intensity patients is 9.6 days. The number of extremely long stay patients will be reduced significantly thus reducing the number of atypical patients High intensity patients who have stabilized at a Hub hospital but who are not ready for discharge should be repatriated to their local hospital to complete their inpatient care. 6. Importantly, it is noted that the hospitals in the NE LHIN will only be able to achieve the provincial average lengths of stay and reduce the number of long-stay atypical cases, if there are significant and sufficient investments in community resources to provide both transitional care and CCAC services so that patients do not remain in ALC status in the local hospitals. 7. Each hub hospital will provide a Heart Failure Clinic to support the transitional phase of care for CHF patients. GIM or Family Medicine led clinics should be located at all Hubs except HSN. (HSN will be expected to provide telemedicine and telehomecare support to the clinics in the other Hub hospitals when required). It is suggested that consideration should be given to offering a combination Heart Failure/Respiratory Clinic at each Hub hospital. These could be run as a combined clinic using a Chronic Disease Management model but will require appropriate types of staffing with sufficient time to provide appropriate care. The clinics will require more access to and support from community resources to monitor patients and prevent readmissions to hospitals. The hub clinics and the community resources should work in tandem with FHTs to care for these patients. 8. The expertise in the hub sites should be made available to the more remote locations using telemedicine and telehomecare to reduce the burden of travel for patients. Proposed Model for Delivery of COPD Services It is recommended that NE LHIN hospitals should use a consistent model of care and clinical pathway/order set in caring for COPD patients across region. Clinicians should provide leadership in the 123 For modeling purposes, the Steering Committee has assumed that NE LHIN hospitals can reduce the % of atypical cases to the lowest percentage achieved by hospitals in other LHINs in the province. Page 149

154 interpretation of the COPD handbook to develop this model of care and clinical pathway/order set. The LHIN should provide coordination for this initiative. The model and approach to care should incorporate the following key elements: 1. Mild exacerbation patients should be discharged from EDs across the LHIN Moderate exacerbation patients should be admitted and managed at the hospital where the patient first presents. All hospitals with an ED should be able to care for moderate exacerbation COPD patients. However, when required, telemedicine from hub hospitals should be available to support clinicians looking after moderate exacerbation patients in local hospitals. The post discharge follow-up model for these patients should be the same as the follow up for mild exacerbation patients who are discharged from the ED. 3. Severe exacerbation COPD patients should be transferred from the local hospital ED to the appropriate Hub hospitals (SAH, TADH, HSN, NBRHC) for admission at that hospital. However, there should be some ability for some severe exacerbation patients to be cared for with BiPAP for 6-12 hours at the site where they present and then continue to be managed locally for the remainder of their stay. Thus, all severe exacerbation patients may not need to be transferred to a Hub hospital. The NE LHIN model of care for COPD patients assumes that 10% of severe exacerbation patients can be and will be managed locally; with the use of a virtual ICU to facilitate care of severe exacerbation COPD patients at the local hospitals. Thus, the model assumes that only 90% of severe exacerbation COPD ED patients should be and will be transferred to Hub hospitals. 4. It is expected that the hospitals will achieve the provincial average lengths of stay performance (or better) in caring for COPD patients admitted for inpatient care: The target maximum average length of stay for moderate exacerbation COPD patients is 5.9 days The target maximum average length of stay for severe exacerbation COPD patients is 10.2 days 124 For modelling purposes, we have used the current NE averages for % of COPD patients in each patient group. Page 150

155 The number of extremely long stay patients will be reduced significantly thus reducing the number of atypical patients Once the severe exacerbation patient is ready for discharge from ICU care, they should be considered for repatriation to the local hospital for the completion of their inpatient episode of care. When repatriated or when discharged to the community the local hospital or the community provider should be provided with a plan for continuing care. 6. Importantly, it is noted that the hospitals in the NE LHIN will only be able to achieve the provincial average lengths of stay and reduce the number of long stay atypical cases if there are significant and sufficient investments in community resources to provide transitional care and CCAC services so that patients do not remain in ALC status in the local hospitals. 7. Each hub hospital should provide a COPD clinic to support the post discharge (from ED or inpatient) community care for COPD patients. This should be a GIM or Family Medicine led clinic at all hubs except HSN. (HSN will be expected to provide telemedicine support to the clinics in the other hub hospitals when required). As has been discussed, it is suggested that consideration should be given to offering a combination Heart Failure/Respiratory Clinic at each Hub hospital. These could be run as a combined clinic using a Chronic Disease Management model but they will require appropriate types of staffing with sufficient time to provide appropriate care. The clinics will require more access to and support from community resources to monitor patients and prevent readmissions to hospitals. The hub clinics and the community resources should work in tandem with FHTs to care for these patients. It is noted that these clinics likely will be a financial burden to the hub hospitals; neither the integration model presented here nor QBP funding will generate sufficient funds to support the operation of the proposed COPD clinic. 8. The COPD expertise in the hub sites should be made available to the more remote locations using telemedicine to reduce the burden of travel for patients. 125 For modeling purposes, the Steering Committee has assumed that NE LHIN hospitals can reduce the % of atypical cases to the lowest percentage achieved by hospitals in other LHINs in the province. Page 151

156 Proposed Model for Delivery of Stroke Services It is recommended that NE LHIN hospitals should use consistent models of care and clinical pathways/order sets in caring for TIA and stroke patients across region. Clinicians should provide leadership in the interpretation of the QBP Clinical Handbook for Stroke to develop these models of care and clinical pathways/order sets. The LHIN should provide coordination for this initiative. The model and approach to care should incorporate the following key elements: 1. Continue with the model of regional and hub/district stroke centers as proposed by the Northeastern Ontario (NEO) Stroke Network. 126 Regional Stroke Centre - Health Science North District Stroke Centre at Sault Area Hospital, Timmins and District Hospital and North Bay Regional Health Centre for each of other hubs. 2. Inpatient acute and rehabilitative stroke care should be consolidated at regional and district stroke centres. 3. Ensure that inter-professional stroke teams are established and functioning in each hub/district stroke centre. 4. Target to reduce admissions of ED TIA patients to the provincial average rate of admission When a stroke patient (TIA, Ischemic, Haemorrhagic) requires admission to inpatient care they should be transferred from the ED where they present for admission to the specialized, geographically defined hospital unit dedicated to the management of stroke patients at the appropriate designated stroke centre Current provincial ALOS will be the target length of stay for TIA patients that are admitted to inpatient care admits. 7. QBP average length of stay targets for Ischemic and Hemorrhagic stroke care will be achieved by NE LHIN acute stroke units: Ischemic Stroke Target ALOS: 5 days Haemorrhagic Stroke Target ALOS: 7 days 126 See NE LHIN Hospital Based Stroke Care: Impact of Consolidating Care. 127 This can be achieved through enhancement of the existing Regional Stroke Prevention Clinic model. 128 For many hospitals this will be a change in practice. Protocols and formal agreements among hospitals to facilitate these transfers will need to be developed. Page 152

157 8. The number of extremely long stay patients should be reduced significantly thus reducing the number of atypical patients Stroke patients requiring inpatient rehabilitation should stay at regional/district stroke centers to receive this care. Upon completion their inpatient rehabilitation; they should be discharged to home Use QBP targets for inpatient rehabilitation: Approximately 40% of Stroke patients should receive inpatient rehabilitation after completing their inpatient acute care. Inpatient Rehabilitation Lengths of Stay should conform to the recommended LOS per RPG as outlined in QBP Clinical Handbook for Stroke. For modeling purposes we have assumed an ALOS of 30 days for all strokes for all RPGs. 13. If a patient is designated ALC-LTC Placement at any time during the patient s acute or rehabilitation care stay then the patient should be repatriated to her/his home hospital. 14. It is recognized that these clinical performance targets will only be achieved if: The existing Stroke Prevention Clinics (SPCs) at each Hub hospital are enhanced to ensure that TIA patients who are not admitted to inpatient care 131 can receive diagnostic and therapeutic care within 48 hours of presentation to an Emergency Department in the North East. 129 For modeling purposes, the Steering Committee has assumed that NE LHIN hospitals can reduce the % of atypical cases to the lowest percentage achieved by hospitals in other LHINs in the province. 130 This is a significant and important change from current practice. 131 Majority of TIA patients do not require admission to hospital and should be referred to an urgent TIA/Stroke Prevention Clinic or comparable ambulatory setting for rapid diagnostic and medical evaluation, within 48 hours of symptom onset/visit to ED Page 153

158 The Outpatient Stroke Clinics at the hub hospitals are enabled to provide for the post discharge needs of stroke patients who are discharged from acute and inpatient rehabilitation 132. Proposed Model for Delivery of Cataract Surgery A single, integrated clinical program for cataract surgery should be established for each hub It is recommended that NE LHIN hospitals should use a consistent model of care and clinical pathway/order sets in the provision of cataract surgery across the region. Standardization of model of care should result in utilization rates that will be standardized across the LHIN so that populations in each hub have equivalent access to care. Clinicians should provide leadership in the interpretation of the QBP Clinical Handbook for cataract surgery to develop and implement these models of care and clinical pathways/order sets 133. The LHIN should provide coordination for this initiative. Additionally, it is recommended that a single, integrated clinical program for cataract surgery should be established for each hub for the provision and oversight of cataract surgery. Within this program, within each hub: Cataract surgery procedures should be consolidated at the Hub hospitals Specialist diagnostic and follow up clinics should be provided at local hospitals 132 It has been suggested by NEOSN that a regional Stroke Re-Check Clinic model should be established (with clinics located at each Hub hospital) to ensure stroke patients discharged home are followed by an interdisciplinary team for a minimum of one year following their discharge. These clinics will address the medical and rehabilitation needs of stroke patients and assist in decreasing hospital readmissions for post-stroke complications. Telemedicine should be used when possible and appropriate to provide this service to patients living in rural communities. Additionally, a regional Stroke Outpatient Services model should be established to ensure stroke patient that do not qualify for CCAC services, can access stroke-specific outpatient services within a 45 minute drive of their home. These clinics would also be connected with the Northern Ontario Independent Living Association (NILA) Regional Post-Stroke Program to assist with stroke community navigation well beyond hospital discharge 133 It should be noted that concurrent with the work of the Clinical Services Review Steering Committee, work has begun in the LHIN to interpret and implement the findings and recommendations of A Vision for Ontario, Strategic Recommendations for Ophthalmology in Ontario. The Provincial Vision Strategy Task Force. The development of models for the delivery of cataract surgery should take into account this broader work related to the delivery of all ophthalmology services in the LHIN. Page 154

159 Simple procedures will be provided at local hospitals at the discretion of the hub clinical program for cataract surgery. All cataract surgery should be provided within the hub where the patient lives. Proposed Model for Delivery of TJR Services It is recommended that NE LHIN hospitals should use a consistent model of care and clinical pathway/order sets in caring for primary, unilateral hip and knee replacement patients across region. Clinicians should provide leadership in the interpretation of the QBP Clinical Handbook for Total Joint Replacements to develop this model of care and clinical pathway/order set. The LHIN should provide coordination for this initiative. The model and approach to care should incorporate the following key elements: 1. TJRs should be provided as part of a single, integrated, hub wide orthopaedic surgery program in each hub. Within this program if a hospital/surgeon is providing major orthopaedic surgery, it/he should also provide hip fracture treatment and should provide for hip fracture treatment 7 days per week. 2. Each hospital providing TJRs, should maintain a Joint Assessment Centres (JACs) as the only route of access to TJR. It is hoped that this will assure appropriate and equitable access to TJRs. 3. For modeling purposes, assume that the current NE LHIN population utilization rates for TJR are appropriate. 4. TJRs should be provided by a hospital in the LHIN where the patient resides. In the future 100% of TJR for NE LHIN residents will be provided within the NE LHIN The wait time target for TJRs should be the QBP target of 182 days. However, achieving the target will require sufficient funding to achieve and maintain performance at that target. 6. NE LHIN orthopaedic surgery programs should adopt the QBP targets for ALOS of 4.4 days. 7. The number of extremely long stay patients should be reduced significantly thus reducing the number of atypical patients Both primary TJRs and revisions will be provided within the LHIN. 135 For modeling purposes, the Steering Committee has assumed that NE LHIN hospitals can reduce the % of atypical cases to the lowest percentage achieved by hospitals in other LHINs in the province. Page 155

160 8. NE LHIN orthopaedic surgery program should adopt the QBP targets for discharge disposition with 90% of patients discharged to home; and 10% discharged to inpatient rehabilitation Patients can and should be repatriated from acute care to their local hospitals for inpatient rehabilitation with a plan of rehabilitative care and access to telemedicine for rehabilitation support. Enhanced rehabilitation resourcing and support in smaller communities will be needed to facilitate effective repatriation. Cross-training of RN s, RPN s and PSWs in hip fracture rehabilitation in smaller communities will facilitate effective repatriation. 10. TJR patients should have enhanced access to physiotherapy in the community with initial therapy provided by the CCAC as appropriate to the needs of the patient and continuing therapy provided in group sessions by hospitals as ambulatory care. Proposed Model for Delivery of Hip Fracture Services It is recommended that NE LHIN hospitals should use a consistent model of care and clinical pathway/order set in caring for Hip Fracture patients across region. Clinicians should provide leadership in the interpretation of the Orthopaedic Expert Panel s Hip Fracture Model of Care to develop this model of care and clinical pathway/order set. The LHIN should provide coordination for this initiative. The model and approach to care should incorporate the following key elements: 1. Assume that the current NE LHIN average percentage of ED Hip Fractures being admitted to inpatient care is appropriate. 2. Assume that current hospital specific Hip Fracture transfer out rate is appropriate (i.e. assume that minor hip fractures are appropriately being treated locally by general surgeons; with more significant fractures being transferred out to a site with orthopaedic surgery capability). All transfers should be from the local ED to inpatient care at the TJR hospital. Hip fracture patients should not be forced to wait as inpatients in a referring hospital; they should be transferred from the referring hospital ED to inpatient or pre operative status in the receiving hospital This would be a significant increase from current practice wherein only approximately 1% of TJR patients are discharged to inpatient rehabilitation. 137 For many hospitals this will be a change in practice. Protocols and formal agreements among hospitals to facilitate these transfers will need to be developed. Page 156

161 3. Hip Fracture Repair should be provided as part of an integrated hub wide orthopaedic surgery program. Within this program if a hospital/surgeon is providing major orthopaedic surgery, it should also provide hip fracture treatment and should provide for hip fracture treatment 7 days per week. 4. Hospitals treating hip fracture should achieve the provincial median ALOS performance (or better) for inpatient acute care. 5. The number of extremely long stay patients will be reduced significantly thus reducing the number of atypical patients % of Hip Fracture patients discharged from acute care in a NE LHIH hospital should be discharged directly to inpatient rehabilitation. 7. Patients can and should be repatriated from acute care to their local hospitals for inpatient rehabilitation with a plan of rehabilitative care and access to telemedicine for rehabilitation support. Enhanced rehabilitation resourcing and support in smaller communities will be needed to facilitate effective repatriation. Cross-training of RN s, RPN s and PSWs in hip fracture rehabilitation in smaller communities will facilitate effective repatriation. 8. Hospitals providing rehabilitation care for hip fracture patients should achieve the provincial median ALOS performance for inpatient rehabilitation for hip fracture patients. Proposed Model for Delivery of Vascular Surgery It is recommended that: 1. NE LHIN hospitals should use a consistent model of care and clinical pathways/order sets in caring for vascular surgery patients across region. 2. QBP vascular surgery procedures should be provided as part of a single, integrated LHIN wide vascular surgery program. 3. The LHIN wide vascular surgery program should operate under an integrated clinical governance and management model. The clinicians involved in vascular surgery working with a small task force should provide leadership in the interpretation of the QBP 138 For modeling purposes, the Steering Committee has assumed that NE LHIN hospitals can reduce the % of atypical cases to the lowest percentage achieved by hospitals in other LHINs in the province. Page 157

162 Clinical Handbook for Vascular Surgery (and the recent and continuing work of the Cardiac Care Network) to fully develop a definitive model of care for the delivery of vascular surgery in the NE LHIN and to determine how best to operationalize the LHIN wide vascular surgery program 139. Proposed Model for Delivery of Endoscopy Services Unless there are significant clinical and economic advantages to providing colonoscopies in out-ofhospital premises, colonoscopies in the NE LHIN should be provided in hospitals It is recommended that NE LHIN hospitals should use a consistent model of care in performing colonoscopies across region. Clinicians should provide leadership in the interpretation of the QBP Clinical Handbook for colonoscopies to develop this model of care and clinical pathway/order set. Led by Cancer Care Ontario, the Regional Cancer Program should provide coordination for this initiative. The model and approach to care should incorporate the following key elements: As a general rule, QBP colonoscopies should be provided in hospitals. Unless there are significant clinical and economic advantages to providing colonoscopies in out-of-hospital premises 140, in the NE LHIN, QBP funded colonoscopies should be restricted to hospital facilities 141. Proposed Model for Delivery of Chemotherapy Services The process has recommended that the NE LHIN should continue the current consolidated model as defined by CCO. This includes the following key elements: A network of Community Oncology Clinics comprised of the Northeastern Ontario community hospitals that work closely with the North East Regional Cancer Program to provide drug treatments closer to patients homes. Sault Area Hospital Algoma District Cancer Program 139 A model that can be used to guide this process is provided in section 15.3 of this report. 140 If QBP funded colonoscopies are to be provided in OHPs, then binding covenants must be provided to ensure that physicians participating in these OHPs continue to be meaningfully involved in supporting the clinical activities of the hospital. 141 The only exception is in Sault Ste Marie where the existing OHP provider of colonoscopies should be allowed to continue, and depending on the emerging policy for Community Based Specialty Clinics, it should be considered for QBP funding for the colonoscopies that it is providing. Page 158

163 An extensive regional ambulatory oncology information system that supports Computerized Physician Order Entry in Sudbury with remote use for 90% of satellite chemotherapy treatments across the region. Page 159

164 Appendix B: Comments and Concerns from Hub Clinical Integration Workshops Page 160

165 Comments from Hub Clinical Workshops Comments, criticisms and suggestions of the workshops with respect to the potential clinical integration models were documented for consideration by the Steering Committee The hub workshops considered the preliminary clinical integration models being considered by the Steering Committee along with the supporting analyses demonstrating the impact of the proposed model on the clinical activity, costs and clinical staffing of each hospital in the LHIN. The comments, criticisms and suggestions of the workshops with respect to the potential clinical integration models were documented for consideration by the Steering Committee. These comments are summarized and presented, briefly, in the sections following Clinical Integration Model for Congestive Heart Failure CHF care needs to be offered in all hospitals and should use standardized model of care Consistent use of order sets across LHIN Model needs to recognize geography and tendency/need to keep patients longer when patient is far from home Should consider including cost of transportation into the carve out Recognize burden on patients and families for travel Model needs to recognize these patients have other chronic conditions Lack of community services that might prevent readmissions Need additional resources to offer CHF clinics at the hubs Clinical Integration Model for COPD Care needs to be offered in all hospitals and should use standardized care (need to develop order sets) Model needs to recognize geography and tendency/need to keep patients longer when patient is far from home Model needs to recognize difficulty diagnosing and should include ED info and that these patients have other chronic conditions Lack of community services to prevent readmissions Need resources to support access to pulmonary rehabilitation following and acute episode Page 161

166 Concern that model will incent hospitals to admit greater proportions of patients for a higher payment Need to bundle post acute care into payments for QBPs Clinical Integration Model for Stroke Ensure integration of NE stroke working group directions Stroke units not feasible in district centers Need to focus on rehab beds & resources Will be a change in practice to have heavier strokes going to rehab Lack of community services for TIAs and for people following discharge Regional and District Centers just starting stroke follow-up & prevention clinics did not have in 2011/2012 TADH does not have enough internal medicine to support this TIA admissions are decreasing with education of primary care physicians Need to do more to repatriate from regional/district centers. Greatest need is physiotherapy resources in local hospitals/centres to be able to do this Clinical Integration Model for Hip Fractures Elliot Lake being in Algoma hub affects base volume Consolidation already occurring and seems to be working Where there are small volumes these are likely coding problems Opportunity to standardize care if the appropriate resources are available in each center Beginning to implement standard order sets and clinical pathways Likely cannot meet proposed performance targets (targets used in south) because of geography issues and lack of access to community support services Need for 7 day per week Hip Fx treatment in all hospitals providing major orthopaedic surgery If doing TJR; should be doing hip fractures Page 162

167 Rehabilitation is biggest issue Rehabilitative services are concentrated in major hub centres and role of smaller, rural hospitals in rehabilitation is unclear Need to keep patients in acute care because of the lack of rehab in local communities No rehab available when sent back to smaller communities so tend to keep patients But, some patients are being repatriated before they get sufficient rehabilitation Patients want to have their care in their own community so smaller hospitals need to have resources to provide rehabilitation Need to determine number of rehabilitation beds required in LHIN (process underway) E.g. in Sudbury have 30 IP rehab beds with 10 of those designated for ABI, leaving 20 for everything else including stroke, hips, & msk. Lack of outpatient services/home services across the NE LHIN impacts inpatient stay, outcomes for patients and as a result, subsequent use of services Internal referrals are faster, more efficient than external referrals with inadequate access to rehab for patients from smaller/rural locations. Some communities have no physiotherapy private or otherwise. Lack of capacity in community for decanting patients, e.g. community housing, assisted living Clinical Integration Model for Total Joint Replacements Low socio-economic status and obesity driving need Joint Assessment Centres (JAC) Working well at HSN (was the pilot site) HSN has lowest wait time at end of 2011/12 at 192 days due to JAC and buy-in from surgeons Pre-op group therapy knee JAC; Post-op goes better if seen in JAC Page 163

168 JAC at SSM JACs now at all TJR sites Long Wait Times in NE in 2011/12 Hip Target 215 day wait; actual performance 325 days Knee Target 300 day wait: actual performance 407 days Cap on volumes contributing to wait time and patients going outside LHIN Repatriation 25% of joints being done outside LHIN- would like to repatriate these cases; have capacity Orthopedic surgeons feel they have the capacity to perform more procedures Concerns re access to rehab Concern that access will be even more difficult under QBP funding Report that CCAC only sees hips at home; nothing available for knees Big difference between physiotherapy in hospital and that done by CCAC Challenge for patients is the drive/transportation to get to physio services $ for physio should flow with the patient Challenge is recruiting physio for smaller communities Clinical Integration Model for Vascular Surgery Feedback from the workshop in Algoma was that there should be a vascular surgeon for a population of 100K 142 and they don t want to lose the surgeon they have in Algoma 142 Literature suggests that 100,000 is insufficient to support Vascular Surgery: NHS England reports: A minimum population of 800,000 is often considered the minimum population required for a centralised vascular service. This is based on the number of patients needed to provide a comprehensive emergency service, maintain competence among vascular specialists and nursing staff; the most efficient use of specialist equipment, staff and facilities, and the improvement in patient outcome that is associated with increasing caseload Page 164

169 Should have a vascular surgeon for a population of 100K and don t want to lose the surgeon in Algoma Perception that patients assessments currently done in Sudbury and then patients don t come back to SAH for surgery, when appropriate (requires confirmation). Could process be different? Initial analysis presented was believed to under-represent numbers done at HSN, however, in further review the differences between Hay Group analysis and HSN analysis is likely related to definition of procedures and what is included within the QBP definition Perception that total number of AAA and EVAR have grown Concerns regarding how EVAR gets reflected in QBP funding. General Comments on QBP Funding Discussion about the dollar value that will be provided for QBPs: Physicians want to know if they are going to have input into the dollar value assigned to QBPs and the definitions of the episode of care. Will the dollar value assigned to QBPs be hospital specific, LHIN specific, Hub specific, community specific, provincial. CIHI s 2012 report: Supply, Distribution and Migration of Canadian Physicians, 2012 According to the CIHI report, there are 75 vascular surgery subspecialists in the province of Ontario. With a population of approximately 13.5 million, this equates to 0.56 vascular surgeons per 100,000 population. This number is pretty much equal to the Canadian average (0.55). The Vascular Society of Great Britain and Ireland. Document entitled The Provision of Services for Patients with Vascular Disease 2012 states that a hospital with a vascular service needs a minimum of one vascular surgical specialist per 150,000 population. (p.15) This number is based on their philosophical approach to the need, timeliness and quality of vascular services. The Royal Australasian College of Surgeons, in their surgical workforce projections to 2025 identify the number of vascular surgeons required by population. The number of needed surgeons is based on current utilization, which is much like CIHI value. They estimate need at 0.69 vascular surgeons per 100,000 population Page 165

170 Questions and discussion of some technical issues related to QBP funding If patients move between hub and local hospitals, how does the QBP get funded? If proposed clinical integration model breaks up the QBP episode of care between two hospitals, does it count for QBP funding will the QBP funding be split between the two facilities? Concerns about hospitals competing with community agencies for components of the episodes of care specifically the outpatient components. Page 166

171 Appendix C: General Assumptions and Planning Parameters Used in Modeling Page 167

172 QBP and Category General Assumptions The following general assumptions have been used in modeling the impact of the QBP Clinical Integration Models of Care. Elliot Lake should be part of Sudbury Hub; Modeling will reflect this change 2012/13 CIHI DAD and NACRS data used as basis for simulation (using HIG weights) HBAM carve-out and QBP revenue calculations not applied to small hospitals (i.e. those currently exempted from HBAM) When Integration model/qbp LOS targets (if any) are applied, NE LHIN hospital projected HIG weights for Typical cases not changed Best Practice (i.e. Lowest) % Atypical cases across LHINs applied to NE, with cases converted from Atypical to Typical given NE LHIN average weight per Typical case. Tends to reduce projected HIG weight for NE LHIN hospitals for atypical cases and thus reduces total QBP payment, since payment amount based on price per HIG weighted case multiplied times projected HIG weighted cases NE LHIN and Best Practice % Atypical Cases by QBP It has been assumed that clinical practice related to QBPs will move toward the best practice models presented in the QBP Clinical Handbooks. With respect to lengths of stay for QBP patients, the length of stay will move towards the QBP targets. The Steering Committee felt that the enhanced clinical practices would lead to a significant reduction in the number of long-stay atypical cases for each QBP. The following table presents the current (2012/13) NE LHIN characteristics of typical and atypical cases in each QBP category. Exhibit 100: Characteristics of typical and atypical cases in each QBP Cases Days "Typical" Avg. LOS HIG Weight Avg. HIG Wgt. Cases Days "Atypical" Avg. LOS HIG Weight CHF High CHF Medium 929 6, , , COPD High 185 1, , COPD Medium 1,567 9, , , Hip Fracture 393 4, , , Avg. HIG Wgt. Page 168

173 QBP and Category Cases Days "Typical" Avg. LOS HIG Weight Avg. HIG Wgt. Cases Days "Atypical" Avg. LOS HIG Weight Hip Replacement 593 2, Knee Replacement 1,283 4, , AA Repair - EVAR AA Repair - Open Non-Cardiac Vascular LEOD Stroke Hemorrhage Stroke Ischemic 450 3, , Stroke TIA Grand Total 6,024 36, , ,337 23, , Avg. HIG Wgt. To reflect the improved clinical practice, the modeling has assumed that the percentage of atypical cases in each QBP would be reduced and the target would be the lower of what is being achieved already in the Northeast or the lowest % atypical of all other LHINs in the province. For all QBPs, at least one other LHIN has a lower percent of cases categorized as an Atypical case, using the HIG methodology Lowest % Atypical from other LHINs has been used for purposes of calculating the impact of achieving best practice The following table presents the current % of QBP cases in the North East LHIN that are atypical and the lowest % from all the LHINs in the province. This lowest % atypical from all the LHINs is the target % atypical cases within the clinical integration model for each QBP in the North East. The exhibit also shows the % reduction in atypical cases if NE LHIN hospitals achieve this target for atypical cases. Exhibit 101: Atypical % of Cases for QBPs QBP NE LHIN LHIN Minimum Red'n of % Atyp. CHF 21.6% 14.3% -7.4% COPD 19.2% 14.5% -4.7% Hip Fracture 40.3% 11.0% -29.3% Hip Replacement 5.1% 2.3% -2.9% Knee Replacement 4.0% 1.0% -3.1% Non-Cardiac Vascular 22.9% 2.0% -20.9% Stroke Hemorrhage 32.8% 21.4% -11.4% Stroke Ischemic 27.6% 20.5% -7.0% Stroke TIA 9.4% 4.1% -5.4% Stroke Unspecified 28.4% 15.8% -12.6% Page 169

174 NE LHIN Hospital QBP Activity by Typical vs. Atypical Category In developing projections of weighted cases (i.e. after application of LOS targets to all cases within a QBP), HIG weights have been adjusted only for Atypical cases: Most of the Atypical cases are long-stay outliers, which receive extra weight because of their long stay Once LOS is reduced to target LOS for a QBP, we needed to make corresponding adjustment to the HIG weight Assigned NE LHIN average weight per Typical case for each of original Typical cases and the Atypical cases that were modeled as being converted to Typical cases under the best practice clinical integration model of care for each QBP Assigned NE LHIN average weight per Atypical case for each case that was modeled as remaining atypical under the best practice clinical integration model of care for each QBP Used the % typical and % atypical to determine the average HIG weight per case that would be used in modeling the projected number of HIG weighted cases and related revenues The following table presents the key modeling parameters for each QBP category along with commentary indicating assumptions that have been made with respect to these modeling parameters. Critically, the exhibit presents the OCCI Cost per Wtd Case which has been assumed to be the QBP price per weighted case for use in determining the revenue that a hospital will receive under the QBP funding model. Exhibit 102: Length of Stay, HIG Weight and QBP Price Parameters QBP/Category Ont. Avg. Acute LOS QBP Target Tgt. Typ. Wght. Tgt. Atyp. Wght. Tgt. % Atyp. Case Avg. Case Wght. QBP Price per Wtd. Activity CHFHigh % $5,110 Comment Provincial average acute LOS used as target. Blended NE LHIN Typical and Atypical HIG weight (@ target % Atypical) used for weighted cases. COPDHigh % $5,352 CHFMedium % $5,110 COPDMedium % $5,352 Page 170

175 QBP/Category Ont. Avg. Acute LOS QBP Target Tgt. Typ. Wght. Tgt. Atyp. Wght. Tgt. % Atyp. Case Avg. Case Wght. QBP Price per Wtd. Activity Hip Fracture % $5,200 Hip Replacement % $5,214 Comment Provincial average acute LOS used as target. Blended NE LHIN Typical and Atypical HIG weight (@ target % Atypical) used for weighted cases. Hip fracture OCCI CPWC not available; $5,200. Provincial average acute LOS used as target. Blended NE LHIN Typical and Atypical HIG weight (@ target % Atypical) used for weighted cases. Knee Replacement % $5,188 Non-Cardiac VascularLEOD Non-Cardiac VascularAA Repair - Open Non-Cardiac VascularAA Repair - EVAR % $4, % $5, % $5,334 Stroke Hemorrhage % $5,452 QBP Target LOS used. Blended NE LHIN Typical and Atypical HIG weight (@ target % Atypical) used for weighted cases. Stroke Ischemic % $4,970 Stroke TIA % $5,513 Provincial average acute LOS used as target. Blended NE LHIN Typical and Atypical HIG weight (@ target % Atypical) used for weighted cases. 103 short-stay cases removed from IP to meet provincial TIA admission from ED target. Cataract NA NA NA NA NA $3,533 Endoscopy NA NA NA NA NA $3,500 Endoscopy OCCI CPWC not available; $3,500. QBP funding will pay for the QBP volumes that a hospital provides. The QBP funding will replace the funds used by hospital in the base year to provide QBP services. This amount of money is referred to as the QBP carve out. The carve out amount is based on the HBAM cost per weighted case, adjusted to remove allowances for teaching, distance and tertiary care. The calculation of this carve out cost per weighted case for each hospital in the Northeast is presented in the following table. Page 171

176 Fac. # Exhibit 103: 2012/13 HBAM Unit Cost Calculations for HBAM QBP Net Unit Cost Estimates Facility Name Actual 12/13 HBAM Unit Cost Tertiary Value Distance Value Teaching Intensity Value HBAM QBP Net Unit Cost HBAM Applies? 2012/13 OCDM % Direct (IP) Direct Unit Cost Net of Adjust. 611 BLIND RIVER District H C $6,475 $21 $213 $22 $6,219 No 61% $3, CHAPLEAU Health Services $8,125 $- $313 $- $7,812 No 66% $5, COCHRANE Lady Minto $5,628 $16 $548 $7 $5,057 No 68% $3, ELLIOT LAKE St Joseph's $3,981 $17 $243 $3 $3,718 Yes 75% $2, ENGLEHART & District $5,156 $16 $328 $- $4,812 No 72% $3, ESPANOLA General $5,543 $- $- $- $5,543 No 69% $3, HEARST Notre Dame $6,090 $21 $679 $28 $5,362 No 72% $3, HORNEPAYNE Community $8,146 $19 $576 $- $7,551 No 67% $5, IROQUOIS FALLS Anson General $4,598 $- $482 $- $4,116 No 71% $2, WAWA Lady Dunn HC $6,309 $562 $321 $- $5,426 No 66% $3, KAPUSKASING Sensenbrenner $4,491 $36 $655 $30 $3,770 No 73% $2, KIRKLAND & District $5,193 $17 $378 $1 $4,797 No 73% $3, MATHESON Bingham Memorial $7,485 $- $441 $- $7,044 No 73% $5, MATTAWA General $7,796 $11 $334 $- $7,451 No 61% $4, LITTLE CURRENT Manitoulin $5,723 $38 $207 $11 $5,467 No 68% $3, SMOOTH ROCK FALLS $4,573 $- $596 $- $3,977 No 70% $2, STURGEON FALLS West Nipissing $4,087 $29 $157 $39 $3,862 No 71% $2, NEW LISKEARD Temiskaming $5,051 $34 $283 $24 $4,710 Yes 71% $3, TIMMINS & District General $5,274 $107 $426 $36 $4,705 Yes 78% $3, PARRY SOUND West Parry Sound $5,523 $27 $207 $32 $5,257 Yes 73% $3, Health Sciences North $5,660 $430 $1 $23 $5,206 Yes 80% $4, SAULT STE MARIE Sault Area $5,717 $123 $592 $16 $5,302 Yes 75% $3, Weeneebayko Area HA $6,000 Not Available $5,000 No 64% $3, NORTH BAY Regional HC $6,486 $125 $225 $23 $6,113 Yes 74% $4,494 Page 172

177 Appendix D: Current and Future NE LHIN QBP Utilization Characteristics Under Current Models of Care Page 173

178 Current and Future NE LHIN QBP Utilization Characteristics Under Current Models of Care Current volumes of QBP acute care services used by the residents of the NE LHIN and the market share and volumes provided by each of the hospitals within the LHIN and by hospitals outside the LHIN We analyzed the most recent available (2012/13) Discharge Abstract Database (DAD) data to determine, under the current models of care, the volumes of QBP acute care services used by the residents of each hub within the NE LHIN and the market share and volumes provided by each of the hospitals within the LHIN and by hospitals outside the LHIN. The North East LHIN hubs are 143 : Algoma Cochrane Coast Manitoulin, Parry Sound, Sudbury (MPSS) Nipissing/Temiskaming Similarly, we developed an inventory of the total volumes of QBP cases provided by each of the hospitals within the LHIN for patients from inside and outside the LHIN combined, again, under the current models of care for QBP patients. Projection of future volumes and related bed requirements based on current models of care and patterns of utilization We analyzed the current use of hospital (and non-hospital) post acute care services (Inpatient Rehabilitation, CCC and CCAC) used by QBP cases. These were measured in terms of the propensity of QBP cases to use post acute care services. We then projected future volumes and related bed requirements based on current models of care and current patterns of utilization for QBP services. These will be the patient volumes and related bed requirements if there are no changes in utilization rates and/or models of care. 143 For purposes of QBP planning, the Steering Committee has determined that St. Joseph s Elliot Lake should be considered to be part of the MPSS hub rather than the Algoma hub. Page 174

179 Exhibit 104: Current Use of Hospitals for QBPs by NE LHIN Residents: Hospital Market Shares Exhibit 105: Current Use of Hospitals for QBPs by NE LHIN Residents: Number of Cases Page 175

180 Exhibit 106: Current Use of Hospitals for QBPs by NON LHIN Residents: Number of Cases Exhibit 107: Current Use of Hospitals for QBPs by NE LHIN Residents & NON Residents: Total Number of Cases Page 176

181 Exhibit 108: Current Use of Hospitals for QBPs by NE LHIN Residents & NON Residents: % of Cases by Hospital Page 177

182 Exhibit 109: Current ALOS by Hospital for QBP Cases Note significant variation in ALOS among hospitals Note: ALOS for Stroke Unspecified declined from 17.5 to 11.1 Page 178

183 Exhibit 110: Current Use of Hospitals for QBPs by NE LHIN Residents & NON Residents: Current No of Pat Days Page 179

184 Exhibit 111: Current Use of Hospitals for QBPs by NE LHIN Residents & NON Residents: Current Number of Beds Used Beds estimated assuming 95% occupancy for medical patients 90% occupancy for surgical patients Page 180

185 Exhibit 112: Current Discharge Destinations for NE LHIN QBP Patients: % of Patients Exhibit 113: Current Discharge Destinations for NE LHIN QBP Patients: No of Patients Page 181