Integrated Service Plan for Northwestern Ontario

Transcription

1 Integrated Service Plan for Northwestern Ontario Project Report Submitted to the Special Advisor to the Minister of Health and Long Term Care for Ontario June 15, 2005 HayGroup

2 Integrated Service Plan for Northwestern Ontario Table of Contents Section Page 1.0 BACKGROUND AND OBJECTIVES PUBLIC CONSULTATION VISION FOR RESTRUCTURING OF HEALTH SERVICES IN NORTHWESTERN ONTARIO INTEGRATION ALONG THE CONTINUUM OF CARE PRIMARY COMMUNITY CARE CURRENT AVAILABILITY OF PRIMARY CARE PRIMARY COMMUNITY CARE IN ISOLATED AND REMOTE COMMUNITIES PRIMARY CARE/CCACS AND HOSPITALS ACUTE CARE HOSPITAL SERVICES CURRENT ACUTE CARE HOSPITAL SERVICES IN NORTHWESTERN ONTARIO RESTRUCTURING OF HOSPITAL SERVICES IN NORTHWESTERN ONTARIO TERTIARY CARE OUT OF REGION SERVICES REQUIRED SIZE OF ACUTE CARE HOSPITALS LONG-TERM CARE RESTRUCTURING LONG-TERM CARE SERVICES IN NORTHWESTERN ONTARIO COMPLEX CONTINUING CARE PALLIATIVE CARE MENTAL HEALTH & ADDICTIONS MANAGEMENT & GOVERNANCE NORTHWESTERN ONTARIO JOINT MEDICAL ADVISORY COMMITTEE UTILIZATION MANAGEMENT FOR NORTHWESTERN ONTARIO HEALTH HUMAN RESOURCES PLANNING E-HEALTH IN NORTHWESTERN ONTARIO THE COST OF CHANGE COSTS OF IMPROVEMENTS IN PRIMARY CARE COSTS OF RESTRUCTURING OF ACUTE CARE SERVICES COST OF RESTRUCTURING LONG-TERM CARE RESTRUCTURING GOVERNANCE AND MANAGEMENT E-HEALTH INITIATIVES SUMMARY OF THE COSTS OF CHANGE...82 HayGroup i

3 Integrated Service Plan for Northwestern Ontario APPENDIX A: SUMMARY OF CONSULTATION PROCESS IN NORTH WEST ONTARIO AND THUNDER BAY APPENDIX B: SUMMARY OF SUBMISSIONS APPENDIX C: SURVEY OF THE LITERATURE ON RURAL HEALTH APPENDIX D: RELATING OBSTETRICAL VOLUME AND OUTCOMES APPENDIX E: ORTHOPAEDIC SURGERY: THE RELATIONSHIP BETWEEN VOLUME AND OUTCOMES APPENDIX F: LOCATION OF INPATIENT HOSPITALIZATION BY PROGRAM CLUSTER CATEGORY APPENDIX G: LOCATION OF SAME DAY SURGERY APPENDIX H: SMALL AREA VARIATION ANALYSES HayGroup ii

4 Integrated Service Plan for Northwestern Ontario 1.0 Background and Objectives Thunder Bay Regional Health Sciences Centre (TBRHSC) recently opened a new 375 bed facility as a replacement for the former McKellar and Port Arthur hospitals. TBRHSC is a tertiary care facility and is one of the teaching sites for the new Northern Ontario Medical School. At the time this project was started, the Hospital s Vision was to:...be an outstanding treatment, education, research and referral centre for acute healthcare services in Northwestern Ontario. We will be a key part of effective and integrated healthcare, which will be responsive to the people we serve. TBRHSC has been unable to fulfill its role as a regional hospital in responding to the needs for hospital care of residents of Northwestern Ontario Recently TBRHSC has been facing numerous pressures and issues that have limited its ability to respond to the needs for tertiary care of residents of Northwestern Ontario. Other than for trauma and stroke, TBRHSC has often been closed to patients from outside Thunder Bay. As a result, patients with acute needs are forced to secure care outside the region in Winnipeg, Duluth, Timmins, Sault Ste. Marie, and Sudbury or delay access to care. Some of the pressures facing TBRHSC that may be causes of the hospitals inability to respond to the needs of patients in its catchment area include: Difficulty in recruiting and retaining medical staff Inability to discharge patients to more appropriate levels of care resulting in: Frequent overcrowding in the ED Use of the old McKellar facility to house 60 ALC patients in interim long-term care beds. Operating deficits in each of the past 3 years Working capital deficit of $13.6 million projected to the end of 2003/04 Operating and capital funding requirements to support the new Northern Ontario Medical School. And these operating issues are compounded by difficulties encountered in the development of the new hospital facility: Large cost overruns on the new hospital building project Costs for the disposal of the two former hospital sites. In the face of these problems and the hospital s inability to fulfill its expected role in meeting the needs for hospital care HayGroup 1

5 Integrated Service Plan for Northwestern Ontario of the people of Northwestern Ontario, the Minister appointed a Special Advisor to develop an Action Plan to enable the hospital to achieve its stated Vision to be a referral centre for acute healthcare services in Northwestern Ontario. The Minister appointed a Special Advisor to develop an Action Plan to enable TBRHSC to achieve its Vision to be a referral centre for acute healthcare services in Northwestern Ontario. The Special Advisor requested and received assistance in fulfilling his mandate from a Steering Committee consisting of key stakeholders of the health system in Northwestern Ontario. The Steering Committee, chaired by the Special Advisor, received consulting support in their work from the Hay Health Care Consulting Group. The focus of the work of this project has been: Clarifying the roles and responsibilities of TBRHSC and other providers in Northwestern Ontario Defining the capacity and resource requirements to fulfill these roles To this end, the Special Advisor and the Steering Committee employed a 9 phase approach to their work: Phase 1: Phase 2: Phase 3: Phase 4: Phase 5: Phase 6: Phase 7: Public Consultation Assessment of population needs for health service Determination of current clinical capacity Assessment of clinical efficiency Assessment of operational efficiency of TBRHSC Determination of implications of Northern Ontario Medical School on health services in NW Ontario Determine Required Clinical Capacities Phase 8: Determine an effective organizational model for health services Phase 9: Develop project report and recommended directions for change. HayGroup 2

6 Integrated Service Plan for Northwestern Ontario In considering the need for and delivery of health services in Northwestern Ontario, the project considered six geographic areas 1 and population groupings: Kenora Urban Dryden Rainy River Sioux Lookout and Isolated Communities Thunder Bay District, and Thunder Bay City The following map provides an overview of these geographies. Exhibit 1.1 Geographical Areas for Analysis 1 Northwestern Ontario divided into 6 geographic areas (based on combinations of county and postal code):thunder Bay City (P7A, P7B, P7C, P7E, P7G, P7J, P7K) 115,640 residents; Thunder Bay District (remainder of TB District) 39,143 residents; Dryden (P8N) 13,351 residents; Rainy River District (Rainy River county) 22,343 residents; Kenora Urban (P9N,P0X,P0Y) 24,753 residents; Sioux Lookout and Isolated Communities 28,026 residents HayGroup 3

7 Integrated Service Plan for Northwestern Ontario This report presents the findings and recommendations of this review and incorporates the recommendations of the Special Advisor. HayGroup 4

8 Integrated Service Plan for Northwestern Ontario 2.0 Public Consultation The project started with an extensive process of consultation that involved interviews with stakeholders and public sessions in communities across Northwestern Ontario. Over 700 people attended consultation sessions conducted by the Special Advisor and the consultants. The Special Advisor visited and met with stakeholders in: Nipigon Thunder Bay Sioux Lookout Dryden The Consultants visited, interviewed stakeholders and conducted public consultation sessions in: Region east of Thunder Bay Nipigon Geraldton Terrace Bay (Schrieber) Marathon Manitouwadge Thunder Bay Region west of Thunder Bay Fort Frances Atikokan Dryden Kenora Sioux Lookout Red Lake Sandy Lake Fort Hope Over 700 people attended the sessions conducted by the Special Advisor and the consultants. The table following presents the attendance at the consultants interviews and consultation sessions in each community. HayGroup 5

9 Integrated Service Plan for Northwestern Ontario Exhibit 2.1 Attendance at Interviews and Consultation Sessions by Community Number of Community participants Manitouwadge 21 Marathon 25 Terrace Bay/Schreiber 100 Geraldton 30 Nipigon 24 East of Thunder Bay Subtotal 200 Thunder Bay 159 Thunder Bay Subtotal 159 Atikokan 24 Fort Frances 29 Dryden 20 Kenora 28 Sioux Lookout 28 Red Lake 19 Sandy Lake/Ft. Hope 15 West of Thunder Bay Subtotal 163 TOTAL 522 The discussion in the interviews and consultation sessions focused on: Deficits in services and unmet needs Issues in access to the services that currently exist Potential improvements in the organization and delivery of services. Additionally, the Northwestern Ontario District Health Council invited and received more than 60 written submissions from interested organizations and individuals. Summaries of the findings of the sessions and the written submissions are presented in an appendix to this report. The interviews, consultation sessions and written submissions served as input into the analysis by the consultants, the deliberations of the Steering Committee and ultimately the advice of the Special Advisor to the Minister of Health and Long-Term Care. This input is reflected in the discussion in this report and is not repeated here. However summaries of the findings of the sessions and the written submissions are presented in an appendix to this report. HayGroup 6

10 Integrated Service Plan for Northwestern Ontario 3.0 Vision for Restructuring of Health Services in Northwestern Ontario The research of this study has led the Special Advisor to articulate his vision for the restructuring of health services in Northwestern Ontario. He sees restructuring initiatives that will: Improve the health status of people in Northwestern Ontario through an emphasis on health education, disease prevention, health maintenance and access to health services that incorporate the physical and mental health of the population. Realization of this vision will require significant attention to the restructuring, integration and enhancement of primary community care and primary hospital care. The recommendations in this report will provide a direction that over time will maximize the populations access to health services by integrating services along the continuum of care, emphasizing culturally sensitive service delivery and providing services as close to home as is feasible with respect to the safety of care, quality of care and the economics of care delivery systems. 3.1 Integration Along the Continuum of Care The population in Northwestern Ontario justifiably desires, expects and is entitled to the integration of health care services and the collaborative interaction of health care providers. The population in Northwestern Ontario justifiably desires, expects and is entitled to the integration of health care services and the collaborative interaction of health care providers. Given the interdependency of hospitals in the Northwest and the amount of necessary patient transfer among facilities, it is not unreasonable for residents to expect a single admission for a single, integrated episode of care in response to a single incident of accident or ill health. The patient should be cared for within one admission from Local, to District to the Regional hospital, and back, as appropriate. By setting up structures and processes which focus on a seamless trip for each patient through the system, and by focusing each individual organization s efforts on their portion of the patient s trip, it is anticipated that more people can be treated closer to their homes and social support networks. Also, this will serve to optimize the use of the limited resources of the regional hospital in Thunder Bay by focusing its services to patients from outside of the city on services and levels of care that can only be provided in a regional centre. The integration of services will be facilitated by the assignment of clearly HayGroup 7

11 Integrated Service Plan for Northwestern Ontario articulated hospital roles and responsibilities supported by district and inter district structures, processes and governance. HayGroup 8

12 Integrated Service Plan for Northwestern Ontario 4.0 Primary Community Care 4.1 Current Availability of Primary Care Addressing the deficits in primary care will help resolve many of the health status and health service utilization issues in Northwestern Ontario The investigation and analyses conducted as part of this project suggest: A shortage of family physicians in several communities most notably in Thunder Bay, Dryden and Kenora. There is a shortage of family physicians in centres that don t qualify for special MD payment plans which make it difficult for them to attract practitioners. Even in communities with an apparently sufficient number of primary care providers, the continuity of residence by practitioners is not ensured. For example, during the course of this study all six GPs in Geraldton announced that they would be leaving. The functional shortage of primary care providers across the northwest is likely contributing to a high rate of hospitalizations that could be avoided with better health maintenance and management of chronic diseases. Health services research and professional opinion suggests that addressing deficits in primary care will contribute to the resolution of many of the health status and health service utilization issues in the northwest. Access to primary care services addressing mental health, addiction, obesity and diabetes is especially important for First Nations Communities Particularly problematic are the challenges of providing primary care services in First Nations Communities related to health maintenance, disease prevention and management of chronic conditions. Especially important in these communities is access to primary care services addressing mental health, addiction, obesity and diabetes Analysis of Supply of Physicians We used the 2003 Ontario Physician Human Resource Data Centre database2 to investigate the supply of primary care physicians in Northwestern Ontario. Although there are many reported deficiencies in this data base, it is the most complete 2 Physician in Ontario (PIO) Reports are prepared by the Ontario Physician Human Resources Data Centre (OPHRDC). OPHRDC is a collaborative project of the College of Physicians and Surgeons of Ontario (CPSO), the Ontario Ministry of Health and Long-Term Care (MOHLTC), the Ontario Medical Association (OMA), and the Council of Ontario Faculties of Medicine (COFM). HayGroup 9

13 Integrated Service Plan for Northwestern Ontario documentation of the distribution of MDs in Ontario 3. The most significant weakness is that the database does not measure intensity of practice so that it can t differentiate between full and part-time practitioners. And it does not provide any information on Nurse Practitioners. Taking into account these data deficiencies, the database suggests that overall the region has a higher number of general practitioners (12.1 per 10,000 population) than is the average for the province as a whole (8.5 per 10,000 population) or for other subregions of the province (ranging from 6.9 per 10,000 in Central East to 10.6 per 10,000 population in the North East). The data base does confirm the qualitative finding that suggests a relative shortage of GPs in Thunder Bay compared to other communities in Northwestern Ontario but it is 3 Physicians in Ontario (PIO) reports are prepared from the annual Active Physician Registry. The following describes the methodology used to select physicians for inclusion in the Active Physician Registry. The Registry is derived substantially from College of Physicians and Surgeons of Ontario (CPSO) data, records of the Ontario Health Insurance Plan (OHIP), information collected from physicians by the OPHRDC dynamic survey, and a number of secondary data sources. First, records of licensees of the CPSO are screened for anomalies and duplicates and rules are applied to exclude physicians who are on the CPSO list but are unlikely to be active. These rules include: Removal of deceased physicians. Removal of licensees with birth years 85 years prior to the census date. Removal of physicians with expired licenses. Removal of physicians with educational, short term or academic visitor license class. Removal of physicians not residing in Ontario. The remaining CPSO records are then matched against OHIP demographic data. Duplicates and suspicious matches are surveyed and explained using other data, or referenced to the owners of the source data. The next step is a record-by-record reconciliation between the Ontario Postgraduate Medical Trainee Registry (also a product of the OPHRDC) and the Active Physician Registry to eliminate postgraduate medical trainees holding a general license who had not completed training by July 31. Location and activity level data from OPHRDC dynamic physician survey is then overlaid on the Registry dataset. A number of secondary sources of data are then used to validate and in some cases to supplement the data used. These sources include lists of salaried physicians employed in government agencies, special clinics and health centres, as well as physicians on a variety of non-fee for service payment plans. These lists identify physicians qualified for entry into the Active Physician Registry who have not been verified by reference to OHIP data. The final Registry then includes only licensed physicians verified as actively in practice in Ontario. Data elements regarding geographic location, specialty of practice, age, gender and other variables are then appended so that the PIO reports can be prepared. HayGroup 10

14 Integrated Service Plan for Northwestern Ontario interesting to note that Thunder Bay has more GPs than elsewhere in Ontario. Outside of Thunder Bay, the data would suggest a problem of access to general practitioners by a widely dispersed population rather than a shortage of physicians. Exhibit 4.1 Physicians per 10,000 Population 2003 Ontario Physician Human Resource Database 4 Ontario Average Toronto South West East Central West Central South Central East Non-Specialist Specialist North East North West Rainy River Thunder Bay Kenora Use of Emergency Departments In urban areas, when populations have a difficult time accessing a primary care provider in the community, they will use the hospital emergency department in place of a primary care provider. This is usually considered poor quality primary care as the care is episodic and there is no continuity in provider-patient interaction. However, in smaller communities where the primary care physicians are the staff of the ED, off-hours coverage for the primary care providers is often and appropriately provided by the member of the primary care group who is covering the ED at that time. This provider will likely have seen the patient previously, and as is normal in an effective coverage situation, will communicate the details of the encounter to the patient s primary provider the next day so that he/she can follow up with the patient as 4 Physician in Ontario (PIO) Reports, 2004, Ontario Physician Human Resources Data Centre (OPHRDC). HayGroup 11

15 Integrated Service Plan for Northwestern Ontario necessary. This is an example of the first stage in the integration of primary community and primary hospital care. In considering the utilization rates of emergency departments in Northwestern Ontario, we see both of these phenomena. The National Ambulatory Care Reporting System (NACRS) system data for visits to hospital Emergency Departments uses the Canadian Triage Assessment System (CTAS) to classify visits into 1 of 5 categories. CTAS 1 Resuscitation CTAS 2 Emergent CTAS 3 Urgent CTAS 4 Semi-Urgent CTAS 5 Non-Urgent Considering the 2003/04 NACRS system data for visits to ED s in hospitals in Northwestern Ontario we find that overall: 8% of ED visits for NW Ontario residents are Resuscitation or Emergent 27% of ED visits are Urgent 65% of ED visits are Semi- or Non-Urgent The population of Northwestern Ontario uses EDs over twice as often as the populations in southern Ontario Many, if not most of the Semi Urgent and Non-Urgent visits to the ED are visits that are appropriately cared for by primary care providers in the community. When we look at the use of ED by the populations of the various districts in Northwestern Ontario, we find different patterns in different communities. As is shown in the exhibit following, the population of Northwestern Ontario uses EDs over twice as often as the populations in southern Ontario. Depending on the community, this is either an example of a weakness within primary care or an example of the integration of primary care providers with the hospital or both. HayGroup 12

16 Integrated Service Plan for Northwestern Ontario Exhibit 4.2 Total ED Visits per 10,000 Age/Gender Standardized Population by Region 2003/04 Central Toronto 3,000 3,170 NE Ontario NW Ontario Sioux Lkt. & Isol. 5,848 8,160 7,631 Dryden 11,419 Kenora Urban Rainy River District Thunder Bay District Thunder Bay City 8,886 8,341 8,490 7,150 In the City of Thunder Bay, one would expect to find a reasonably robust primary care system and little need to use the hospital ED as a substitute for community based primary care. However, the use of the ED by residents of Thunder Bay is over twice that of residents of Toronto and other communities in the South. Conversely, the low use of hospital EDs by residents of Sioux Lookout and Isolated communities is probably an indication that much of the population live in isolated and remote communities without discretionary access to and ED. And we hypothesize based on the interviews and consultation in Dryden that the high use of the hospital ED by residents of that community is an example of the integration of community primary care with the hospital. When we consider the triage levels of the visits to EDs by residents of each community we find that most of the visits to the EDs in the smaller communities are semi urgent or nonurgent visits that closely resemble the services that could and should be provided by primary care providers. In these communities, the hospital is likely providing an alternative to or a complement to primary care in the community. HayGroup 13

17 Integrated Service Plan for Northwestern Ontario Exhibit 4.3 Total ED Visits per 10,000 Age/Gender Standardized Population by Region and Triage Acuity 2003/04 Central Resuc. / Emerg. Toronto Urgent NE Ontario NW Ontario Semi-Urgent / Non-Urgent Sioux Lkt. & Isol. Dryden Kenora Urban Rainy River District Thunder Bay District Thunder Bay City 0 2,000 4,000 6,000 8,000 10,000 12, Avoidable Hospitalizations Avoidable hospitalizations are admissions to hospital related to conditions and events that primary care providers should be able to manage without the need for hospitalization. Health services researchers have identified a set of hospitalization conditions that can be considered to be potentially avoidable, because early and consistent access to good primary care can prevent the condition or can manage the condition and reduce the severity of impact such that hospitalization is unlikely (or infrequent). The conditions considered to be potentially avoidable hospitalization conditions are: Pneumonia Congestive Heart Failure Asthma Cellulitis Ulcer Pyleonephritis Diabetes HayGroup 14

18 Integrated Service Plan for Northwestern Ontario Ruptured Appendix Hypertension Hypokalemia Immunizable Conditions Gangrene Rate of avoidable hospitalizations for residents of Northwestern Ontario is almost 50% higher than the rates for residents of the province as a whole. High rates of admissions for these conditions may signify the need to enhance the primary care system. The exhibit following shows the 2001/02 rates of inpatient admission (per 10,000 population) for avoidable hospitalization conditions for districts in Northwestern Ontario and other regions in Ontario. Exhibit 4.4 Avoidable Hospitalization Condition Inpatient Admissions per 10,000 Age/Gender Standardized Population (2003/04) All Ontario Elsewhere Central East Toronto NE Ontario NW Ontario Sioux Lkt. & Isol. 212 Dryden 81 Kenora Urban Rainy River District Thunder Bay District Thunder Bay City The rate of avoidable hospitalizations for the residents of the Sioux Lookout & Isolated Communitiesand remote communities is over 250% the rate for residents of the rest of the province. With the exception of Dryden, the rate of admission for avoidable hospitalization conditions is high throughout Northwestern Ontario suggesting a weakness in the delivery of primary care. The rate of avoidable hospitalizations for residents of Northwestern Ontario is almost 50% higher than the rates for residents of the province as a whole. The highest rate of admission for potentially avoidable hospitalization conditions is for residents of Sioux Lookout and the isolated communities to the north. The rate of avoidable HayGroup 15

19 Integrated Service Plan for Northwestern Ontario hospitalizations for this population is over 250% the rate for residents of the rest of the province. This indicator would suggest that these populations are most in need of improvements in primary care. This confirms the findings of the public consultation sessions held throughout the northwest. If the rate of avoidable hospitalization in Northwestern Ontario were reduced by to 17% to 100 per 10,000 population which is still 25% higher than the provincial average, then 514 annual hospital admissions could be avoided and the cost of hospital care would be reduced by approximately $1.1 million Primary Community Care in Isolated and Remote Communities There are many smaller communities in Northwestern Ontario that have no year-round road access. And there are many where there is an extended distance to the first significant population centre. There are significant challenges in ensuring access to health services for residents of these communities. As has been seen, the first, and perhaps most important challenge is the provision of primary care The care providers working in the isolated and remote communities should work together as a virtual health care team The findings of this study suggest that there needs to be significant enhancement in the effectiveness of primary care for these isolated and remote communities. Based on experience in other similarly remote districts in Canada, especially the Grenfell Region of northern Newfoundland and southern Labrador, the enhancement to primary care should be based on an expansion in the distribution and use of Nurses and Nurse Practitioners (NPs). The NPs should be located in clinics in the isolated and remote communities; the smallest of these communities would be served by regular visits by traveling Nurses and Nurse Practitioners. It is also recommended that these communities expand the use of pointof-care diagnostic technologies which will support decisionmaking as to whether patients need to move from isolated or remote care settings to another health care setting. In addition, it is recommended that the care providers working in the isolated and remote communities work together as a virtual health care team to serve the widely dispersed populations in these communities. This would provide phone, telemedicine, and visiting support from a variety of health care professions 5 Based on an estimated cost per day of $300 for avoidable hospitalization cases and an average length of stay of 7.4 days per case. HayGroup 16

20 Integrated Service Plan for Northwestern Ontario to each of the remote and isolated communities. Importantly, the Nurse Practitioners in these smaller communities should have 24-hour access to the Emergency Departments at the District and Regional level using telemedicine linkages. Recommendations: The Special Advisor recommends that: (1) The MOHLTC should adapt primary health models for isolated and remote communities to include virtual teams that use of Nurse Practitioners and nurses as the primary care givers linked together and to a supporting family practitioner and other health professionals by telemedicine technologies. (2) The LHIN should ensure that all isolated communities have 24-hour telemedicine link to their closest District Hospital and to TBRHSC. 4.3 Primary Care/CCACs and Hospitals Primary Care Teams should focus on health education, suicide and injury prevention, disease prevention, health maintenance and treatment related to both physical and mental health. Family Health Teams (FHTs) outside of Thunder Bay should be operationally integrated with the services of the CCAC and the closest hospital. Primary care should be provided through integrated, multidisciplinary teams. These teams would focus on health education, suicide and injury prevention, disease prevention, health maintenance and treatment related to both physical and mental health. To better respond to the breadth of services required by the general and special populations in the Northwest, the Family Health Teams should incorporate not only Family Practitioners and Nurse Practitioners, but also other health professionals such as midwives, clinical nutritionists, social workers, health educators, etc. as appropriate to the needs of the population to be served. Family Health Teams (FHTs) outside of Thunder Bay should be operationally integrated with the services of the CCAC and the closest hospital. As feasible, FHT facilities should be located within (or adjacent to) the hospital so that the FHT can make use of diagnostic and therapeutic services of the hospital and easily support the outpatient, ED and inpatient services of the hospital. Similarly, the FHT and CCAC should work closely together in providing community based and in-home care. Importantly, pre-natal care should be provided locally by midwives, GPs, or NPs in as many communities as possible. Birthing should be provided at hospitals operating under the Society of Obstetricians and Gynaecologists of Canada MORE (Managing Obstetrical Risk Efficiently) program. Health services in Dryden already follow a model much like that described here. The FHT proposal in Red Lake HayGroup 17

21 Integrated Service Plan for Northwestern Ontario also will provide for much of the suggested integration of hospital and FHT services. Recommendation: The Special Advisor recommends that: (3) The MOHLTC should ensure that each Family Health Team approved model outside Thunder Bay, to the extent possible, is operationally integrated with the services of the CCAC and the closest hospital. HayGroup 18

22 Integrated Service Plan for Northwestern Ontario Patient Residence 5.0 Acute Care Hospital Services 5.1 Current Acute Care Hospital Services in Northwestern Ontario Currently, the residents of Northwestern Ontario use 52,388 episodes of Inpatient and Same Day Surgery (SDS) hospital care per year in hospitals in Northwestern Ontario, Winnipeg and elsewhere in Ontario. The exhibit following shows the volume of hospitalizations by type of care used by residents of each of the six districts established in this project to support data analysis. The hospitalizations are categorized in relation to the type of problem and/or treatment that was the most responsible reason for hospitalization (Broad Groups based on Patient Diagnosis.) Exhibit 5.1 Hospital Utilization by Patient Residence Broad Group Based on Patient Diagnosis Medicine Surgery SDS Birthing Neonates Mental Hl. Dryden , ,412 Kenora Urban 1, , ,235 Rainy River District 2, , ,111 Sioux Lkt. & Isol. Comm. 2, , ,106 Thunder Bay City 7,301 4,095 11,793 1,270 1, ,565 Thunder Bay District 2, , ,959 Grand Total 16,610 7,281 20,385 3,287 2,828 1,997 52,388 Total Currently the fourteen 6 hospitals in Northwestern Ontario provide a range of services in response to the needs of the residents of their communities. The following exhibit presents the number of inpatient and SDS acute care cases treated in each of the hospitals in Northwestern Ontario. As can be seen, several of the hospitals currently provide very small numbers of surgeries and births. Although not conclusive, the literature does suggest that there is a volume:outcome relationship for surgical procedures and for birthing. (Reviews of the literature regarding rural health, obstetrics and orthopaedic surgery are presented as Appendices C, D and E to this report.) Extremely low volumes of births (fewer than 100) have been shown to significantly increase the risk of infant 6 Riverside Health Care Facilities Inc. operates La Verendrye General Hospital in Fort Frances, Rainy River Health Centre in Rainy River and Emo Hospital in Emo. HayGroup 19

23 Integrated Service Plan for Northwestern Ontario mortality. If surgery and birthing is to continue to be provided in these hospitals, it would be advantageous and reduce risk if volumes could be increased. Exhibit 5.2 Hospital Volumes in NW Ontario Hospitals in 2003/04 Hospital Broad Group Based on Patient Diagnosis Community Medicine Surgery SDS Obstetrics Neonates Psych. Inpatients Kenora 1, , ,839 Red Lake Dryden 1, , ,690 Sx Lookout 1, ,104 Ft Frances + 1, , ,309 Atikokan Nipigon Geraldton Manitouwadge Terrace Bay Marathon TBRHSC 8,383 4,630 14,925 1,801 1,627 1,149 17,590 Hospitals in Red Lake, Sioux Lookout and in Thunder Bay District are providing a relatively small proportion of the inpatient and same day surgery hospital care used by residents of their communities. The Exhibits following shows the number and the percentage of hospital care used by residents of each community that is provided by the local hospital and by other hospitals inside and outside Northwestern Ontario. As can be seen, residents of communities outside Thunder Bay receive a significant amount of their care in Thunder Bay or somewhere else in Ontario or Manitoba 7. Residents of Thunder Bay District are especially dependant on TBRHSC for both inpatient and same day surgery care; 48% of the inpatient care and 89% of the SDS care received by residents of Thunder Bay District was provided by TBRHSC. And residents of Red Lake, Sioux Lookout and Remote Communities are dependant on TBRHSC, other hospitals in the Northwest and hospitals in Winnipeg for 16%, 13% and 13% of their inpatient hospital care and 24%, 18% and 10% of their Same Day Surgery. 7 The small amount of care provided by hospitals in the U.S are not reflected in these tables. HayGroup 20

24 Integrated Service Plan for Northwestern Ontario Exhibit 5.3 Where Patients in Northwestern Ontario Get Inpatient Hospital Care (Cases) Patient Residence In Own Sub-Area TB City Elsewhere Elsewhere in NW in Ont Winnipeg Dryden 1, Kenora Urban 2, Rainy River District 2, Sioux Lkt. & Isol. Comm. 2, Thunder Bay City 13,729 13, Thunder Bay District 1,848 2, Grand Total 24,714 17, ,447 1,351 Patient Residence In Own Sub-Area TB City Elsewhere Elsewhere in NW in Ont Winnipeg Dryden 79% 9% 3% 2% 8% Kenora Urban 83% 3% 3% 1% 11% Rainy River District 79% 12% 2% 1% 5% Sioux Lkt. & Isol. Comm. 57% 16% 13% 1% 13% Thunder Bay City 93% 93% 0% 6% 0% Thunder Bay District 42% 48% 1% 8% 1% Grand Total 77% 54% 3% 5% 4% Exhibit 5.4 Where Patients in Northwestern Ontario Get Their Same Day Surgery (SDS) Patient Residence In Own Sub-Area TB City Elsewhere Elsewhere in NW in Ont Winnipeg Dryden Kenora Urban Rainy River District Sioux Lkt. & Isol. Comm Thunder Bay City 11,508 11, Thunder Bay District 20 2, Grand Total 15,244 14, Patient Residence In Own Sub-Area TB City Elsewhere Elsewhere in NW in Ont Winnipeg Dryden 79% 10% 4% 1% 7% Kenora Urban 74% 1% 3% 0% 21% Rainy River District 60% 29% 2% 1% 9% Sioux Lkt. & Isol. Comm. 47% 24% 18% 1% 10% Thunder Bay City 98% 98% 0% 2% 1% Thunder Bay District 1% 89% 0% 9% 1% Grand Total 75% 73% 2% 2% 4% The following exhibits show the numbers and percentage of hospitalizations for residents of each sub-area provided by a hospital in their own sub-area, by TBRHSC, by another hospital in the Northwest, by a hospital elsewhere in Ontario and by a hospital in Winnipeg for each of 4 key categories of care: HayGroup 21

25 Integrated Service Plan for Northwestern Ontario Surgery Medicine Neonates Psychiatry The cases are categorized in relation to the type of problem and/or treatment that was the most responsible reason for hospitalization (Broad Groups based on Patient Diagnosis.) Exhibit 5.5 Where Patients in Northwestern Ontario Get Inpatient Surgical Hospital Care Patient Residence In Own Sub-Area TB City Elsewhere Elsewhere in NW in Ont Winnipeg Dryden Kenora Urban Rainy River District Sioux Lkt. & Isol. Comm Thunder Bay City 3,279 3, Thunder Bay District Grand Total 4,240 4, , Patient Residence In Own Sub-Area TB City Elsewhere Elsewhere in NW in Ont Winnipeg Dryden 60% 21% 2% 4% 15% Kenora Urban 52% 9% 6% 3% 30% Rainy River District 48% 33% 1% 4% 13% Sioux Lkt. & Isol. Comm. 22% 34% 19% 4% 20% Thunder Bay City 80% 80% 0% 19% 1% Thunder Bay District 1% 72% 1% 23% 3% Grand Total 58% 62% 3% 15% 7% HayGroup 22

26 Integrated Service Plan for Northwestern Ontario Exhibit 5.6 Where Patients in Northwestern Ontario Get Inpatient Medical Hospital Care Patient Residence In Own Sub-Area TB City Elsewhere Elsewhere in NW in Ont Winnipeg Dryden Kenora Urban 1, Rainy River District 1, Sioux Lkt. & Isol. Comm. 1, Thunder Bay City 7,111 7, Thunder Bay District 1, Grand Total 14,381 8, Patient Residence In Own Sub-Area TB City Elsewhere Elsewhere in NW in Ont Winnipeg Dryden 89% 5% 1% 1% 3% Kenora Urban 90% 2% 2% 1% 6% Rainy River District 91% 6% 1% 0% 2% Sioux Lkt. & Isol. Comm. 70% 9% 13% 1% 7% Thunder Bay City 97% 97% 0% 2% 0% Thunder Bay District 64% 31% 1% 3% 1% Grand Total 87% 50% 2% 2% 2% Exhibit 5.7 Where Northwestern Ontario Neonates are Delivered Patient Residence In Own Sub-Area TB City Elsewhere Elsewhere in NW in Ont Winnipeg Dryden Kenora Urban Rainy River District Sioux Lkt. & Isol. Comm Thunder Bay City 1,149 1, Thunder Bay District Grand Total 2,072 1, Patient Residence In Own Sub-Area TB City Elsewhere Elsewhere in NW in Ont Winnipeg Dryden 75% 4% 3% 1% 17% Kenora Urban 93% 0% 3% 0% 5% Rainy River District 78% 14% 1% 0% 7% Sioux Lkt. & Isol. Comm. 49% 23% 7% 1% 21% Thunder Bay City 99% 99% 0% 1% 0% Thunder Bay District 18% 76% 0% 5% 1% Grand Total 73% 57% 2% 1% 7% HayGroup 23

27 Integrated Service Plan for Northwestern Ontario Exhibit 5.8 Where Patients in Northwestern Ontario Get Inpatient Psychiatric Care Patient Residence In Own Sub-Area TB City Elsewhere Elsewhere in NW in Ont Winnipeg Dryden Kenora Urban Rainy River District Sioux Lkt. & Isol. Comm Thunder Bay City Thunder Bay District Grand Total 1,601 1, Patient Residence In Own Sub-Area TB City Elsewhere Elsewhere in NW in Ont Winnipeg Dryden 55% 5% 36% 0% 4% Kenora Urban 87% 0% 2% 1% 10% Rainy River District 68% 10% 22% 0% 0% Sioux Lkt. & Isol. Comm. 57% 8% 32% 1% 3% Thunder Bay City 99% 99% 0% 0% 0% Thunder Bay District 55% 42% 2% 1% 1% Grand Total 80% 55% 9% 1% 2% As can be seen, local hospitals provide most of the inpatient medical care required by residents of their districts. However, hospitals outside of Thunder Bay are providing significantly less of the surgery being received by residents of their districts, ranging from only 1% of surgeries provided by hospitals in Thunder Bay District to a high of 60% by the hospital in Dryden. Hospitals outside of Thunder Bay provide for a varying percentage of neonate deliveries ranging from 18% by hospitals in Thunder Bay District to a high of 93% by the hospital in Kenora. 5.2 Restructuring of Hospital Services in Northwestern Ontario There is an opportunity to reduce the reliance on TBRHSC for hospital care by enhancing the capability and increasing the volumes of selected hospitals outside of Thunder Bay. There is an opportunity to reduce the reliance on TBRHSC and Winnipeg Regional Health Authority (WRHA) for hospital care, especially surgical and birthing care, by enhancing the capability and increasing the volumes of some of the hospitals outside of Thunder Bay. This would serve to: Provide more care closer to where people live Improve the quality and safety of surgical and obstetrical care provided by hospitals outside of Thunder Bay Reduce the demand for inpatient and SDS care at TBRHSC HayGroup 24

28 Integrated Service Plan for Northwestern Ontario Hospitals in Northwestern Ontario should be designated as Local, District or Regional Hospitals Hospitals in Northwestern Ontario should have clearly designated roles and responsibilities in responding to the needs of the population in the region. Hospitals should be designated as Local, District or Regional Hospitals with roles and responsibilities as defined below Local Hospitals The designation as a Local hospital would mean that the hospital would provide: office and treatment space for Family Health Teams (FHTs), diagnostic technologies that would allow care decisions to be made locally (e.g. ultrasound), emergency care, inpatient medical care for observation, treatment and stabilization, general practitioner procedures and surgeries, and continuation of treatment and recovery for local patients after they have received their initial stages of acute care treatment in a District or the Regional hospital. Complex Continuing Care and/or Long-Term Care beds It is recommended that the hospitals in: Red Lake Emo Rainy River Atikokan Nipigon Geraldton Terrace Bay should be designated as Local Hospitals. However, because of the difficulties for residents of Geraldton in accessing the proposed District Hospital in Marathon, the Geraldton Hospital would be expected to provide an enhanced level of services. These services should be developed to reduce the need for residents of Geraldton to visit Thunder Bay to receive District Hospital services. HayGroup 25

29 Integrated Service Plan for Northwestern Ontario District Hospitals The designation as a District Hospital would mean that a facility would provide 8 : office and treatment space for Family Health Teams, advanced diagnostic technologies (e.g. CAT Scanners), emergency care, inpatient medical care for observation, treatment and stabilization, general inpatient medicine, specialty outpatient medicine services, general practitioner procedures and surgeries some inpatient general surgery, selected subspecialty surgery by visiting surgeons, birthing for low risk neonates by general practitioners operating under the Society of Obstetricians and Gynaecologists of Canada MORE (Managing Obstetrical Risk Efficiently) program. visiting paediatricians inpatient mental health provided by GPs 9 visiting psychiatrists continuation of treatment and recovery for local patients after they have received their initial stages of acute care treatment in the Regional hospital Complex Continuing Care and/or Long-Term Care beds It is recommended that the hospitals in: Kenora, Dryden, Sioux Lookout, Fort Frances and 8 9 Roughly equivalent to Level B Med/Surg Hospitals in Rural and Northern Framework Additionally, Lake of the Woods Hospital in Kenora would continue as a Schedule 1 Psychiatric facility with local psychiatrists. Patients could be transferred to the tertiary care program in Thunder Bay for more intensive treatment as necessary. HayGroup 26

30 Integrated Service Plan for Northwestern Ontario Marathon should be designated as District Hospitals. The hospital in Geraldton should also develop enhanced services given the absence of direct road access to Marathon. The special circumstance in Sioux Lookout The airport in Sioux Lookout receives medical transfers for approximately 90,000 patient visits per year. These patients are from isolated communities traveling to receive health care in the hospital in Sioux Lookout or points further south. Given the geography and transportation services of the Northwest, the need to access care from all points north, and the fact that most of these patients require care that is sensitive to their culture and language, the Province of Ontario should commit to an investment in the Meno-Ya-Win Hospital which would allow it to serve as a District Hospital and provide more care and procedures locally than is currently possible. The facility should continue its focus on providing culturally sensitive care and should be given a formal responsibility to lead in developing and implementing this approach to care throughout Northwestern Ontario Regional Hospital The Regional Hospital is Thunder Bay Regional Health Sciences Centre and the creation of a hierarchy of facilities with increasing capabilities along the continuum means that TBRHS will need to adopt a regional approach to patients as they move through the system. It also requires formal recognition and acceptance by TBRHSC and its medical staff that their role is to provide necessary secondary and tertiary subspecialty care for the population of the entire Northwest and active support for specialists and family practitioners practicing in communities and hospitals outside of Thunder Bay. Generally, the TBRHSC will be expected to provide: Primary Hospital Care for City of Thunder Bay Secondary Hospital Care For City of Thunder Bay Support for District Hospitals Tertiary Hospital Care For Region of Northwestern Ontario Quaternary Hospital Care Referral relationships with hospitals in Southern Ontario for access to Quaternary Care. HayGroup 27

31 Integrated Service Plan for Northwestern Ontario Cardiac Revascularization are the procedures most frequently referred to hospitals outside of Northwestern Ontario Recommendations: The Special Advisor recommends that: (4) The MOHLTC should invest in the redevelopment of Meno-Ya-Win Hospital as a Centre of Excellence which will enable it to serve as a District Hospital and to assume leadership in Northwestern Ontario for the development of region-wide, culturally sensitive care. (5) The MOHLTC should invest in the redevelopment of Wilson Memorial Hospital in Marathon to enable it to serve as a District Hospital. Consideration should also be given to increasing the services available in the hospital in Geraldton. 5.3 Tertiary Care Cardiac Revascularization and Neurosurgery are tertiary services requiring specific attention in Northwestern Ontario Revascularization/Cardiac Surgery Cardiac Revascularization procedures are not provided in Northwestern Ontario and as a result they are the procedures most frequently referred out of the region. Exhibit 5.9 Out of Region Inpatient Activity Highest Volume Out of Region CMGs 2003/04 Case Mix Group TBRHSC Elsewhere in Region Total in Region Winnipeg RHA Elsewhere out of Region Total Out of Region Total % Out of Region 189 PTCA No Comp Card Condition % 179 Cor Bypass W Pump No Crd Cath % 609 Vaginal Del W Complicating Dx % 648 Neo,Wt>2500G,Normal Newborn , , % 177 Crd Vlv Rep W Pump No Cath % 647 Neo,Wt>2500G,Minor Problem Dx % 271 Unilateral Hernia Proc (MNRH) % 611 Vaginal Delivery , , % 1 Craniotomy Procedures % 846 Aftercare Follow Surgery/Tx % 579 Maj Ut/Adnexal Proc No Malig % 194 Minor Cardiothor Proc No Pump % 294 Esoph/Gastro/Misc Digest Dis , , % 143 Simple Pneumonia & Pleurisy % 646 Neo,Wt>2500G,Caesarean Delivr % 619 False Labour,LOS <3Days(MNRH) % 253 Major Intestinal/Rectal Proc % 188 PTCA With Comp Card Condition % 218 Card Cath No Cond Or LOS < % 255 Less Ext Esoph/Stom/Duod Proc % HayGroup 28

32 Integrated Service Plan for Northwestern Ontario Recent trends in Ontario and elsewhere suggest that in many instances cardiac surgery is being replaced by angioplasty as the treatment of choice. As a result it is anticipated that the rate of use of cardiac surgery will decline with a corresponding or perhaps more rapid increase in the rate of angioplasty procedures. Exhibit 5.10 Bypass Surgery Trend Procedures per 100,000 Population North West Ontario / / / 04 Exhibit 5.11 Angioplasty Trend Procedures per 100,000 Population North West Ontario / / / 04 HayGroup 29

33 Integrated Service Plan for Northwestern Ontario TBRHSC should develop an angioplasty service that would receive its emergency surgical back-up in Duluth There are currently insufficient patients requiring cardiac surgery in Northwestern Ontario for the development of a cardiac surgery program. And trends suggest that there may be fewer patients in the future. Patients should continue to be referred to programs in southern Ontario for cardiac surgery. However, a large and growing number of patients from Northwestern Ontario are forced to travel to southern Ontario and to Winnipeg for angioplasty. This procedure could be provided at TBRHSC. The only issue is the risk of complication during the procedure and the absence of a local cardiac surgery capability to provide the emergency intervention. After careful consideration, we feel that TBRHSC should develop an angioplasty service that would receive its emergency surgical back-up in Duluth. In doing so, it is recognized that there is a small risk that patients who might experience a perforation during angioplasty might not survive a trip to Duluth for cardiac surgery. But, this risk is small and there is a risk of death associated with the wait for transportation for an angioplasty in Southern Ontario. Recommendation: The Special Advisor recommends that: (6) The MOHLTC should establish an angioplasty service in Thunder Bay with a formal agreement for emergency cardiac surgery backup in Duluth Neurosurgery Neurosurgery is required to support the trauma program located at TBRHSC. In order to provide coverage on a 24- hour, seven-day-a-week basis which is a fundamental requirement of a trauma program, TBRHSC should have a minimum of three neurosurgeons on staff. As the numbers of patients requiring the services of a neurosurgeon is insufficient to financially support the practice of three neurosurgeons through OHIP billings, it will require an Alternate Payment Plan. Those surgeons can augment their general neurosurgery practice with complex spinal surgery and neuro-radiology. Also, the establishment of the Northern Medical School will provide academic opportunities and commitments for these staff. HayGroup 30

34 Integrated Service Plan for Northwestern Ontario Recommendation: The Special Advisor recommends that: (7) The MOHLTC should establish an Alternate Payment Plan (APP) for Neurosurgery that supports 3 neurosurgeons to enable 24/7 coverage for trauma. 5.4 Out of Region Services Almost 92% of hospitalizations for residents of Northwestern Ontario are in a hospital located in Northwestern Ontario. There is a perception that very large numbers of patients in Northwestern Ontario receive their care in Winnipeg, Duluth and Southern Ontario. However, only 4.2% of inpatient hospitalizations by residents of Northwestern Ontario are in Winnipeg hospitals and only 4.5 % of inpatient hospitalizations require travel to an Ontario hospital outside of Northwestern Ontario for emergency or very specialized care 10. Exhibit 5.12 Use of Hospital Services Outside of Northwest Ontario Inpatient Cases SDS Cases Patient Residence Elsewhere Winnipeg Elsewhere in Ont in Ont Winnipeg Dryden Kenora Urban Rainy River District Sioux Lkt. & Isol. Comm Thunder Bay City Thunder Bay District Grand Total Dryden 1.7% 7.9% 0.7% 7.2% Kenora Urban 0.9% 10.5% 0.4% 21.2% Rainy River District 1.1% 4.9% 0.8% 8.5% Sioux Lkt. & Isol. Comm. 1.2% 12.9% 0.7% 10.3% Thunder Bay City 6.5% 0.3% 1.8% 0.5% Thunder Bay District 7.7% 1.4% 9.2% 1.1% Grand Total 4.5% 4.2% 2.4% 3.9% Over half of the inpatient cases that are treated elsewhere in Ontario are for cardiac care. Over half (732) of the inpatient cases that are treated elsewhere in Ontario are cardiac (cardio-thoracic and cardiology) cases. And almost half of these relate to angioplasty, which we are suggesting should be repatriated to TBRHSC. 10 It should be noted that a large number of Thunder Bay District residents are receiving SDS elsewhere in Ontario. It is likely that some of these people are traveling to Sault Ste. Marie for SDS and not to Southern Ontario. HayGroup 31

35 Integrated Service Plan for Northwestern Ontario TBRHSC should investigate the other types of elective cases that are being treated in southern Ontario and in Winnipeg to determine the feasibility of repatriation. Appendices F and G to this report present the number and percentages of inpatient and SDS hospitalizations for residents of Northwestern Ontario in hospitals in their own area, in Thunder Bay, in another Northwestern hospital, elsewhere in Ontario and in Winnipeg for each of 29 Program Cluster Categories 11 A significant amount of inpatient and SDS care for residents of Kenora, Dryden and Sioux Lookout are being provided by hospitals in Winnipeg All air ambulance service in the Northwest should be directed to Thunder Bay rather than Winnipeg. As can be seen a significant amount of inpatient and SDS care for residents of the Kenora, Dryden and Sioux Lookout districts are being provided by hospitals in Winnipeg. As has been discussed, there are patient volume requirements to ensure the continuing clinical capabilities of TBRHSC and to provide sufficient caseload to support its emerging academic mission. To this end, it will be important for much of the secondary care and most of the tertiary care for residents of NW Ontario to be provided by TBRHSC. This specifically includes most first nation people who are currently directed to Winnipeg for care by the Federal Government. It is recognized that, because of the differences in driving time and distance, people drive from the Kenora area to Winnipeg for emergency care and for assessments and treatments by medical specialists and subspecialists rather than going to Thunder Bay. This pattern of hospital use will and should continue and ground ambulances should continue to travel from Kenora to Winnipeg. However, to address the patient volume requirements of the specialized services that need to be provided and of the academic programs at TBRHSC, within the range of clinical competencies of TBRHSC, all air ambulance service in the Northwest should be directed to Thunder Bay rather than Winnipeg. There will be many circumstances when Winnipeg Regional Health Authority (WRHA) is the appropriate provider of care for residents of the western part of Northwestern Ontario. At present, WRHA is providing an ad hoc service to the residents of Northwestern Ontario. A more formal recognition of the use of Manitoba s health service by Ontario residents would do much to ease the concern that access to the services will close. Given the geographic realities of this part of the 11 Program Cluster Categories are groupings of Case Mix Groups that were developed by the MOHLTC to reflect the specialty or subspecialty area of practice related to the patient problem or condition. HayGroup 32

36 Integrated Service Plan for Northwestern Ontario Province of Ontario, it is appropriate for the governments of the Provinces of Ontario and Manitoba to formalize the provision of selected elective and emergency and urgent services by Winnipeg Regional Health Authority for the residents of Kenora and, when TBRHSC cannot meet the surge demands for care, for the remaining population of the northwest. Travel for emergency and very specialized care to Winnipeg and Southern Ontario will and should continue. However, it is anticipated that, by increasing the capabilities in hospitals designated as District Hospitals that the need for some of the travel to Winnipeg can be eliminated and by increasing the capabilities of TBRHSC the need for some of the travel to Southern Ontario can be eliminated. Providers in Northwestern Ontario plan to provide almost all of the services to local residents. The expectation should be that providers in Northwestern Ontario plan to provide almost all of the services to local residents but that some formal provision should be made for Ontario residents to access services in Manitoba when surges are being experienced that cannot be met within the Northwest. Throughout the period of consultation, the issue of travel grants for transportation of patients came up many times. Stories of individuals transported by ambulance and/or air ambulance in an emergency situation and then stranded in a location remote from their home were common. The MOHLTC s policy is that patients who are transported for medical reasons and who continue under care, are transported back via ambulance or air ambulance. Given the distances, the financial difficulties faced by those who travel for health care, and the lack of public transportation in many areas, the LHIN should take a look at travel grants, policies governing transportation of patients and determine how many cases of stranded patients there are within the region. Recommendations: The Special Advisor recommends that: (8) The LHIN should plan to provide capacity within the region for almost all of the health services needed by Northwestern Ontario s residents. Negotiations should take place with the Federal Government to have all First Nations people who reside within Ontario s boundaries, be cared for within the Ontario system. HayGroup 33

37 Integrated Service Plan for Northwestern Ontario (9) The LHIN and the MOHLTC should negotiate a formal agreement with the Winnipeg Regional Health Authority to provide emergent and elective tertiary care for residents of the city of Kenora and environs. (10) The LHIN and the MOHLTC should negotiate a formal agreement with the Winnipeg Regional Health Authority to address situations when the facilities in Northwestern Ontario cannot meet surge demands for care. 5.5 Required Size of Acute Care Hospitals The required acute care system capacity (i.e. the number of hospitalizations that need to be accommodated) depends upon: Population projections for Northwestern Ontario Population utilization/need rates for acute care Reliance of Northwestern Ontario population on hospitals inside and outside Northwestern Ontario, the Self- Sufficiency of the Northwestern Ontario acute care hospital system Reliance of populations outside Northwestern Ontario on Northwestern Ontario acute care hospitals The required size of the acute care system size (e.g. beds, ambulatory procedures) depends upon: Projected mix of activity by modality Target % of care as Same Day Surgery (SDS) Target % of care as Inpatient Admissions Target inpatient lengths of stay Target occupancy rates Population Estimates Population estimates/projections were prepared using Ministry of Finance data for each of the 6 sub-areas by 5 year age and gender cohorts. The resulting population projections by sub area of Northwestern Ontario are presented in the following table. HayGroup 34

38 Integrated Service Plan for Northwestern Ontario Sub-Area Exhibit 5.13 Population Projections by Sub Area Female Population % Chge. Male Population % Chge. Total Population % Chge. Thunder Bay City 58,806 55, % 56,834 53, % 115, , % Thunder Bay District 18,942 17, % 20,201 18, % 39,143 36, % Rainy River District 11,114 10, % 11,229 10, % 22,343 20, % Kenora Urban 12,387 12, % 12,365 12, % 24,753 24, % Dryden 6,620 6, % 6,731 6, % 13,351 13, % Sioux Lkt. & Isol. Comm. 13,712 13, % 14,314 14, % 28,026 27, % NW Ontario Total 121, , % 121, , % 243, , % As can be seen the overall population of Northwestern Ontario population is projected to decrease by 4.5% by The population projections for each of the age/gender cohorts is presented in the exhibit following. Exhibit 5.14 Population Projections by Age/Gender Cohort Female Population Male Population Total Population Age Group % % % Change Change Change ,130 6, % 7,099 6, % 14,229 12, % ,941 6, % 8,150 6, % 16,091 12, % ,667 7, % 8,982 7, % 17,649 14, % ,696 8, % 9,256 8, % 17,952 16, % ,834 7, % 8,179 8, % 16,013 16, % ,002 7, % 7,099 7, % 14,101 14, % ,829 6, % 7,986 6, % 15,815 12, % ,888 6, % 8,977 6, % 17,865 13, % ,339 7, % 10,681 7, % 21,020 15, % ,605 9, % 10,160 9, % 19,765 19, % ,148 9, % 8,700 9, % 16,848 19, % ,611 8, % 7,101 8, % 13,712 16, % ,172 6, % 5,240 7, % 10,412 14, % ,541 4, % 4,347 4, % 8,888 9, % ,199 4, % 3,877 3, % 8,076 7, % ,819 3, % 3,138 2, % 6,957 6, % ,863 2, % 1,776 2, % 4,639 5, % 85+ 2,298 2, % 926 1, % 3,224 3, % Total 121, , % 121, , % 243, , % Acute Care Hospital Care Requirements of the Population of Northwestern Ontario We applied actual current (2003/04) acute care utilization rates by Program Cluster Category (PCC) by sub-area to the projected 2010 population by sub area to project the volume of hospitalizations (inpatient and same day surgery combined) for each sub area of Northwestern Ontario. HayGroup 35

39 Integrated Service Plan for Northwestern Ontario The utilization rates are specific to each age/gender cohort We developed separate utilization rates for Primary/Secondary and Tertiary/Quaternary cases within each PCC In spite of the projected overall decrease in the population, we project an increase in the number of acute care hospitalizations and related capacity requirements. 0.8% increase in Primary/Secondary cases 3.7% increase in Tertiary/Quaternary cases 1.0% overall case increase The increase is being driven by the changing age and gender mix of the population. There is a dramatic increase in the number of near elderly (ages 55-64) and in the number of oldold (ages 85+). The exhibit following presents the projected volume of acute care hospitalization by PCC and level of care. HayGroup 36

40 Integrated Service Plan for Northwestern Ontario Exhibit 5.15 Projected Acute Care Case Volumes for Residents of Northwestern Ontario Primary/Secondary Tertiary/Quaternary All Cases PCC 2003 Cases 2010 Cases Proj. Growth 2003 Cases 2010 Cases T/Q Growth 2003 Cases 2010 Cases Total Case Growth Orthopaedics 2,805 2, % % 3,044 3, % Neurology 1,144 1, % % 1,184 1, % Neurosurgery % % % Rheumatology % % % Dermatology % % % Trauma 1,657 1, % % 1,839 1, % Urology 3,503 3, % % 3,550 3, % Nephrology % % % Gynaecology 1,437 1, % % 1,443 1, % Obstetrics 3,923 3, % % 3,932 3, % Neonatology 2,797 2, % % 2,828 2, % Otolaryngology 1,603 1, % % 1,659 1, % Dental/Oral Surgery 1, % 0 0 1, % Cardiology 3,804 4, % % 3,912 4, % Cardio/ Thoracic % % 987 1, % Pulmonary 2,578 2, % % 2,639 2, % Oncology 1,400 1, % % 1,548 1, % Haematology % % % Endocrinology % % % Psychiatry 1,667 1, % % 2,032 1, % Ophthalmology 2,174 2, % % 2,177 2, % Gastro/Hepatobiliary 8,682 8, % % 8,703 9, % General Surgery 2,179 2, % % 2,405 2, % General Medicine 4,198 4, % % 4,305 4, % Vascular Surgery % % % Plastic Surgery % % % Rehabilitation % % % Not Generally Hosp % % Ungroupable % % Total 50,307 50, % 2,735 2, % 53,042 53, % As might be expected from the changing demographics of the population in Northwestern Ontario, the greatest decreases in case volume are related to the needs of the young and of premenopausal women: Neonatology -13.0% Dental/Oral Surgery -10.3% Otolaryngology - 8.0% Gynaecology - 7.3% Obstetrics - 5.3% And the greatest increases in volume relate to the hospitalization needs of the near elderly and old: Oncology +9.1% Cardio/Thoracic +9.1% HayGroup 37

41 Integrated Service Plan for Northwestern Ontario Cardiology +7.9% Vascular Surgery +7.2% Required Capacity of Acute Care Hospitals in Northwestern Ontario The required capacity of acute care hospitals in Northwestern Ontario is the sum of: The hospitalizations for residents of Northwestern Ontario that will be provided by hospitals in Northwestern Ontario. The hospitalizations for residents from outside Northwestern Ontario that will be provided by hospitals in Northwestern Ontario. In 2003/04, hospitals in Northwestern Ontario provided 144 hospitalizations for people from outside Northwestern Ontario. For modeling purposes we will assume that there will be no change in the amount of care provided by hospitals in Northwestern Ontario for people from outside the area. The exhibit following shows the number of admissions for nonresidents of Northwestern Ontario by hospital and PCC. Exhibit 5.16 Actual 2003/04 Additional Acute Care Activity for Non-Residents of NW Ontario PCC Dryden RHC Geraldto n DH Red Lake Marg Coch. Riverside Rainy River Sioux Lookout Thunder Bay RHSC Wilson Memorial Obstetrics Gastro/Hepatobiliary Psychiatry Neonatology General Medicine Trauma Pulmonary Otolaryngology Orthopaedics Ophthalmology 6 6 Dental/Oral Surgery 5 5 Urology 5 5 General Surgery Gynaecology 3 3 Rheumatology Haematology Neurology Neurosurgery 2 2 Not Generally Hosp Cardiology 1 1 Dermatology 1 1 Nephrology 1 1 Plastic Surgery 1 1 Vascular Surgery 1 1 Total Total HayGroup 38

42 Integrated Service Plan for Northwestern Ontario In keeping with previous discussion and assumptions we assume that there will be less reliance on hospitals outside the region to provide care for residents of Northwestern Ontario: Angioplasty will be provided at TBRHSC Most Neurosurgery previously provided in Winnipeg to be provided at TBRHSC (to support teaching and critical mass requirements) air ambulance and air transport referrals for care will be directed to Thunder Bay rather than Winnipeg. Winnipeg will however continue to be asked to provide: emergent and referral based care for residents of Kenora and the surrounding area. additional capacity to address surges in need/demand for hospital care that are beyond the capacity of hospitals in Northwestern Ontario to address. We calculated the acute care bed requirements by site based on the following assumptions: Used calculated case volume projection for 2010 by subarea, by PCC and by level of care (P/S, T/Q) Used actual 2003/04 market share captured by each hospital except: Modeled greater retention of P/S activity at the proposed District Hospital serving a sub-area Modeled patriation of emergent and elective hospitalizations from Red Lake, Sioux Lookout and Isolated Communities to TBRHSC from WRHA Modeled patriation of all neurosurgery and angioplasty hospitalizations to TBRHSC Targets for % use of ambulatory procedures, and length of stay based on clinical efficiency best quartile performance: Separate targets for Regional, District, and Local hospitals based on peer performance characteristics Targets specific to each PCC, level of care, and patient age Occupancy targets are based on the clinical characteristics of the PCC and the hospital type (higher occupancy for medicine, lower occupancy for local hospitals) HayGroup 39

43 Integrated Service Plan for Northwestern Ontario Hospital Based on these assumptions and modelling parameters, the table following presents the projected future requirements for acute care beds by hospital site. Exhibit 5.17 Acute Care Bed Requirements in 2010 by Site IP Cases IP Days Avg. LOS Ambul. Proc. Req'd. Beds Avg. Occup. Current Beds in Oper. Add'l Operating Beds Req'd Atikokan 448 2, % 11 0 Dryden 1,487 7, % 31 0 Geraldton 940 4, % 23 0 Lake of the Woods 2,969 15, , % 64 0 Manitouwadge % 9 0 McCausland 208 1, % 10 0 Nipigon 445 2, % 15 0 Red Lake Marg. Coch , % 20 0 Riverside 2,408 12, , % 46 0 Sioux Lookout 2,549 11, , % 32 7 TB RHSC 16, , , % Wilson Memorial 1,095 4, % 9 8 All NW Hospitals 29, , , % The calculated bed requirements are based on the complete length of stay for each patient s episode of acute care to be provided in TBRHSC. However, it is feasible and desirable for patients, once there condition has stabilized, to complete their episode of care in a district or local hospital in or close to their home community. As has been discussed, patients receiving primary and secondary level care should be transferred to the hospital closest to their home community for continuation of treatment and recovery after they have received their initial stages of acute care treatment in a District or the Regional hospital. In 2003/04 there were 58 beds at TBRHSC used to provide care for patients from outside TB City. We have recalculated the estimated bed requirement by site by modeling a situation wherein patients from outside Thunder Bay City receiving primary or secondary hospital care are repatriated to their local or district hospital after 2/3 of acute stay in TBRHSC. For modeling purposes, we have assumed that an equivalent stay (2/3 of acute stay) will again required in local/district hospital to complete the episode of care. Repatriation of TBRHSC primary and secondary hospital care patients who reside in other sub-areas of Northwestern HayGroup 40

44 Integrated Service Plan for Northwestern Ontario Ontario, after 2/3 of their acute stay would reduce TBRHSC bed requirements by ~ 12 beds. The hospitals in the other subareas would require an additional 24 beds to accommodate the transfers. The numbers of additional beds that will be required by site are presented in the following exhibit. Exhibit 5.18 Additional Beds Required For Patient Transfers for Continuation of Acute Care District Add'l Beds Thunder Bay District 11.3 Rainy River District 4.7 Kenora Urban 0.5 Dryden 1.5 Sioux Lkt. & Isol. Comm. 6.5 Total 24.4 It is important to note that implementation of this model of shared care for patients from outside Thunder Bay would require enhanced patient/medical transportation services in the Northwest. The table following presents an estimate of the impact of the projected changes in the population and the proposed changes in patterns of care delivery on the volume of hospital care that will be expected of each hospital in Northwestern Ontario and the number of beds that will be required to provide that care. HayGroup 41

45 Integrated Service Plan for Northwestern Ontario Exhibit 5.19 Projected Changes in Patient Volume at Each Hospital Hospital Actual 2003/04 Volumes IP Cases Ambul. Proc. Total Cases Projected Volumes for 2010 IP Cases Ambul. Proc. Total Cases Percent Change from 2003/04 IP Cases Ambul. Proc. Total Cases Atikokan % 126.1% 0.6% Dryden 1, ,153 1, , % 31.4% 10.5% Geraldton , , % % 132.1% LOTW 2, ,372 2,995 1,465 4, % 95.5% 32.3% Manitouwadge % 194.7% 1.3% McCausland % 11.4% -0.5% Nipigon % 137.6% -0.4% Red Lake Marg. Coch % 86.3% 0.4% Riverside 2, ,910 2,656 1,192 3, % 48.6% 32.2% Sioux Lookout 1, ,694 2,998 1,398 4, % 92.6% 63.2% TB RHSC 16,667 15,848 32,515 16,323 14,662 30, % -7.5% -4.7% Wilson Mem , , % % 426.9% All NW Hospitals 28,128 18,922 47,050 31,251 20,904 52, % 10.5% 10.8% Exhibit 5.20 Beds Required at Each Hospital to Accommodate Changes in Acute Care Patient Volume Hospital IP Cases IP Days Projected Requirement Avg. LOS Ambul. Proc. Avg. Occup. Acute Care Beds Reported Acute Beds in Operation* Reported Acute Care Bed Capacity^ Add'l Built Capacity Required LTC Beds in Use Atikokan 448 2, % Dryden 1,562 8, % Geraldton 1,272 6, % Lake of the Woods 2,995 15, , % Manitouwadge % McCausland 208 1, % Nipigon 445 2, % Red Lake Marg. Coch , % Riverside 2,656 14, , % Sioux Lookout 2,998 12, , % TB RHSC 16, , , % Wilson Memorial 1,427 6, % All NW Hospitals 31, , , % * MOHLTC February, ^ Sum of current acute care beds in use and additional capacity (assumes no change in beds used for LTC). It should be noted that the Riverside Hospital in Ft. Frances, and Wilson Memorial Hospital in Marathon may need to add HayGroup 42

46 Integrated Service Plan for Northwestern Ontario acute care beds or convert LTC beds to acute care in order to accommodate the patient volume and patient days that will be required when they assume their new roles as District hospitals. Reducing the number of patients and the time spent waiting for admission to Complex Continuing Care (CCC) and Long Term Care (LTC) facilities would reduce the number of ALC patient days by as much as 69% and free up 41 beds at TBRHSC for use in caring for acute care admissions It also should be noted that these beds will not be sufficient to accommodate an excessive number of ALC patients or ALC patient days. It will be important for each hospital, but especially TBRHSC to expeditiously discharge patients to appropriate levels of care once the acute care phase of the patient s episode of care is completed. The proposed restructuring and expansion of long-term care services in Northwestern Ontario should facilitate expeditious patient discharge. Also, the transfer of patients from TBRHSC to the appropriate hospital close to their home will also allow TBRHSC to better manage its bed complement. The current number of days devoted to ALC patients from Thunder Bay is presented in the exhibit following. As can be seen, reducing the time spent waiting for admission to Complex Continuing Care (CCC) and Long Term Care (LTC) facilities would reduce the number of ALC patient days by as much as 69% and free up 13,518 bed days or 41 beds at 90% occupancy. Institution Transfer To Exhibit 5.21 ALC Days by Discharge Destination for Residents of Thunder Bay Region Where Patients Live: IP Cases % of All IP Cases Total IP Days % of All IP Days Thunder Bay City ALC Days % ALC % of All ALC Days Avg. ALC Days per Case Home 10, % 53, % 1, % 5.4% 0.10 Acute % 5, % % 0.2% 0.08 Chronic % 19, % 10, % 54.6% Home Care 1, % 18, % 2, % 10.3% 1.28 LTC % 5, % 2, % 14.3% 8.30 Other % 1, % % 2.1% 4.60 Rehab % 3, % 1, % 6.2% 3.48 Died % 5, % 1, % 6.8% 3.14 Total 14, % 112, % 19, % 100.0% 1.33 HayGroup 43

47 Integrated Service Plan for Northwestern Ontario 6.0 Long-Term Care In this review, Long Term Care places includes: Complex Continuing Care Nursing Home Care Homes for the Aged Eldcap LTC Supportive Housing Long-term home care Currently there are 2,835 long term care places in Northwestern Ontario. The distribution of these places by type of care and sub-area is presented in the exhibit following. 12,13 12 Long-term home care is defined to be care for a client who stays in home care for more than 180 days, or who stays on home care for less than 180 days but is discharged to another type of long term care. Current capacity for long-term home care is calculated by dividing the total number of days of enrollment of long-term home care clients divided by 365 days. Thus the capacity can be considered to be the number of equivalent places wherein a place is 365 days of long-term home care. 13 The count of the current number of nursing home and home for the aged beds in Thunder Bay City does not include the interim LTC beds at the old McKellar Hospital site operated by TBRHSC. HayGroup 44

48 Integrated Service Plan for Northwestern Ontario Exhibit 6.1 Current Long-Term Care Capacity Current Number of Places Region Sub-Area Nursing Home Home for the Aged ELDCAP Complex Continuing Care Supportive Housing LT Home Care Places Total Places Kenora Dryden Kenora Kenora Urban Sioux Lkt. & Kenora Isol. Comm. RR District RR District TB TB City ,660 TB TB District NW Ont All ,835 The utilization of long-term care places varies significantly from district to district to district across Northwestern Ontario. Because the largest, but definitely not the only user of longterm care is the elderly, it has been found to be most effective to measure utilization of long-term care as places per 1,000 population over 75 years. In calculating this measure the places in a geographical area are compared to the population in the area. For much of long-term care, the original residence of an individual is not as important as the location of her/his current placement. And, it is hoped that long term care can be provided in or at least close to the community where a person lives. Using this measure the current utilization of long-term care in Northwestern Ontario is presented in the Exhibit following. HayGroup 45

49 Integrated Service Plan for Northwestern Ontario Exhibit 6.2 Current Utilization of Long-Term Care in Northwestern Ontario Long-Term Care Places per 2005 Projected 1,000 Population > 75 Region Sub-Area Nursing Home Home for the Aged ELDCAP Complex Continuing Care Supportive Housing LT Home Care Places Total Places Senior's Apartment Units Kenora Dryden Kenora Kenora Urban Sioux Lkt. & Kenora Isol. Comm. RR District RR District TB TB City TB TB District NW Ont All Restructuring Long-Term Care Services in Northwestern Ontario Thunder Bay City and Thunder Bay District have a shortage of long-term care places Compared to the current utilization of long-term care places in the rest of the province and compared to the long-term care planning guideline of the Health Service Restructuring Committee of places per 1000 population over 75 14, the communities west of Thunder Bay currently seem to have an adequate supply of long term care places. Thunder Bay City has fewer places than the planning standard and Thunder Bay District has significantly fewer places. The following table compares the current capacity for longterm care with the projected population over 75 in 2010 and contrasts this with the HSRC long-term care planning standard 14 Home Care has changed since HSRC methodology development: A substantial portion of the long-term (more than 180 day duration) home care in NW Ontario in 2003/04 was for children receiving services through the school program. Home care data used by the HSRC did not include home care provided through a school program. To ensure consistency in measurement, all long-term home care provided for children under 20 years old was removed from the current Northwestern Ontario home care data, and the HSRC planning target was also recalculated with removal of long-term home care for children. The revised HSRC planning target was long-term care places per 1,000 population aged 75 years and older. HayGroup 46

50 Integrated Service Plan for Northwestern Ontario to determine the adequacy of the current long-term care capacity 15. Exhibit 6.3 Required Long-Term Care Places in 2010 Region Sub-Area Nursing Home Current Number of Places Home for the Aged ELDCAP Complex Continuing Care Supportive Housing LT Home Care Places Total Places 2010 Pop. >75 Years Old (2003) Places per 1,000 Pop. > 75 Years Old HSRC Average Ontario Places per 1,000 Pop. > 75 Additional Places HSRC Ratio for 2010 % Increase from Current Places Kenora Dryden % Kenora Kenora Urban , % Sioux Lkt. & Kenora % Isol. Comm. RR District RR District , % TB TB City ,660 9, % TB TB District , % NW Ont All ,835 15, % Kenora, Thunder Bay City and Thunder Bay District will require an increase in long-term care places by 2010 As can be seen, Kenora, Thunder Bay City and Thunder Bay District will require an increase in long-term care places by 2010 to be able to respond to the needs of the population in a fashion similar to the average response across the province. The required increases in the capacity of long-term care are: Kenora: 9% - 29 Places Thunder Bay: 21% Places Thunder Bay District: 198% Places In expanding the capacity for long-term care in these jurisdictions, the following principles are recommended to the MOHLTC and/or the new LHIN for Northwestern Ontario. The expansion of long term care capacity in Northwestern Ontario should: Maximize independence Provide for maximizing social interaction for clients 15 The current capacity does not include the interim LTC beds operated by TBRHSC at the McKellar Hospital site. HayGroup 47

51 Integrated Service Plan for Northwestern Ontario Exhibit a preference for long-term care in the client s home community. Exhibit a preference for in-home care over congregate housing. Exhibit a preference for supportive housing over nursing home care. Provide for psycho-geriatric care in all treatment settings. Although the final determination of the types of long-term care places that should be provided in each community should be based on the specific input of these communities, for planning purposes we have compared the current capacity/utilization of each type of long-term care with the HSRC planning guidelines. Exhibit 6.4 Comparison of Long-Term Care Places in Northwestern Ontario with HSRC Findings Long-Term Care Places per 1,000 Population > 75 (2005) Region Sub-Area Nursing Home Home for the Aged ELDCAP NH, HFA, ELDCAP Subtotal Complex Continuing Care Supportive Housing LT Home Care Places Total Places Kenora Kenora Urban TB TB City TB TB District NW Ont All Ont. Avg (HSRC 1995) In comparison with HSRC findings for the province: Kenora Urban requires an increase in supportive housing and long-term home care Thunder Bay City requires and increase in long-term home care. Thunder Bay District requires an increase for all modalities except complex continuing care. For purposes of modeling the required increases in LTC places, we have assumed that investments should be made: First to increase the supportive housing capacity to at least 40 places per 1,000 population 75+. HayGroup 48

52 Integrated Service Plan for Northwestern Ontario Second to increase long-term home care capacity to at least 80 equivalent places per 1,000 population 75+. Third to increase LTC beds until reach planning guideline. Based on these assumptions, the required increases in each community are projected to be: Kenora Urban requires 29 additional LTC places that should be provided as: 29 additional supportive housing units Thunder Bay City requires 341 additional LTC places that should be provided as: 192 supportive housing units, and 149 equivalent long-term home care places Thunder Bay District requires 208 additional LTC places that should be provided as 58 supportive housing places, 93 additional long-term home care places, and 57 additional nursing home beds The addition of these places in these communities would better respond to the need for long term care and will keep individuals requiring care closer to their social support networks in their home communities Recommendation: The Special Advisor recommends that: (11) The MOHLTC should expand long term care places in Northwestern Ontario to provide: 29 supportive housing units in Kenora; 192 supportive housing units, and 149 equivalent long-term home care places in Thunder Bay; and 58 supportive housing places, 93 equivalent long term home care places, and 57 nursing home beds in Thunder Bay District. 6.2 Complex Continuing Care Currently there are 19 Complex Continuing Care beds per 1,000 population over 75 in Northwestern Ontario: HayGroup 49

53 Integrated Service Plan for Northwestern Ontario Exhibit 6.5 Complex Continuing Care Beds per 1,000 Population > 75 Years Old by District District Beds per 1, Dryden 16 Kenora Urban 20 Sioux Lkt. & Isol. Comm. 12 Rainy River 17 Thunder Bay City 19 Thunder Bay District 27 N.W. Ontario 19 This exceeds by over 100% the HSRC planning guideline for Complex Continuing Care beds of 8.23 beds per 1000 population over 75. In the communities west of Thunder Bay, the excess CCC beds may not be needed In the communities east of Thunder Bay the excess CCC beds are likely being used to address a shortage of LTC capacity In Thunder Bay, there appears to be a different approach to the use of Complex Continuing Care from the rest of the province. In the communities west of Thunder Bay, these excess beds may not be needed currently and patients currently being directed to CCC might be more appropriately cared for in alternative levels and types of care. In the future (2010), as new long-term care places are created in Kenora, some of the current CCC capacity should be converted (either physically or through funding transfers) to alternative modalities of longterm care. In the other communities, some of the complex continuing care beds might appropriately be closed and the resources redirected to other elements of the health system, most notably primary care. In the communities east of Thunder Bay, there is a shortage of long-term care and the excess CCC beds are likely being used to address this shortage. As additional long-term care capacity is introduced in NW Ontario, these excess CCC beds can and should be converted (either physically or through funding transfers) to alternative modalities of long-term care. In Thunder Bay, there appears to be a different approach to the use of Complex Continuing Care from the rest of the province. Overall, 7.1 % of acute care discharges go to either CCC or LTC (Nursing Home/Home for the Aged) compared to 3.9% in the rest of the province. The discharge rate to CCC/NH- HFA is 82 % higher in Thunder Bay than in the rest of the province. And the distribution between CCC and LTC is even HayGroup 50

54 Integrated Service Plan for Northwestern Ontario The rate of discharge from acute care to CCC in Thunder Bay is 4 times higher than elsewhere in province. more dramatically different in Thunder Bay than in the rest of the province: The percentage of acute care discharges to CCC is 4 times that of the rest of the province. The percentage of acute care discharges to NH/HFA is only 85% that of the rest of the province. The percentages for Thunder Bay and for the rest of the province are presented in the exhibit following. Exhibit 6.6 Discharge Disposition of Acute Care Separations: Comparing CCC and LTC facilities Patient Residence % of Acute Care Patients Discharged to: Ratio of LTC to CCC LTC CCC TB City Residents 2.3% 4.8% 48% All Ontario Residents 2.7% 1.2% 225% This would be understandable because of the shortage of LTC places in Thunder Bay if the patients being discharged to CCC were being discharged for Continuing Care. However, most of these patients do not stay in CCC beds for extended periods. Most are discharged to a nursing home or to home after a relatively short stay in the CCC beds at St. Joseph s Care Group. Only 67 of 174 Complex Continuing Care Beds at St. Joseph s are designated as being used for long term Complex Continuing Care Even though there is a shortage of long-term care places in Thunder Bay, only 67 of 174 Complex Continuing Care Beds at St. Joseph s are designated as being used for long term Complex Continuing Care. Fully 70 are designated for and apparently are being used for short term programs of transitional care and reactivation. HayGroup 51

55 Integrated Service Plan for Northwestern Ontario Exhibit 6.7 Use of Complex Continuing Care Beds at St. Joseph s Care Group (Data Provided by SJCG) Program Beds Admits Patient Days Avg LOS Occup. Complex Cont Care , % Respite % Geriatric Assessment % Reactivation , % Transition , % Palliative Care , % Hospice , % CMI Total 174 1,139 59, % Over 40% of admissions to CCC at SJCG are discharged to home and another 12% are discharged to other rehabilitation or long-term care programs. Exhibit 6.8 Discharge Disposition of SJCG Patients Discharge Disposition Program Beds Died Home Acute Spec Rehab Gen Rehab Psych Hosp LTC Interim ALC Sign- Out Prog. Xfer Total Sep's % Home Complex Cont Care % Respite % Geriatric Assessment % Reactivation % Transition % Palliative Care % Hospice % Total ,115 41% Over 70 beds at St. Joseph s Care Group are being used for subacute care It appears that over 70 beds at St. Joseph s Care Group are being used for subacute care: 50 Transitional Care 20 Reactivation A % of the 67 beds designated by St. Josephs as CCC. HayGroup 52

56 Integrated Service Plan for Northwestern Ontario The pattern of care in Thunder Bay for a significant subset of patients is such that prior to being sent to long-term care, home care or home, they are being sent to SJCG for some form of subacute care. This use of CCC for subacute care is: not consistent with the MOHLTC models of care delaying placement to LTC, in-home care or home, not necessary and is contributing to backup in TBRHSC; TBRHSC, the CCAC and SJCG should change this model of care and discharge patients directly from acute care to their ultimate destination for care without an intermediate admission to SJCG for subacute care. Based on the HSRC planning guidelines we estimate that as many as 100 CCC beds at SJCG could be closed and the resources redirected to long-term care. SJCG should focus the use of its CCC Beds on continuing care; not on subacute care. If these beds are not needed for CCC, then SJCG should use the beds or the related resources for needed long term care services such as interim nursing home beds or supportive housing. The HSRC planning guidelines would suggest a requirement of only 74 CCC beds (including beds for palliative and respite care). Based on the HSRC planning guidelines we estimate that as many as 100 CCC beds at SJCG could be closed and the resources redirected to long-term care. The table following provides an estimate of the total number of excess CCC beds and the potential savings that would accrue if Nursing Home beds were substituted. (It should be noted that the savings would be even more substantial if Supportive Housing or Long-Term Home Care were substituted for these excess CCC beds.) Exhibit 6.9 Savings from Potential Reduction in CCC Capacity in Northwestern Ontario CCC Beds per 1, CCC Beds To HSRC Standard Daily Cost per CCC Bed Avge Daily MOHLTC Cost/NH Bed Area Current CCC Beds Annual Savings NH Beds to Add Annual Increase Net Savings Dryden $200 -$345, $70 $0 -$345,278 Kenora $200 -$1,361, $70 $476,668 -$885,241 Sioux Lkout & Isol $200 -$229, $70 $0 -$229,968 RR District $200 -$1,034, $70 $0 -$1,034,673 TB City $200 -$7,131, $70 $2,495,984 -$4,635,399 TB District $200 -$1,975, $70 $691,581 -$1,284,365 All $200 -$12,079, $70 $3,664,234 -$8,414,924 HayGroup 53

57 Integrated Service Plan for Northwestern Ontario 6.3 Palliative Care There are currently 7.5 times more beds designated for palliative care and hospice care in Thunder Bay than would be suggested by the HSRC planning guideline for palliative care beds. Currently there are 3.06 Complex Continuing Care beds per 1,000 population over 75 in Thunder Bay City and District: Exhibit 6.10 Current and Required Palliative Care Beds in Thunder Bay City & District Beds Designated Palliative or Hospice 32 TB City Popn 75+ 9,026 9,272 TB City Beds per 1, TB District Popn 75+ 1,438 1,450 Total TB Region Popn ,464 10,722 Total TB Region Beds per 1, HSRC Target Beds per 1, TB City Rq'd Palliative HSRC TB Dist Rq'd Palliative HSRC TB Region Rq'd Palliative HSRC This is 7.5 times more beds than would be suggested by the HSRC planning guideline for palliative care beds of 0.41 beds per 1000 population over 75. SJCG and the CCAC should give preference to in-home palliative care rather than inpatient palliative care. SJCG reports that it is using 32 of its Complex Continuing Care beds for palliative and hospice care. The HSRC planning guidelines suggest that only 4.3 beds are required for palliative care to address the needs of both Thunder Bay City and Thunder Bay District. Given this disparity in numbers, it might be that inpatient palliative care is not necessary, and perhaps is not appropriate for many of the patients being admitted to these beds. Also, the use of these beds for palliative care may be displacing patients that require continuing or long-term care. SJCG and the CCAC should review their approach to providing palliative care to give preference to in-home palliative care in place of inpatient palliative care. A significant portion of the 32 beds or the associated resources currently devoted to inpatient palliative care could then be redirected to this in-home palliative care initiative or to expanding and enhancing long-term care services in Thunder Bay. HayGroup 54

58 Integrated Service Plan for Northwestern Ontario 7.0 Mental Health & Addictions There is insufficient access to mental health services across Northwestern Ontario Family Health Teams, supported by mental health professionals, need to be active in providing primary mental health care related to prevention, diagnosis and treatment of mental health problems. The District Hospitals should provide inpatient mental health for short term stabilization Mental was more frequently commented than almost any other area of service. We were repeatedly told that there is insufficient access to mental health services across Northwestern Ontario, especially community mental health services. Family Health Teams, supported by mental health professionals, need to be active in providing primary mental health care related to prevention, diagnosis and treatment of mental health problems. They need to be supported in these efforts by enhanced and expanded community and institutional mental health and addiction services. There needs to be better and easier access to therapy, special housing and support services in communities across Northwestern Ontario for people with mental health and addiction problems. District hospitals will be expected to provide primary hospital inpatient mental health care. The primary mental health care efforts of FHTs and the District hospitals will need to be supported by psychiatrists in the regional hospital in Thunder Bay and perhaps in centres elsewhere in Ontario using both telemedicine and periodic visits to the supported communities and FHTs 16. The District Hospitals should provide support to the primary mental health care of the FHTs and the community mental health care providers by providing inpatient mental health for short term stabilization prior to: Connection or reconnection with an appropriate community provider or Admission to more acute beds in Thunder Bay for more complex management or longer term treatment Family Practitioner staff of the District Hospitals will need education and telehealth support from Thunder Bay 16 The Ontario Psychiatric Outreach Programs (OPOP) is a collaborative network of psychiatrists who deliver clinical services and education to Ontario s rural and remote communities with a focus on Northern Ontario. OPOP currently delivers psychiatric services to a number of communities in the Northwest including some first nations communities. This involves both outreach services delivered by travel to the community or by telemedicine. OPOP is working towards being a centralized agency that will organize all outreach psychiatric service in the North. The FHTs and District Hospitals in Northwestern Ontario should work with OPOP to expand the breadth and depth of their support to communities and providers. HayGroup 55

59 Integrated Service Plan for Northwestern Ontario psychiatrists or psychiatrists in a major psychiatric centre in Southern Ontario 17. TBRHSC support to community mental health providers and District Hospitals will be enhanced if it were to initiate its program and open the approved beds for inpatient adolescent psychiatry. Integrating funding for mental health services across Northwestern Ontario, or its districts, would allow the development of a comprehensive response to the unique needs of the communities being served. Also, we were told that the special vote funding of many of mental health activities by the MOHLTC is limiting their success; the special vote and separate envelope funding means that money cannot be moved from one type of service to another. Integrating the funding for mental health services, or minimally for community mental health services across Northwestern Ontario, or its districts, would allow for greater flexibility in developing a comprehensive response to the unique needs of the communities being served. It is felt that those who deliver these services have far greater knowledge of what is needed in their communities than do those responsible for the funding envelopes within the Ministry in Toronto. Allowing individuals in the communities to work together and deliver the best services they can for the total dollars they receive would go some way towards assisting Northwestern Ontario in providing more effective mental health and addiction services. Recommendation: The Special Advisor recommends that: (12) The MOHLTC should discontinue the special vote approach to funding mental health and addiction services and provide sufficient funds in a global manner to the LHIN so that decisions can be made locally in a flexible manner on how best to use these funds. 17 Again, as appropriate, the District Hospitals can build on the work of The Ontario Psychiatric Outreach Programs. HayGroup 56

60 Integrated Service Plan for Northwestern Ontario 8.0 Management & Governance There should be District Governance and Management structures to facilitate the restructuring of health services to better respond to patient needs through enhanced integration along the continuum of care There are many examples of how individual institutions in Northwest Ontario have come together to plan and implement the delivery of care across institutions. For examples of how consolidation could take place, institutions in the Northwest should look at the work being done in Grey Bruce Health Services. In that instance, the Centre Grey Hospital, Bruce Peninsula Health Services, the Meaford General Hospital, and the Grey Bruce Regional Health Centre have all come together with one board, a common structure for information management, quality improvement, common credentialing and human resources planning and recruitment. Similarly, Riverside Health Care Facilities Inc operates three facilities: La Verendrye Hospital in Fort Frances, Emo Health Centre in Emo and Rainy River Health Centre in Rainy River, as well as a non-profit supportive housing corporation. To facilitate the restructuring of health services to better respond to patient needs through enhanced integration along the continuum of care, there should be District Governance and Management structures for each of six districts: Sioux Lookout & isolated communities, Kenora, Dryden-Red Lake, Fort Frances-Rainy River, Thunder Bay District Thunder Bay City The new governance and management model will require dissolution of most existing local service delivery governance structures and recruiting of new boards and new management staff. These new District governance and management structures would lead management of health care services in Northwestern Ontario. These new entities would be challenged to introduce a new focus on integrated management of health services across the continuum at the District level. Planning and funding allocations among the Districts would be led by the LHIN. This new model will require dissolution of most existing local service delivery governance structures and recruiting of new boards and new management staff. The integration of organizations should provide an opportunity to reduce administrative costs. The new District governance should use common processes and competency criteria for selection of District CEOs. Special consideration will need to be given to governance of denominational service delivery agencies such as the St. Joseph s Care Group. HayGroup 57

61 Integrated Service Plan for Northwestern Ontario Recommendation: The Special Advisor recommends that: (13) The Ministry of Health and Long Term Care should implement a District Governance model for service delivery replacing most existing local service delivery governance structures to enhance the responsiveness of health services in Northwestern Ontario to the needs of the population. 8.1 Northwestern Ontario Joint Medical Advisory Committee A Northwestern Ontario Joint MAC will encourage and facilitate the integration of care for patients as they move along the continuum of care The Joint MAC would serve as the MAC of each of the new District Governance entities in Northwest Ontario and would be responsible for the quality of medical care throughout Northwestern Ontario There should be a single Medical Advisory Committee providing oversight of the clinical activities of all physicians in all the health care settings across Northwestern Ontario and providing a single voice for advice to the new District Boards regarding issues in the quality of medical care within a District and across Northwestern Ontario. A Northwestern Ontario Medical Advisory Committee (MAC) can facilitate integrating hospital care along the continuum. The Joint MAC would ensure consistency and continuity in medical practice and processes in all hospitals in Northwestern Ontario. The Joint MAC would serve as the MAC of each of the new District Governance entities in Northwest Ontario and would be responsible for the quality of medical care throughout the Northwest. Medical staff of individual Districts, as appropriate, could form district advisory committees that would become sub-committees of the Joint Northwestern Ontario MAC allowing local issues to be identified at the individual facility/district and local interests and needs to be brought to the attention of the Northwestern Ontario Joint MAC. It would then be the Joint MAC, acting as MAC of the District that would bring these local issues to the District Board. This will ensure consistency of advice regarding medical human resources planning and issues related to the quality of medical care. Creation of a Joint MAC would facilitate and provide a vehicle for integrated and collaborative Medical Manpower Planning, Recruiting and Credentialing across Northwestern Ontario. Creation of a joint MAC would facilitate and provide a vehicle for integrated Utilization & Quality Management across Northwestern Ontario. As patients move along the provider and hospital continuum of care, it will be important for HayGroup 58

62 Integrated Service Plan for Northwestern Ontario policies, practices and expectations to be consistent from community to community and from facility to facility. With the introduction of more and more widespread use of visiting specialists, it will be important that oversight of practice can span the communities where physicians may practice. Importantly, creation of a Joint MAC will encourage and facilitate the clinical interaction of physicians across the northwest and contribute to the continuity and integration of care for patients as they move along the continuum of care. Recommendations: The Special Advisor recommends that: (14) The LHIN should establish a Joint Medical Advisory Committee (MAC) to facilitate the continuity of care for patients as they move along the continuum of care. (15) Each District should recognize the Joint MAC as fulfilling the District s requirement for an MAC for each of its hospitals under the Public Hospitals Act. 8.2 Utilization Management for Northwestern Ontario In terms of utilization rates, the people in Northwestern Ontario have equivalent or better access to inpatient and SDS hospital services than the population in other parts of the province. During this study, the admission rates for a variety of illnesses and procedures were looked at with a view to determining the whether Northwestern Ontario s utilization rates were comparable to other Ontario communities. Across the northwest, the population of each of the districts uses hospitals (inpatient and same day surgery) more frequently than in Southern Ontario. The utilization rate of inpatient and SDS hospital services for the population in Northwestern Ontario is 20% higher than the rate for populations in other parts of the province. The overall rate for Northwestern Ontario is 2,129 hospitalizations per 10,000 age-gender standardized population compared to a rate of 1,762 for the rest of the province. (The utilization rate for residents of Northwestern Ontario includes care received in hospitals in Ontario and Winnipeg, but does include a very small amount of care received in hospitals in the United States.) In terms of utilization rates, the people in Northwestern Ontario have equivalent or better access to inpatient and SDS hospital services than the population in other parts of the province. But there are interesting differences in the patterns of utilization. HayGroup 59

63 Integrated Service Plan for Northwestern Ontario Overall Utilization Rates for Inpatient and SDS Exhibit 8.1 Overall Acute Care Utilization IP & SDS Separations per 10,000 Age/Gender Standardized Population in 2003/04 All Ontario Elsewhere Central East Inpatient Toronto Day Surgery NE Ontario NW Ontario 1,291 1,304 1, Sioux Lkt. & Isol. 1, Dryden Kenora Urban 1,121 1, Rainy River District 1, Thunder Bay District Thunder Bay City 1,247 1, The rate of hospitalization of residents of Sioux Lookout and Isolated Communities is dramatically higher than elsewhere in the province As can be seen, the rate of hospitalization of residents of Sioux Lookout and Isolated Communities is dramatically higher than elsewhere in the province. At 2,813 hospitalizations per 10,000 age-gender standardized population it is 32% higher than the average for all of the Northwest and 60% higher than the average for the rest of the population of the province. There was an expectation that there would be modestly higher rates of hospitalization in the isolated and remote areas, given the vast distances that individuals must travel and a tendency to admit for services that a local resident might receive as an outpatient. However the size of the difference between Sioux Lookout and the isolated communities and the rest of the northwest and the rest of the province is larger than expected. It may be a result of the hospitalization patterns for isolated populations, or a less than average state of health and well being in these communities or a propensity to admit that may be higher than necessary or a combination of these three reasons. HayGroup 60

64 Integrated Service Plan for Northwestern Ontario The hospital utilization rate for residents of Thunder Bay City is significantly higher than the rate for other urban communities in Ontario. Also the utilization rate for residents of Thunder Bay City is significantly higher than the rate for other urban communities in Ontario. The overall rate (inpatient and SDS) for Thunder Bay is 2,155 episodes of hospital care per 10,000 age-gender standardized population. This is 22% higher than the rate for communities outside of Northwestern Ontario and fully 39% higher than the rate for Toronto. Appendix H to this report presents similar small area variation analyses for each Program Cluster Category Utilization Rates for Same Day Surgery There are also interesting differences when the number of hospitalizations is considered separately for inpatient and for SDS. The exhibit following compares the Same Day Surgery utilization rate of the population in Northwestern Ontario with the rates for populations elsewhere in Ontario. Exhibit 8.2 SDS Separations per 10,000 Age/Gender Standardized Population in 2003/04 All Ontario Elsewhere Central East Toronto NE Ontario NW Ontario Sioux Lkt. & Isol. Dryden , Kenora Urban 497 Rainy River District Thunder Bay District Thunder Bay City 944 It appears that people residing in communities outside of Thunder Bay are being admitted for surgery rather than receiving care as outpatients. Curiously, the rates of SDS for populations of Red Lake, Sioux Lookout and Remote Communities are similar to the rate for rest of Ontario. But the rate for Thunder Bay is 14% higher than the rate for the rest of the province. And the rates for the rest of Northwestern Ontario are significantly lower than the rates for the rest of the province. The Kenora Urban district is the most striking with a rate for SDS that is 40% lower than the rate for the rest of the province. It would HayGroup 61

65 Integrated Service Plan for Northwestern Ontario appear that people residing in communities outside of Thunder Bay are being admitted for surgery rather than receiving care as outpatients. This is likely a function of the need to travel to Thunder Bay for most surgical procedures and a tendency to admit patients from out-of-town rather than provide care on an ambulatory basis. The recommendation to provide more surgery locally in the new District Hospitals using visiting surgeons should significantly increase the number of ambulatory procedures and correspondingly reduce the number of admissions for care Admission for Conditions Classified as May Not Require Hospitalization There is a high rate of admission for the population of Northwestern Ontario for conditions that May Not Require Hospitalization There is a high rate of admission for the population of Northwestern Ontario for conditions that the Canadian Institute for Health Information (CIHI) has classified as May Not Require Hospitalization. Exhibit 8.3 May Not Require Hospitalization IP Separations per 10,000 Age/Gender Standardized Population in 2003/04 All Ontario Elsewhere Central East Toronto NE Ontario NW Ontario Sioux Lkt. & Isol. 138 Dryden Kenora Urban Rainy River District Thunder Bay District Thunder Bay City HayGroup 62

66 Integrated Service Plan for Northwestern Ontario The tendency to admit for conditions that generally do not require hospitalization will likely be reduced when the hospital in Sioux Lookout achieves the level of a District Hospital so that more care can be provided closer to home and when hostel facilities are available. The rate is especially high for the population in Sioux Lookout and Isolated Communities which might be expected because of the need for people in many of these communities to travel for care. The rate is almost 3 times the rate for populations elsewhere in Ontario. This tendency to admit for conditions that generally do not require hospitalization will likely be reduced when the capability and capacity of the hospital in Sioux Lookout are enhanced and expanded to the level of a District Hospital so that more care can be provided closer to home and in a culturally friendly environment. Also, the creation of hostel arrangements for patients from the remote communities should reduce the propensity to admit for conditions that are not generally hospitalized. The need to travel for much care from the other districts in Northwestern Ontario may also explain rates that are approximately twice the rate for populations from other parts of Ontario. Again, the this tendency to admit for conditions that generally do not require hospitalization will likely be reduced when the capability and capacity of selected hospitals in each of the Districts are enhanced and expanded to the level of a District Hospital so that more care can be provided closer to home. Also, the creation of hostel arrangements for patients from the Districts outside of Thunder Bay City should reduce the propensity to admit these people for conditions that are not generally hospitalized when they still need to go to Thunder Bay for more specialized care. If the rate of MNRH admissions for the population in Thunder Bay were reduced by only 25% to be only 33% higher than the rate for the rest of the province, then TBRHSC would use 3 fewer beds that could be available to provide necessary care for patients from the region. What is most surprising is the relatively high rate of admission for conditions that are not generally hospitalized for patients from Thunder Bay City. There are 85 admissions per 10,000 population in Thunder Bay City compared to a rate of only 48 elsewhere in Ontario and only 43 in Toronto. The rate of MNRH admissions for residents of Thunder Bay City is 77% higher than the rate for residents of the rest of the province. If the rate were reduced by only 25% so that the rate of MNRH admissions for the population in Thunder Bay was only 33% higher than the rate for the rest of the province, then TBRHSC would use 3 fewer beds 18 that could be used to provide necessary care for patients from the region. 18 This reduction in MNRH admissions is included in the analysis of opportunities to improve clinical efficiency presented later in this chapter. HayGroup 63

67 Integrated Service Plan for Northwestern Ontario Utilization of Tertiary Care Hospital Services Differences in utilization of tertiary hospital services among communities in Northwestern Ontario are so large that they are likely the result of difference in access to care rather than differences in need for care. There is a wide variation in the utilization of tertiary and quaternary hospital services by residents of the various Districts in Northwestern Ontario. The differences in utilization are so large that they are likely the result of difference in access to care rather than because of differences in need for care. Residents of Dryden appear to have an especially difficult time in gaining access to tertiary and quaternary care. The utilization rate for tertiary and quaternary care of residents of Dryden is 35% less than the rate for populations elsewhere in Ontario. More strikingly, the rate is 57% less than the rate for residents of Thunder Bay City. Residents of Thunder Bay City are more than twice as likely to use tertiary/quaternary care services than the residents of Dryden and the residents of Thunder Bay District are almost twice as likely. This apparent inequity in access should be explored and corrected Exhibit 8.4 Tertiary/Quaternary Acute Care Utilization: IP Separations per 10,000 Age/Gender Standardized Population in 2003/04 All Ontario Elsewhere Central East Toronto NE Ontario NW Ontario Sioux Lkt. & Isol Dryden 54 Kenora Urban 77 Rainy River District Thunder Bay District Thunder Bay City 126 HayGroup 64

68 Integrated Service Plan for Northwestern Ontario Clinical Efficiency Clinical efficiency analysis refers to opportunities to reduce use of inpatient days through a shift from inpatient to ambulatory surgery or through reduced length of stay. We have examined the clinical efficiency of the care processes at Thunder Bay Regional Health Science Centre. Clinical efficiency analysis refers to the examination of opportunities to reduce use of inpatient days through a shift from inpatient to ambulatory surgery or through reduced length of stay. There are often variations between hospitals (or regions) in use of ambulatory care and variations in lengths of stay for apparently similar patients. Identifying these variations (and sharing the information with clinical staff) is an important step in reducing the variation and reducing the use of inpatient beds and the total cost of inpatient care. For the purposes of this study, we have used targets for clinical efficiency based on demonstrated performance of peer hospitals from across Canada that are similar in clinical characteristics to TBRHSC. CIHI data for these hospitals, as reported to the annual CIHI/HayGroup benchmarking study have been included. The peer hospitals are: In Ontario: Grey Bruce Health Services (Owen Sound Hospital) Kingston General (/Hotel Dieu) Peterborough St. Catharine's Sault Ste. Marie Southlake Sudbury Regional Hospital Windsor (HDGH and WRH) Outside Ontario Interior Health (KGH, Kelowna) Interior Health (Royal Inland, Kamloops) Palliser Health Region (Medicine Hat) David Thompson HR (Red Deer) Atlantic Health Sciences (Saint John) Peace Country Health (QE 2, Grande Prairie) Targets for use of ambulatory surgery and length of stay were developed for each hospital based on peer hospital performance for individual CMGs, age groups and case complexity levels. Targets were only applied where at least HayGroup 65

69 Integrated Service Plan for Northwestern Ontario one hospital had at least 30 cases in a fiscal year in the CMG/age group category. The best quartile target for use of ambulatory surgery and the best quartile target for length of stay were calculated for each possible CMG and patient age combination. The best quartile target for ambulatory surgery in a CMGpatient age cell is the percent use of ambulatory surgery where one quarter of the hospitals (with at least 30 cases) in the peer group had a higher percent use of ambulatory surgery, and three quarters of the hospitals had a lower percent use of ambulatory surgery. The best quartile target for length of stay in a CMG-patient age cell is the length of stay (for Typical and Outlier cases, including all ALC days) where one quarter of the hospitals (with at least 30 cases) in the peer group had a shorter LOS and three quarters of the hospitals had a longer LOS. The best quartile targets for length of stay were calculated after application of the best quartile targets for ambulatory surgery. A hospital may have a low average LOS for a CMG because patients who would be treated on an ambulatory basis in other hospitals get admitted as inpatients for 1 or 2 days. The inclusion of these very short stay cases reduces the average length of stay, and could cause the hospital to look very efficient (based on average LOS) when in fact they have opportunities to further reduce use of inpatient beds. To avoid this we simulate the achievement of best quartile ambulatory performance for each hospital (and remove short stay inpatient cases that could have been treated on an ambulatory basis) before calculating the target length of stay. For a hospital that has aggressively shifted inpatient surgery to ambulatory surgery, this adjustment will have little impact. However, for a hospital that has not shifted inpatient surgery to ambulatory surgery, the adjustment will remove a large number of 1 or 2 day stay cases, and establish a new, longer, average length of stay that gets used with the assessment of length of stay reduction opportunities. For some CMG-patient age combinations no hospital exceeded the minimum annual volume requirement of 30 cases, so no target was established. Death, transfer, and signout cases (and their associated days) are excluded from the clinical efficiency analysis. HayGroup 66

70 Integrated Service Plan for Northwestern Ontario The analysis results shown in the following charts show what percent of actual total inpatient days would be saved if each hospital achieved the best quartile targets for ambulatory surgery and length of stay for every CMG-patient age combination. The hospitals with the smaller estimated savings opportunities are those whose patterns of practice are already close to the best quartile performance levels and who would be considered to be relatively clinically efficient. The hospitals with the larger estimated savings opportunities are those who would be considered to be clinically inefficient. No one hospital is likely to be able to achieve the best quartile targets across the board, so even the most efficient hospital will have some further savings opportunities identified through this analysis. The following exhibit shows the results of the clinical efficiency analysis for TBRHSC. The most efficient of the peer hospitals, Southlake Regional Health Centre would save only 6.3% of total inpatient days at the best quartile targets. TBRHSC would save 13.5% of 2001/02 inpatient days. All but one of the Ontario peer hospitals are more efficient than TBRHSC. Exhibit 8.5 % of Total IP Days to Best Quartile Targets via SDS and LOS Reduction Red Deer 3.1% 16.9% Medicine Hat 3.1% 15.4% Sault Ste Marie 1.6% 15.2% Saint John 1.7% 13.6% Grand Prairie 2.2% 12.7% TBayReg 1.0% 12.5% Royal Inland 1.6% 8.6% OwenSnd 1.4% 8.2% Sudbury 1.1% 8.1% Kelowna 3.0% 6.0% St.Catharines Kingston G/DH 2.4% 0.9% 4.9% 6.1% Via SDS Via LOS WindsorReg 1.4% 5.6% HDieuGrace 1.4% 5.5% Peterborough 1.1% 5.4% Southlake 1.3% 5.0% HayGroup 67

71 Integrated Service Plan for Northwestern Ontario If TBRHSC were able to achieve only 50% of its clinical efficiency opportunity then it would be able to reduce 8,719 patient days or 26.5 beds that would then be available to provide greater access to patients from outside of Thunder Bay If TBRHSC were to achieve the full 13.5% clinical efficiency opportunity to reduce inpatient days of care, it would be able to reduce 17,438 inpatient days. If it were able to achieve 50% of this opportunity, then it would be able to reduce 8,719 patient days or 26.5 beds at 90% occupancy 19. As can be seen a greater focus on clinical efficiency at TBRHSC would provide it with more capacity to address the needs of patients from outside of Thunder Bay City. Also, if TBRHSC were able to reduce 8,719 patient days through improved clinical efficiency, we estimate that it would be able to reduce its operating costs by approximately $2.4 million 20 The following table presents the Case Mix Groups with the most significant savings opportunity. As can be seen the more significant opportunities span the 4 major hospital programs: Medicine, Surgery, Obstetrics and Psychiatry. 19 It should be noted that clinical efficiency opportunity of 17,438 patient days is much less than the number of ALC days at TBRHSC in 2003/04. There were 21,258 ALC days at TBRHSC in 2003/04. ALC day reduction will be critical element of achieving clinical efficiency targets and freeing up capacity to address the needs of patients from the regions. 20 Calculation of associated savings based on RIW components wherein we remove typical RIW and add corresponding DPG RIW for cases shifted from IP to SDS; reduce RIW by routine/ancillary per diem to reflect marginal savings of LOS reduction. Calculated equivalent impact of CE target reduction of 8,719 days is weighted cases. TBRHSC direct acute care cost per RIW for 2003/04 was $2,492. Estimated savings:= $2,492X956.7 =$2,383,800. This is equivalent to $273 per day or $90,000 per bed direct cost. HayGroup 68

72 Integrated Service Plan for Northwestern Ontario Exhibit CMGs with Greatest Calculated Opportunity to Reduce Inpatient Days at TBRHSC CMG CMG Name IP Cases IP Days IP Cases to SDS Days to Save Resulting LOS Via SDS Via LOS Total 294 Esoph/Gastro/Misc Digest Dis 617 3, ,059 1, Spec Cerebrovasc Disord(xTIA) 214 2, Schizophren/Psy No ECT/Axis , Chr Obstructive Pulmonary Dis 208 2, Oth Factors Cause Hospitaliz 260 1, Arrhythmia 317 1, Heart Failure 331 3, Signs & Symptoms 109 1, Dementia W Or W/O Del No Ax Simple Pneumonia & Pleurisy 387 3, Card Cath No Cond Or LOS < Neo,Wt>2500G,Moderate Problem 193 1, Dementia W Or W/O Del W Axis3 36 1, G.I. Hemorrhage 193 1, Nutrit/Misc Metabolic Disord 184 1, Chronic Bronchitis 270 2, Diabetes 165 1, Major Intestinal/Rectal Proc 150 2, G.I. Obstruction Syncope And Collapse Avg. LOS Need for Utilization Management To create capacity to equitably address patient care requirements now and into the future, there needs to be an aggressive, Northwestern Ontario-wide utilization management program The data collected for this study demonstrates a high use of inpatient care in Northwestern Ontario compared to other areas in the province. To create capacity to equitably address patient care requirements now and into the future, there needs to be an aggressive, Northwestern Ontario-wide utilization management program which ensures that patients are cared for in the way and in the place that is most suited to their clinical needs for the most appropriate period of time. The recommended Northwestern Ontario Joint MAC and the recommended District structures for governance and management of health services will provide the vehicle for better managing access to hospital care. The proposals to significantly expand the capacity for long-term care services will facilitate reduction the number ALC days and thus the Average Lengths of Stay (ALOS) of patients at TBRHSC. These initiatives will both reduce the demand for inpatient care on TBRHSC, reduce the utilization of beds by patients admitted for inpatient care and thus increase the ability of TBRHSC to respond to needs for inpatient care from across Northwestern Ontario. HayGroup 69

73 Integrated Service Plan for Northwestern Ontario Recommendation: The Special Advisor recommends that: (16) The LHIN should establish a Northwest-wide program for utilization management to ensure that patients are cared for in the most appropriate setting reducing the utilization of inpatient beds at TBRHSC to enable it to respond to the needs of the region. 8.3 Health Human Resources Planning The new LHIN should work with the Health Districts and the NW Ontario Joint MAC to establish a single mechanism for recruiting health professionals to Northwestern Ontario There is a severe shortage of health resources in Northwestern Ontario and it continues to be extremely difficult to attract staff. At the present time, communities and hospitals are recruiting independently for health human resources and as a result end up competing in trying to attract physicians, nurses, and allied health professionals to their communities. A collaborative, unified approach to recruiting staff to Northwestern Ontario will be much more effective than current disjointed approaches. The needs of the population of Northwestern Ontario will be better served by comprehensive planning for health human resources and implementation of the plans across the new Health Districts. The new Local Health Integration Network should work with the Health Districts to establish a single mechanism for recruiting health professionals and should collaborate with the Northwestern Ontario Joint Medical Advisory Committee in recruiting medical staff. Recommendation: The Special Advisor recommends that: (17) The LHIN should establish a Northwestern Ontariowide approach to all health human resources planning. TBRHSC needs an APP to assist in recruiting and retaining medical specialists and subspecialists to address its clinical and academic requirements. In order to assist TBRHSC in recruiting and retaining medical specialists and subspecialists to address its clinical and academic requirements there needs to be a successful negotiation of an Alternative Payment Plan (APP). The current fee-for-service physician compensation model and the relatively small population base in Northwestern Ontario makes it all but impossible for TBRHSC to attract and retain enough specialists to cover on-call requirements in most areas of specialty practice. There are insufficient cases to support an adequate complement of specialists if the only source of income for these physicians is through billings. The HayGroup 70

74 Integrated Service Plan for Northwestern Ontario requirement to assume teaching and research duties within the northern medical school also will require an alternative way to compensate these physicians. Therefore, the Northern Medical School should be involved in the negotiation of the APP. APP must include an obligation to support specialists and primary care providers outside of the Thunder Bay through telemedicine and visiting clinics/services within the District Hospitals Within the APP negotiations, there must be an understanding that these physicians have an obligation to support specialists and primary care providers outside of the Thunder Bay through telemedicine and by providing visiting clinics/services within the District Hospitals. There is a need to formalize the role for TBRHSC and its medical staff with regard to their responsibility for the delivery of specialty and subspecialty care for the population of the entire region. There are other places in Ontario such as the work being done from the Ottawa Hospital which has reached out to provide support throughout the Ottawa Valley where an academic centre has assumed responsibility for care throughout the region. Given the size of this region and the designated role of TBRHSC, it is important that the hospital and its physicians assume a regional responsibility. Similarly, it will be important for the MOHLTC to come to agreement around Alternate Payment Plans for specialists practicing in the proposed District Hospitals in Northwestern Ontario. Recommendation: The Special Advisor recommends that: (18) The MOHLTC should establish Alternative Payment Plans for specialist physicians in Northwestern Ontario to attract and retain enough of them to provide 24/7 service coverage for patients from the entire region. The APP must formalize their regional and academic responsibilities. HayGroup 71

75 Integrated Service Plan for Northwestern Ontario 9.0 E-Health in Northwestern Ontario Northwestern Ontario is leading most other areas of the province in its adoption of e-health Northwestern Ontario would benefit from a formal partnership for access to telemedicine and visiting psychiatrist support with a large psychiatric program elsewhere in the province. Northwestern Ontario is leading most other areas of the province in its adoption of telemedicine and the delivery of health care services through other e-health strategies. This is applauded, encouraged and should be expanded. All isolated communities that are not already linked/partnered for telehealth services should be provided with the infrastructure for such work as soon as possible. Also, the isolated communities should have a 24-hour link to the emergency facilities at their closest District Hospital and TBRHSC should expand its ability to provide 24-hour emergency consultation to all isolated and remote communities. Northwestern Ontario would benefit from a formal partnership for access to telemedicine and visiting psychiatrist support with a large psychiatric program elsewhere in the province which could then provide much greater availability of psychiatric services throughout the Northwest. The Ontario Psychiatric Outreach Programs (OPOP) is a collaborative network of psychiatrists who deliver clinical services and education to Ontario s rural and remote communities with a focus on Northern Ontario. OPOP currently delivers psychiatric services to a number of communities in the Northwest including some first nations communities. This involves both outreach services delivered by telemedicine and by travel to the community. OPOP is working towards being a centralized agency that will organize all outreach psychiatric service in the North. The LHIN in Northwestern should explore with the new District Governance structures the sufficiency of the type of support available from OPOP. It should then explore with OPOP the feasibility of expanding the breadth and depth of these services to address the needs of all FHTs and hospitals in Northwestern Ontario. There are additional services, which would be expanded in the telemedicine program over time, but augmenting mental health services would address a current and pressing need. Recommendations: The Special Advisor recommends that: (19) The LHIN should ensure that all isolated communities have 24-hour telemedicine link to their closest District Hospital and to TBRHSC. HayGroup 72

76 Integrated Service Plan for Northwestern Ontario (20) The LHIN should establish a telemedicine and outreach partnership to provide psychiatric support to community and hospital mental health services in Northwestern Ontario The significant amount of movement of patients from facility to facility along the care continuum in Northwestern Ontario mandates that information about their current needs and treatments and about pre-existing and comorbid conditions follow the patient from facility to facility The significant amount of movement of patients from facility to facility along the care continuum in Northwestern Ontario mandates that information about their current needs and treatments and about pre-existing and comorbid conditions follow the patient from facility to facility. Moving paper records from facility to facility is a cumbersome, time consuming and inefficient process that often results in delays in treatment or repeated tests and procedures. More importantly, there is not one repository of information regarding the patients episodes of in-hospital care. When a patient next presents at a hospital, it is not likely that the clinicians will have timely access to clinical (and non-clinical) information that will be important to effectively address the patient s problem. Integration of care along the continuum and integration of information related to each episode of hospital care for a patient will be facilitated and enhanced through the creation of a fully integrated electronic hospital record that is used by each of the hospitals in Northwestern Ontario. The creation of the integrated electronic record will be facilitated by the work already completed by the Northwest Health Network and the considerable pre-existing investments in information systems by the hospitals in the Northwest. Once the hospital records are integrated across facilities, the next step will be to add in the patients interactions with providers in the community to create a Northwestern Ontario Health Information Network and an integrated electronic health record including participation by physicians offices, pharmacies, CCACs, etc. Again, this extension of the electronic record to include community interaction will be facilitated by the current work of the Northwest Health Network. Recommendation: The Special Advisor recommends that: (21) The LHIN should ensure the continuation of the work of the Northwest Health Network to develop a Northwestern Ontario Health Information Network and implement an Integrated Electronic Health Record for each of the residents of Northwestern Ontario. HayGroup 73

77 Integrated Service Plan for Northwestern Ontario 10.0 The Cost of Change Some of the recommendations presented here can be implemented by refocusing current health services spending in Northwestern Ontario. However, some of these will require investments in capital and additional spending on operations. The paragraphs following presents a best estimate of the order of magnitude of the potential savings and required funding of all of the recommendations made in this report Costs of Improvements in Primary Care There are several proposed changes to the organization and delivery of primary care services in Northwestern Ontario including enhancing the capacity and capability of virtual primary care teams serving isolated and remote communities through additional distribution of Nurses and Nurse practitioners and enhancements to telemedicine and visiting services, reorganization of primary care into Family Health Teams and operational integration of FHTs into local CCAC services and the local hospital. We estimate that the costs associated with improving primary care will be: Adding as many as 5 Nurse Practitioners to provide primary care working as part of virtual primary care teams in isolated and remote communities at a cost of approximately $100,000 per position. Introducing Family Health Teams throughout Northwestern Ontario will be funded through the health transformation initiatives of the OMHLTC Health Results Teams And, as discussed in the body of this report we estimate that over time, investments in and enhancements to primary care will reduce the volume of admissions to hospital for avoidable hospitalization conditions. We estimate that approximately 500 admissions with an ALOS of 7.4 days can be avoided with a resultant saving of $300 per inpatient day or approximately $1.1 million Costs of Restructuring of Acute Care Services There are several changes anticipated and proposed for hospital acute care services in Thunder Bay. HayGroup 74

78 Integrated Service Plan for Northwestern Ontario Increases in Volume Due to Demographic Changes At current utilization rates, demographic changes in the population will lead to a requirement for 507 additional hospital cases or 1,347 weighted cases at a cost of $2,491/weighted case. This will increase the costs of acute care services used by the population of Northwestern Ontario by $3,360, Local and District Hospitals The restructuring of hospital services to provide for more capable Local and District hospitals closer to people s homes will require investments in new facilities. Most notably: Wilson Memorial Hospital in Marathon will require investments in enhanced surgical facilities and 15 additional acute care beds (either through new construction or conversion of nursing home beds to acute care). We estimate that the capital costs of these changes will be between $5 and $7 million. As is currently planned by the MOHLTC, the hospitals in Sioux Lookout should be replaced by a new facility focusing on providing primary and secondary acute care and long-term care for the populations of Sioux Lookout and the isolated communities to the north. This will require new construction of 46 acute care beds, enhancements to surgery and LDR, extensive diagnostic facilities and technologies, ambulatory care facilities and 25 CCC/LTC beds. We estimate that the capital costs of this new facility will be between $60 and $70 million. The increases in patient volumes and associated operating costs of the additional volumes in Local and District hospitals will be offset by decreases in patient volumes and operating costs at TBRHSC, Winnipeg and Dryden Improved Clinical Efficiency at TBRHSC Improvements in clinical efficiency at TBRHSC should provide for a reduction of 8,719 days of care. We estimate that this will provide savings equivalent to equivalent HayGroup 75

79 Integrated Service Plan for Northwestern Ontario weighted cases at $2,492/wtd case for a total potential cost savings of approximately $2,400, Completion of Care at Hospitals Close to Home The proposed changes in patterns of care to allow patients from outside of Thunder Bay to finish their episode of primary or secondary hospital care at a hospital close to their home will enhance the quality of their hospital experience and ensure that they are provided with easy return to their home community and to their primary care provider. It may however lengthen modestly their length of stay in hospital. We are estimating that 1,463 primary and secondary care patients will transfer from TBRHSC to their home hospital for the last part of their acute care hospitalization. This may extend their stay requiring 3,731 additional days of stay at an estimated $273/day for a total additional cost of $1,018,563. The transfer to the patients home District or Local hospital will require medical transportation at a cost of approximately $500/trip for a total additional cost of $731, Introduction of Angioplasty at TBRHSC The Special Advisor is also recommending that angioplasty be introduced at Thunder Bay Regional Hospital. This will eliminate the need for patients to travel to a hospital in Southern Ontario for care and for some to need to wait in hospital at TBRHSC for transfer to the hospital in Southern Ontario for the procedure. This change should reduce the cost of providing these procedures for residents of Northwestern Ontario. The increase in costs at TBRHSC estimated at $1.5 million to provide angioplasty will be offset by a similar decrease in costs in southern hospitals. In 2003/04 there were 286 cardiac patients who were transferred from TBRHSC to another hospital after using 3,876 patient days waiting for transfer. If we assume that half of these were patients transferred for angioplasty then there were 143 patients transferred for angioplasty who used 1,938 patient days waiting for transfer to a southern 21 Calculation of associated savings based on RIW components wherein we remove typical RIW and add corresponding DPG RIW for cases shifted from IP to SDS; reduce RIW by routine/ancillary per diem to reflect marginal savings of LOS reduction. Calculated equivalent impact of CE target reduction of 8,719 days is weighted cases. TBRHSC direct acute care cost per RIW for 2003/04 was $2,492. Estimated savings:= $2,492X956.7 =$2,383,800. This is equivalent to $273 per day HayGroup 76

80 Integrated Service Plan for Northwestern Ontario hospital. Eliminating the 1,938 days waiting for transfer, at an estimated cost of $400/day, would provide savings of approximately $775,000. It should be noted that not all NW Ontario patients receiving cardiac care in a southern hospital are admitted to TBRHSC first. Many travel to southern Ontario and are first admitted as an elective admission to the southern hospital. Approximately 300 NW Ontario patients currently travel to southern Ontario for angioplasty every year. If we assume that they use commercial travel for 200 transfers at $1000/procedures and air ambulance for 100 transfers at $5000, then providing angioplasty at TBRHSC will save $700,000 in travel costs. If 2% of angioplasty patients (which is likely a high estimate) require emergency surgery in Duluth, then 6 patients would require emergency transfer and surgery at an American hospital. We estimate that this would cost approximately $40,000 per occurrence for a total potential expense of $240, Cost of Restructuring Long-Term Care There is an imbalance in the supply of long-term care services across Northwestern Ontario with some communities having a significant over supply relative to other communities in Ontario and some with a shortage. Also there is an unusual pattern of use of Complex Continuing Care in Thunder Bay. Providing sufficient long-term care services to meet the population s need for care in 2010 will require an additional: 242 Long-Term Home Care places 279 Supportive Housing places 57 Nursing Home beds We developed estimates of the cost of these long-term care places from the data available to us Additional Long-Term Home Care Places We estimated the cost per place for long-term home care using data provided by the Thunder Bay and Kenora-Rainy River CCACs. The Thunder Bay CCAC provided its rates 22 for different types of services as follows: 22 No rate was provided for Nursing ( C ); we used the rate for OT and SLT as a surrogate. HayGroup 77

81 Integrated Service Plan for Northwestern Ontario Type of Service Standard Cost Unit Nursing (A) $45 visit Nursing (R) $45 visit Nursing ('C')* $108 hour Nutrition $94 visit Physio Therapy $98 visit Occupational Therapy $108 visit Speech Language Path. $108 visit Social Work $60 visit Home Maker $21 hour We then determined the Long Term Home Care places corresponding to adults over 20 who stayed on home care for at least 180 days, where homemaking was not the only service provided. We found 283 places from the Thunder Bay CCAC data, and 353 places from the Kenora Rainy River CCAC data. We then determined the total volume and cost of services consumed in the year 2003/04 by these cases. For the Thunder Bay CCAC the total value of the services used by clients on long-term home care was $3,389,502, and for Kenora-Rainy River CCAC, this was $1,642,484. Dividing the total cost by the number of clients provided an estimate of the cost per equivalent long-term home care place per year. We then added a provider travel allowance at 25% of the rate to come up with an estimated cost per year. In Thunder Bay this cost was $14,971 and in Kenora Rainy River it was $5,816. (It is interesting to note that homemaking accounts for 76% of the costs for long-term home care in Thunder Bay and 77% of the costs of long-term home care in Kenora Rainy River.) We took the weighted average of the costs of Thunder Bay and Kenora Rainy River to establish an estimated cost of long-term home care in Northwestern Ontario in 2010 to establish the cost per year for a long-term home care place in Northwestern Ontario at $9,890. For the purposes of these analyses, we have estimated the annual cost of a long-term home care place at $10,000. Thus we estimate that the cost of providing an additional 242 long-term home care places will be $2,420,000 per year. Because this would be an expansion of an existing service, we did not provide a start up allowance for this incremental service volume Additional Supportive Housing Places In consultation with architects and planners active in special purpose housing, we estimate the capital cost of a supportive housing unit is $150,000. Thus, we estimate that the capital HayGroup 78

82 Integrated Service Plan for Northwestern Ontario cost of providing 279 units will be approximately $41,850,000. We have also assumed that these units will be provided by a housing agency and/or private sector developers. The MOHLTC provided an estimate of the annual cost of services provided in supportive housing based on based on Community Support Service code SHU 11A- Homemaking/Personal Support/Attendant Service provided to the elderly who are living in supportive housing who require services available on a 24-hour basis: The 2001/2002 provincial "average" ministry subsidy per SHU 11 client was $5,966 as derived by the ministry's Finance and Information Management Branch (FIM). (Note: FIM calculates unit costs and costs per client based on total program expenditures). For these analyses we have used an estimated cost of services to a resident of Supportive Housing at $6,000 per year. Based on this we estimate that the annual operating cost to the MOHLTC of providing an additional 279 supportive housing places will be approximately $1,674, Additional Nursing Home Beds In consultation with architects and planners active in longterm care, we estimate that the capital cost of a nursing home unit in Northern Ontario is $150,000. Thus, we estimate that the capital cost of providing 57 nursing home units will be approximately $8,550,000. We have also assumed that these units will be provided by not-for profit and/or private sector developers. We have estimated the annual cost of these additional nursing home places based on the average MOHLTC payment for a Nursing resident with a CMI of 1.0 which we estimate to be $70/day. Based on this we estimate that the annual operating cost to the MOHLTC of providing an additional 57 nursing home beds will be approximately $1,453, Substitution of Nursing Home Care for Complex Continuing Care There appears to be unusual and excessive use of Complex Continuing Care in Northwestern Ontario. If these beds are closed and where necessary replaced with Nursing Home care we estimate that there can be an operating cost savings of as much as $8.5 million. This would be achieved by closing 165 CCC beds which are currently funded at approximately $200/day and replacing them, where necessary with 143 HayGroup 79

83 Integrated Service Plan for Northwestern Ontario Nursing Home or Home for the Aged beds which would be funded by the MOHLTC at $70/day Substitution of In-home for Inpatient Palliative Care There appears to be unusual and excessive use of inpatient palliative care in Northwestern Ontario. If these beds are closed and where necessary replaced with in-home palliative care we estimate that there can be an operating cost savings of as much as $1.2 million. This would be achieved by closing 27 palliative care beds which are currently funded at approximately $200/day and replacing them, where necessary with 27 in-home palliative care places that we estimate would cost less than $70 per day Restructuring Governance and Management Creating District and Northwest wide governance and management structures will allow for greater efficiency in management and opportunities to improve access to and quality of medical care across the Northwestern Ontario Administrative Efficiencies from District Governance & Management Creation of District governance and management structures should provide opportunities to share administrative functions across institutions and agencies. As a minimal estimate, we have modeled the reduction of 3 administrative positions at each hospital that enters into a district governance structure. Thus we have estimated the following staff reductions in each of the new Districts: Kenora: No reduction Dryden: 3 positions Sioux Lookout & Isolated Communities: No reduction Rainy River: 6 positions Thunder Bay District: 15 positions Thunder Bay City: No reduction Thus we estimate that there can be a total reduction of 24 positions at an average saving of $60,000 per position for a total saving of $1.44 million Alternate Payment Plans In some specialties, there is inadequate patient volume to support the number of medical staff required to provide HayGroup 80

84 Integrated Service Plan for Northwestern Ontario adequate clinical coverage and to support the academic mission of TBRHSC. There will need to be alternate payment plans for these specialties and subspecialties to ensure sufficient staff. We estimate that the equivalent of 11 positions will need to be fully funded through an APP established at TBRHSC and that the APP cost of these positions will be approximately $300,000 for a total cost of $3.3 million E-Health Initiatives The Special Advisor has recommended several e-health initiatives Telemedicine Although telemedicine is critical to the proposed restructuring and enhancement of health services in Northwestern Ontario, much of the suggested change is within the mandate, current plans and funding of North Network. As a result, we are not estimating any additional costs for the telemedicine proposals contained in this report Electronic Hospital Record We have proposed a single integrated electronic health record for use across all hospitals in Northwestern Ontario to facilitate patient and provider movement from hospital to hospital. Based on discussion with staff of TBRHSC and review of the Northern Ontario Information and Communication Blueprint, we estimate that, building on the existing systems in Northwestern Ontario, the additional capital cost of completing an integrated hospital information system and electronic health record for use across all hospital in Northwestern Ontario will cost approximately $28 million. The incremental annual operating cost of the hospital information system will be approximately $3.3 million Electronic Health Record The second step in the e-health strategy for Northwestern Ontario would see the hospital information system extended to encompass community providers including Family Health Teams, CCACs, nursing homes, pharmacies, etc. We estimate the cost of extending the system into the community will be approximately $19 million with an incremental annual operating cost of $2.2 million. HayGroup 81

85 Integrated Service Plan for Northwestern Ontario 10.6 Summary of the Costs of Change The following table provides a summary of the estimated costs of change as recommended by the Special Advisor to the Minister and as described in this report. HayGroup 82

86 Integrated Service Plan for Northwestern Ontario Exhibit 10.1 Summary of the Costs of Change Initiatives Capital & One Time Costs Operating Costs Comment Improve Primary Care Increase NPs in Isolated Communities $500,000 Add 5 Nurse $100,000 Increase FHTs in NW Ontario No new costs; part of funding for Health Results $0 Team Transformation Initiatives Reduced Hospital Admissions for Avoidable Conditions -$1,100,000 Reduce 514 annual $2220 Increased Acute Care Volumes for Population of Northwestern 507 additional cases or 1,347 wtd $3,360,000 Ontario due to demographic changes $2,491/wtd case Restructuring of Acute Care Increase operating cost in Marathon offset by Additional acute care capability and capacity in Marathon $5,000,000 $0 decrease at TBRHSC 46 beds acute, surgery and LDR, extensive New, enhanced acute care facility in Sioux Lookout. $60,000,000 diagnostics, ambulatory care, 25 beds CCC/LTC/ $0 Increase operating cost offset by decrease at TBRHSC, Dryden & Winnipeg 1463 transfers from TBRHSC requiring 3,731 Completion of Hospital Care in District and Local hospitals $1,018,563 additional $273/day Medical Transportation to District & Local hospitals $731,500 1,463 medical transportation $500/trip Clinical Efficiency at TBRHSC Reduction of 8,719 days or equivalent wtd -$2,400,000 cases at $2,492/wtd case Introduction of Angioplasty at TBRHSC Procedure and acute care costs Increase at TBRHSC (estimated at $1.5 million) $0 offset by decrease in southern hospitals 143 patients admitted to TBRHSC used 1938 Reduction in Days Waiting for Transfer -$775,200 patient $400/day waiting for transfer Approximately 200 commercial $1,000 Reduction in Travel Grants -$700,000 and 100 air ambulance $5,000 Emergency Surgery in Duluth 2% of patients,6 patients require emergency $240,000 surgery in $40,000 per occurrence. Add long-term care capacity Long Term Home Care $2,420, $10K/place/year Supportive Housing $41,850,000 $1,674, $150K/place and $6K/place/year Nursing Home Beds $8,550,000 $1,453, K/bed and $25.5K/bed/year Substitution of NH Beds for CCC Beds Reduce 165 CCC $200/day and replace -$8,500,000 with 143 NH $70/day Substitution of in-home for inpatient palliative care in Thunder Bay 27 converted to 27 long-term -$1,200,000 home care $70/day Creation of District Governance & Management Reduction of 3 administrative positions per site in -$1,440,000 new multi-hospital Districts APP for Specialists and Subspecialists. $3,300, $300K ICT Initiatives Enhancement to Telemedicine $0 $0 Included in mandate of North Network Based on communication from TBRHSC and Electronic Hospital Record $28,000,000 $3,300,000 Northern Ontario Blueprint Based on communication from TBRHSC and Electronic Health Record $19,000,000 $2,200,000 Northern Ontario Blueprint Total Net Costs of Restructuring $162,400,000 $4,082,363 Potential Private Sector Financing of LTC Places $50,400,000 Net Cost to MOHLTC and Local Communities $112,000,000 $4,082,363 HayGroup 83

87 Integrated Service Plan for Northwestern Ontario Appendix A: Summary of Consultation Process in North West Ontario and Thunder Bay HayGroup

88 Summary of Consultation Process in North West Ontario and Thunder Bay 1

89 Contents Overview of Process Population Need Unmet needs Issues of access to care Opportunities for Change Roles Role of Regional Centre Role of Hospitals in Smaller Communities Roles of Other Providers 2

90 Overview of Consultation Process Objective for consultation: To obtain qualitative information from providers and community members that will inform the: Assessment of Unmet Need Assessment of Issues in Access to Services Identification of potential improvements in organization and delivery of services Identification of enablers for change Approached consultation through Visiting communities and talking to existing groupings and open meetings for public input Mix of individual interviews, group meetings, site visits 3

91 Overview of Consultation Process Process involved: Initial interviews with key informants to develop meeting/focus group discussion guide Distribution of discussion guide prior to meetings with option to respond by of fax if invitee was unable to attend at scheduled time. Opportunity for input through DHC web site Participation in each community was flexible but generally included the following: Hospital CEO and Board Chair Municipal representative(s) Physicians Mental health and addictions providers Long term care providers Acute care program directors/leaders front-line managers Public sessions in each community 4

92 Overview of Consultation Process Communities that were visited included: Region east of Thunder Bay Nipigon Geraldton Terrace Bay (Schrieber) Marathon Manitouwadge Thunder Bay TBRHSC, SJCG Region west of Thunder Bay Fort Frances Atikokan Dryden Kenora Sioux Lookout Red Lake Sandy Lake Fort Hope 5

93 Overview of Consultation Process Very broad inclusive consultation process Mr. Closson held meetings across the region in September 2004 and written submissions were provided. More than 500 people participated in the consultation process in October and November of 2004 Following the initial consultation process in October and November of 2004, additional meetings were held in February and March particularly with individual physicians/providers and with the Medical Staff Association of Thunder Bay Visits to fly-in first nations communities were to Sandy Lake and Fort Hope were done in December 2004 There still may be some perspectives that not enough opportunity was provided for input. This feedback provides some of the foundational information for the project 6

94 Overview of Consultation Process Written Submissions Feedback was also received through written submissions in addition to the face to face meetings. A total of 63 written submissions were analyzed. The main problems or themes identified in the submissions were: Wait lists; Bed utilization; Regional responsibility and role; Overcrowded emergency department; Recruitment and retention of health care workers; Leadership at Thunder Bay Regional Health Sciences Centre. 7

95 Overview of Consultation Process Participant summary by category Other Admin Directors/M anagers MH & Addictions Participant summary by community Municipal reps Public meeting CEO/ Board CNO/DON Physicians LTC Other TOTAL Subtotal East of Thunder Bay Subtotal West of Thunder Bay Subtotal Thunder Bay TOTAL Number of Community participants Manitouwadge 21 Marathon 25 Terrace Bay/Schreiber 100 Geraldton 30 Nipigon 24 East of Thunder Bay Subtotal 200 Thunder Bay 159 Thunder Bay Subtotal 159 Atikokan 24 Fort Frances 29 Dryden 20 Kenora 28 Sioux Lookout 28 Red Lake 19 Sandy Lake/Ft. Hope 15 West of Thunder Bay Subtotal 163 TOTAL 522 8

96 Presentation of Findings Findings presented by sub-area East of Thunder Bay West of Thunder Bay Thunder Bay Findings specific for remote communities Key themes identified Participant perspectives on: Unmet needs Issues of access Key opportunities for change Roles 9

97 Presentation of Findings All of the sub-areas identified geography as overarching all of their issues and impacting potential solutions Vastness of region Distances to travel for services Weather related barriers to traveling for services Growing isolation of communities with decreasing access to transportation Large number of communities which are not accessible by road Travel costs for families and patients exceed any grants provided and are not sufficient to meet challenges of receiving services so far away from home perceived inequities between what people in south get to travel to Thunder Bay for services and what people in the North West get to travel to the south for services. 10

98 Population Need Unmet Needs Issues of Access 11

99 Sub-area East of Thunder Bay 12

100 Unmet Needs East of Thunder Bay Clients with alcohol/drug addiction with need for their counselor to help they stay healthy having significant difficulties. Mental Health and Addiction Services not adequate to meet the needs of the population Community mental health services very stretched Resources insufficient to deal with case loads Fragmentation of services Current labor dispute causing significant care issues and risk for clients and families Stories of uncoordinated care, different diagnoses and/or different medications depending on what traveling psychiatrist sees patient. Services almost broken down completely Especially for patients with more complex needs Various services trying to do a good job Lack of continuity of care from psychiatrist(s) who fly in from London to provide service; client sees different person each time Can t get access to acute care psychiatrist or inpatient care in urgent situations Issues with Form I patients can t use criticall no system for these patients Lack of psychology expertise Various ministries involved and micro-management issues Insufficient resources for child/ adolescent psychiatry Little/no services for addiction/detox as inpatient or outpatient 13

101 Unmet Needs East of Thunder Bay Some hospitals not successful in RFP process to provide services in home. Staff in communities limited and these nursing staff know these patients and could follow after discharge Care of the elderly in the communities Little/no supportive housing or home care supports to maintain elderly in their homes Behavioral problems in some elderly exceed knowledge/ability of staff in most communities No psycho-geriatric services available These patients often end up in acute care because there is no other place within the system Model of having choice of 3 nursing homes means family member often placed hundreds of kilometers away from home and resources of family High proportion of elderly in these communities Who will not move out of community Who need more support to stay out of acute care Not enough LTC beds in area east of Thunder Bay 14

102 Unmet Needs East of Thunder Bay Wife of a pt with MI who was transfered to Thunder Bay had a colostomy which she could not manage herself. CCAC refused service as she did not meet criteria and she was told she could walk to the hospital to get treatment. Home Care Services for chronic disease processes Current services focus only on acute management Patients often end up back in hospital because appropriate supports are not provided in the home Lack of specialized human resources including: Physician specialties including radiology, psychiatry, neurology, orthopedics, Allied health especially physiotherapy Lack of invasive cardiology services means that patients are transported significant distances for service 15

103 Issues of Access East of Thunder Bay Took 12 hrs. through Criticall because TB was closed for patient with MI to transfer to Sault Ste. Marie, patient put on respirator and died before family could get there. Family in MVA on way to Sault. 74 year old with badly # leg could not get timely access to Thunder Bay, complications, as a result of wait, now will require knee replacement Access to services at TBRHSC for critically ill, trauma, cardiac, obstetrics frequently impossible Perception of poor attitude, lack of responsiveness on the part of TBRHSC Perception that leadership and physicians don t have appreciate the needs of smaller communities Physicians spend hours on the phone including time with criticall to get help for patients Although terminology has been changed, there is deep resentment to the closed to the region position Feeling that calls are made to Thunder Bay only when they can t handle patient in region. Safer and more adequate care could be delivered where there are more skilled staff and back-up. Sense that some people in Thunder Bay think they are called unnecessarily Transfer for secondary care when small community cannot provide service is an issue Lack of coordinated approach to utilization of resources in all of region No service such as criticall for this level of patient or for mental health patients 16

104 Issues of Access East of Thunder Bay Concern re almost losing a mom and baby even though patient was a registered Thunder Bay patient, booked for elective section, early labor, Thunder Bay refused to take patient Open for transfers for only certain specialties still a form of closed to the region Some critical patients still not accepted People believe they are being treated as second class because they/family not accepted for care at TBRHSC People getting in cars and driving to Thunder Bay to the emergency to get treatment and not be refused placing extra burden on ED at Thunder Bay Urgent referrals at least 2 month wait, longer for orthopedics Orthopedic wait reported to be 12 months for initial visit and months following that for surgery 17

105 Issues of Access East of Thunder Bay Pt. Presented with an MI at 0800, transferred to Sudbury at Refused admission to Thunder Bay even though he was booked for angioplasty the next day. Access to timely diagnostics/imaging tests and results in Thunder Bay Long waits for MRI (6-8 months) Timmins is 8 week wait but 8 hour drive each way Have stopped ordering MRIs for orthopedic patients, this just delays them being seen Results reporting unacceptable Wait for weeks and months Sending films to Burlington and get 24 hour turnaround, when it would be weeks from Thunder Bay Working around system sending patients to Duluth 18

106 Issues of Access East of Thunder Bay Patients cannot get cardiac rehabilitation or poststroke rehabilitation. Unmet needs for physio and occupational therapists Thunder Bay unable to fill role of providing education/consultative support to staff in smaller communities to prepare them to provide these services Rehab network just beginning but sub-area has not seen benefit as yet. Chronic disease management Diabetes network is meeting substantial need, difficulty with access to dietician Pilot arthritis project worked but when funding stopped patients have not received adequate care 19

107 Issues of Access East of Thunder Bay Operational Issues Concerns about leadership of TBRHSC Perception of arrogance Perception of lack of communication Lack of understanding of what happens in the region beyond Thunder Bay Non-responsive; not sure people in leadership are listening Uncoordinated efforts in seeing patients from region who have to travel long distance for services in regional centre multiple trips and increased expense for patient and family Requirement to send staff from small hospitals to Thunder Bay a barrier Thunder Bay has no resources/system in place to provide support to these patients Escort costs are creating huge impacts for smaller organizations 20

108 Sub-area West of Thunder Bay 21

109 Unmet Needs West of Thunder Bay Key health status issues that could be addressed through prevention and therapy Diabetes North Network insufficient Lack diabetes education foot care Obesity Vision Support for health units an issue Limited access to physicians/primary care in Dryden and Kenora Too large to be considered for incentives Lack of specialist services Insufficient numbers in Thunder Bay to meet demand 22

110 Unmet Needs West of Thunder Bay Mental health and addiction services for far north communities Especially difficult for anyone with an acute presentation Lack of substance abuse program for youth Very high rates among youth in far north Have to send youth very far from home to access any programs Adolescent committed suicide day of return to his own community after leaving residential school Geriatric Psychiatry a big issues Generally withdrawal services don t exist Lack of adolescent beds Suicide support for youth Among highest rate in country Nothing available in communities to prevent or address concerns Lack of infrastructure and space for service delivery Need safe house for many of these kids don t always require acute care 23

111 Unmet Needs West of Thunder Bay When spouse dies and couple are living in supportive housing unit, the remaining spouse must leave. Long Term Care Generally, not enough long term care beds in the west area of NWO Not able to keep people within reasonable distance of home Need ways to provide care in communities for elders without having to send out to locations where they cannot be cared for/supported by family Beginning to see more First Nations elders on list to be cared for institutionally Limited supportive housing Long waiting lists for very few units Restrictive criteria Need for satellite dialysis 24

112 Unmet Needs West of Thunder Bay Communicable disease a big issue now and for the future Large number of Canada s Tuberculosis population in this sub area Need to determine how we are going to respond Lack of traditional healing approaches or comprehensive services for first nations peoples Very few first nations health care professionals Missing in key areas such as social services, diabetes and nutrition counseling Insufficient, inadequate or refused northern travel subsidies Inequities especially when compared to things such as WSIB grants Patients treated in distant community and then limited/no travel grant to return home 25

113 Unmet Needs West of Thunder Bay Takes a full day to travel (fly) to Sudbury for service for cardiac Specialty services that are significant gap Lack full service cardiac in Thunder Bay Thunder Bay is not a realistic alternative for the western region of NWO as not full service is available there Manitoba is usually the first call makes more sense from travel time and distance Lack of a real vascular service Have had a visiting pediatrician for 30 years from Manitoba and this will be ending with no alternatives in future Lack visiting specialty services 26

114 Issues of Access West of Thunder Bay Patient who was transported to Thunder Bay needed oxygen and couldn t get it Access to CT scan/diagnostics Use of CT scan rapidly becoming standard of care Lack access in busy communities such as Sioux, Dryden People brought to Sioux from northern communities Everyone has to be medevac d out for CT Long wait lists in Thunder Bay for other procedures Unacceptable delays in reports from Thunder Bay Back log in pathology Kenora has offered to assist Thunder Bay but no response or facilitation to make things happen No coordinated scheduling of appointments for patients who have to travel It was reported that Thunder Bay had someone who was looking after this but no one was able to report who this was or how the process worked. Sending facility has to send staff with patient Are very short staffed already Staff can t do anything in Thunder Bay hospital when they are there 27

115 Issues of Access West of Thunder Bay Lack of inpatient mental health beds for area Almost have to put patient on Form I to get people seen Use Kenora from communities in far North Use Winnipeg for special services for child/adolescents Concern re lengthy delay in opening adolescent mental health beds in Thunder Bay Only 1 psychiatrist to service West sub-area Using creative ways to provide services Physical space (inpatient unit) not ideal for patient care and impacts recruitment of physicians 28

116 Issues of Access West of Thunder Bay Long waiting lists for orthopedic services especially joint replacement Claim that waits result in more complications and longer stays when service is finally available Doing joint replacement in Dryden with visiting surgeon from Thunder Bay Doing arthroscopy in Sioux cannot do more without more infrastructure State of hospital buildings in Sioux Lookout a major impediment to meeting needs Especially for traditional healing and culturally sensitive care Impediment to expanding services Multi-site issues impact efficiency Delays in approvals from MoHLTC 29

117 Issues of Access West of Thunder Bay Operational/process barriers Lack of communication from Thunder Bay regarding closed to region Never know when they are going to be closed or open again or why No apparent attempt at contingency planning with other providers in the region When Winnipeg must close, they communicate why and how long they expect and still try to take very emergent patients Concerns about leadership of TBRHSC Perception of arrogance Perception of lack of communication Lack of understanding of what happens in the region beyond Thunder Bay Non-responsive; not sure people in leadership are listening 30

118 Issues of Access West of Thunder Bay 8 months of patient being referred from one doctor to another and one test to another. Biopsy test results took over 2 months for results of breast cancer. It appears surgeon in Thunder Bay will consult only on initial visit and patient will have another delay before cancer can be removed. Unable to have things done on same visit. Operational/process barriers No coordination for visits of patients from smaller/northern communities Very difficult and costly for patients No review of urgent referrals in DI before patient leaves department Thunder Bay does not seem to recognize clinical limitations in smaller communities Transfer issues Transfer of care back to local MDs without adequate communication, delays in getting specialist discharge summaries and follow-up advice TBRHSC often refuses to take on follow-up of patient who has been treated elsewhere and is being returned to region Need for staff to accompany patient to TBRHSC when smaller communities don t have resources a significant issue 31

119 Issues of Access West of Thunder Bay Operational/process barriers Diagnostic Imaging Regional PACS slow; currently working on increasing local storage Issues with payment for imaging Charges for CT in Kenora Medevac inconsistent Communication frequently mentioned as an issue Coordination of medical supplies Even when a stabilized patient and an accepting physician, there are delays in approval and the need to take an extensive history before plane sent Communication with base in Toronto seen as difficult Don t appear to be concerned about issues of the North 32

120 Issues of Access West of Thunder Bay Small communities, First Nations reserves, and Thunder Bay are all like separate regions trying to work within one large region Turf protection Issue for Kenora is that access to Winnipeg is 2 hours by a good road and access to Thunder Bay is 5 hours by mostly poor roads Concern in this process that hospital will be forced to partner with Thunder Bay at the expense of providing more appropriate service for patients Signs that Manitoba may be less available in the future causing concerns 33

121 Summary of Feedback to Remote Communities Sandy Lake and Fort Hope 34

122 Remote Community Visits Most Pressing Health Needs Diabetes Alcohol and Drug Abuse Dental Hygiene Trauma Social issues such as housing and education. Evidence that populations have been adversely affected by lack of access to health services. Councils are not aware of any specific data sources. Disease rates are acknowledged to be high (e.g., diabetes). The reserves are isolated and there is a lack of access to physician services and other services. The bands are not specifically aware of the extent to which the differential access affects health. Most of the information available first hand appears to be anecdotal. 35

123 Remote Community Visits 5 most significant health issues with respect to access Lack of predictability with respect to which hospital patients will be sent if they require health services off reserve. Physician services, secondary and tertiary Mental health services Culturally sensitive services off reserve Diagnostic services 36

124 Remote Community Visits Solutions that are achievable and sustainable The bands did not generally regard themselves as disadvantaged with respect to access to health care. There was recognition that the reserves are isolated and on that basis, access will remain a challenge. The key concerns were around funding to ensure access and cultural sensitivity with respect to services provided by TBRHSC. The band councils seemed to be frustrated with addressing issues of cultural sensitivity, although they felt that it should be possible to achieve meaningful solutions through discussion with board, management and staff at TBRHSC. 37

125 Remote Community Visits What is working well? Locally delivered health services (on reserve). Access to secondary services off reserve (acute care) What would a strong system in the north look like? Predictable access Services off reserve acknowledge aboriginal cultural issues. Clarification of funding issues Affordable support for patients and families who get care off reserve. 38

126 Remote Community Visits What would the role of the regional centre? No different than now, but attuned to cultural issues that are unique to aboriginals. What would be the role of the health centre be in your community? To provide primary care resources to the local community. To provide a broad range of services that includes acute care and community programs. What could hospitals in the region do to support the needs in the region? Consider improving access to physician services through use of telemedicine infrastructure. 39

127 Thunder Bay Area 40

128 Unmet Needs Thunder Bay Lack of family physicians is very acute Major orphan patient problem in Thunder Bay with 30-40,000 patient who do not have a family doctor Family doctors are going to smaller communities because of AFAs Lack of primary care in Thunder Bay impacting whole system Public Health unit in Thunder Bay does a lot more clinical work than other typical units because of this problem Lack of specialists Areas of acute shortage include orthopedics (to meet demand), vascular surgery, ENT, plastic surgery, urology, neurology, gastroenterology, rheumatology Gaps in general internal medicine in Thunder Bay and region Access to cardiac surgery in other regions Proposal prepared and submitted to be included with this review and plan 41

129 Unmet Needs Thunder Bay Mental health and addictions mentioned most frequently as area of most need Acute shortage in psychiatry Crisis atmosphere in Thunder Bay 1 psychiatrist to manage 24 bed inpatient unit at TBRHSC, takes most of call, clearly inadequate services Virtually no services to broader region Number and content of work of psychiatrists at LPH raised as concern/opportunity Adolescent psychiatry Beds built and waiting to be staffed capital approval but no operating approval Wait for approval from MoHLTC has been very lengthy Lack of behavioral management beds of significant concern ABI, psycho-geriatrics 42

130 Unmet Needs Thunder Bay Gaps in services for physiotherapy, occupational therapy, speech/language services, social work, hospital pharmacists Home care is insufficient Can t meet chronic needs Patients often have to pay and not financially able TBRHSC expanded its clinic to meet the need when the CCAC reduced services for dressing changes Hospital has been trying to respond when community services have an impact on inpatient stay Home IV meds Insufficient hostel or longer term housing for people who need to stay in Thunder Bay for longer term assessment/ treatment 43

131 Unmet Needs Thunder Bay Lack of supportive housing and home care resources to support elders in their home Results in people in LTC who should be in home ALC patients waiting in system and impacting acute care Lack of prevention services especially for aboriginal populations Early screening assessment Timely intervention Transportation to and from hospital in Thunder Bay Particularly for regular visits such as dialysis 44

132 Issues of Access Thunder Bay Patients who have been at the hospital and missed appointment because they couldn t find way or didn t understand instruction and told they had to rebook appointments Inadequate supports/access to services for First Nations people Lack of translation services at TBRHSC even after many requests Culturally sensitive support services for long term patients are often lacking to help with transition from rural to urban living Few aboriginal staff or volunteers No Traditional Healer 45

133 Issues of Access Thunder Bay Abnormal patient results were sent to wrong physician. Patient continued with complaints and with follow-up family physician discovered abnormal result from 6 months earlier. Outcome may not have been different but patient died from cancer. Patient admitted to a physician without admitting privileges days before problem resolved Issues for some Family Physicians in access to TBRHSC Feeling undervalued by hospital with such demand on time easier to give up hospital work Reflects similar issues across health system with disenfranchisement of family physicians in last 15 years Communication between hospital and family physicians is problematic Test results not communicated Patients admitted to wrong physicians General lack of ability to access specialist services in a timely fashion either related to workload or no specialist available Inability to get assessments soon enough Specialists often repeat work-up of physicians in smaller communities Perception that specialists expect people can come back next week with no sensitivity to the challenges of getting to Thunder Bay for care. 46

134 Issues of Access Thunder Bay ALC issues have not been dealt with Results in many problems for the acute care hospital and impacts the broader region TBRHSC has been labeled as the problem as they are the front door ALC and LTC issues are really in community and at SJGC TBR has responded by opening beds at another site Perception that SJGC should be more actively involved in addressing this issue e.g. opening additional beds at one of their sites 47

135 Issues of Access Thunder Bay Diagnostic Imaging Long waits for test Poor results reporting/turnaround Steps taken recently to improve but impact not seen yet Perception of insufficient inpatient bed resources and OR time at TBRHSC System bed issues need to be resolved Many of the issues beyond the control of TBRHSC SJGC needs to respond with more urgency to ALC needs New building at TBRHSC Issues with disabled access Poor signage and way-finding reported 48

136 Issues of Access Thunder Bay Patient discharged from day surgery earlier than expected. Hospital provided a taxi home staff went the extra mile Staff brought reading material from home for patient when nothing was available Operational/process issues Mixed perception re commitment of staff in delivery of care perception that staff are overworked Relationship with physician groups and leadership at TBRHSC not collegial for the most part Perceived inequities in the way that individual and groups of physicians are treated Physicians generally feeling dis-empowered and fatigued in efforts to make things work Communication with physician groups appears to have been poor, not meeting need or threatening in nature Sense that organization is not willing to be responsive to regional concerns Concerns re leadership at TBRHSC Perceptions of lack of responsiveness, communication and interpersonal relationship styles Lack of visibility Poor communication Concerns re lack of responsibility and accountability 49

137 Opportunities for Change What s working well 50

138 What s working well Stories of excellent support to satellite chemo stations; telephone access to specialists for consultation Approach to cancer care in the region Prevention and screening Outreach to communities Expert support available to smaller communities Model that works well in the North. Increased use of telehealth KNet and North Network Especially for psychiatric support, but significant amount more is needed Follow-up consultation with patients in remote communities capacity is expanding Services where there has been collaboration between organizations (even with problems in implementation and low trust levels) Laboratories Imaging Electronic Health Record 51

139 What s working well North West Health Network Hospitals, CHCs, CCAC, DHC, 2 public health units Improved connectivity and communication with telehealth Network of hospitals East of Thunder Bay Working on shared services 52

140 Opportunities for Change 53

141 Opportunities for Change Creation of a true regional structure with appropriate responsibility Will reduce conflict between trying to run hospital and trying to run a region Resources to run the region needs a different perspective Time devoted to regional responsibility Regional Medical and Health Human Resources Manpower Plan Reduce competition among providers in sub-areas Create an AFA for Region Utilization of Nurse Practitioners to meet needs for primary care Create under-serviced area for Thunder Bay to attract family physicians Similar situation for Dryden and Kenora but to a lesser extent 54

142 Opportunities for Change Some reports of physicians giving up on a transfer since they find it difficult to, for example, cover the ER while also trying to provide all the necessary information to criticall or a colleague to get a patient out - and they don't necessarily know where the best / closest transfer point with appropriate available services would be. Improved bed utilization across region Reduce ALC pressures on TBRHSC SJGC take more responsibility for solving ALC pressures Use of capacity in smaller hospitals to reduce ALC pressures Create a transfer service to facilitate secondary level care would know what services are available in what communities and also have a sense of where beds might be available Change in attitude/response of regional centre Review of leadership team competencies Ombudsman/Senior leader with responsibility for facilitating regional centre s response to patient needs in the region More culturally sensitive services available in the regional centre Processes & policies that are focused on facilitating access to regional centre as opposed to restricting access to centre 55

143 Opportunities for Change Increase in capability and capacity in subareas to provide a greater range of services and relieve pressures on the regional centre Role for sub-centre in west area Increase in visiting specialists/clinics to smaller communities Service closer to home Improved assessment Reduction in travel expenses for system as whole 56

144 Opportunities for Change Overall coordinated approach for management of mental health needs in the region Mental Health Authority Appropriate utilization of resources Reduced number of ministries involved Reduced micro-management by people in the south Disease management models like cancer care Applied to diabetes, dialysis Coordination along disease lines Increase in outreach and tele-health management from regional centre or centres of excellence Improvement in travel reimbursement and housing for people traveling to regional centre and/or sub-areas 57

145 Opportunities for Change Increase in use of tele-health (Knet, North Network) Haven t yet used up current capacity Support of local businesses Trained tele-health coordinators from communities to support the technical aspect of work and allow health practitioners to focus on their primary job More involvement of practitioners outside north west to support specialties/consultation Increased investment to speed up/support implementation of technological solutions CT Scan capability in sub areas (e.g. Sioux Lookout and/or Dryden) PACS Electronic record Hardware and software investments 58

146 Roles 59

147 Roles Role of Regional Centre Meeting the higher more acute level needs of the region Providing specialized services to smaller hospitals Leadership in standards and education to enhance capability of smaller hospitals Open to the region 24/7 most of the time Supporting the smaller hospitals to accept back patients Understanding limitations of smaller communities Formal arrangement with Manitoba for Winnipeg to act as regional referral centre for patients in west end of region 60

148 Roles Role of hospitals in smaller communities Leadership role in responding to health status indicators Primary care and secondary care with disease management models Capability to manage within community with support from regional centre Requires increase in infrastructure for some centres Providing support to regional centre with respect to areas such as: Additional capacity for appropriate OR services with visiting surgeon Cultural education/support for First Nations care and service delivery Temporary support for ALC issues 61

149 Roles Roles of other providers Support of patients/clients in the community to stay in community or home Coordination with other sectors in health system 62

150 Integrated Service Plan for Northwestern Ontario Appendix B: Summary of Submissions HayGroup

151 Summary of Submissions to Tom Closson Special Advisor to the Minister of Health and Long-Term Care on A Regional Service Plan for Northwestern Ontario/Role Study for Thunder Bay Regional Health Sciences Centre Prepared by: Northwestern Ontario District Health Council March 29, 2005