A Systems Model to Meet the Needs of Adults Living with Chronic Mechanical Ventilation Needs Phase 2. April 24, 2014

Transcription

1 A Systems Model to Meet the Needs of Adults Living with Chronic Mechanical Ventilation Needs Phase 2 April 24, 2014

2 Overview Background Phase 1: Setting the Stage Phase 2: Accomplishments Phase 3: Recommendations Acknowledgements Appendices References

3 1. Who are the people who are living with chronic mechanical ventilation needs? Jim s Journey 2. What is chronic mechanical ventilation (CMV)? 3. Alignment with: Access to Care Background South West LHIN IHSP Support from the South West LHIN Investments between 2009 and Description of Phases 1, 2 and 3 3

4 Background Who are the people? The people who live with chronic mechanical ventilation needs are adults: who have slow progressive neuromuscular genetic disorders from childhood with conditions causing diaphragm weakness, chest wall restriction, or abnormal breathing control that result in chronic respiratory failure of a variable, slow, or nonprogressive nature such as myotonic dystrophy or kyphoscoliosis who acquire a rapidly progressive neuromuscular disease such as Amyotropic Lateral Sclerosis (ALS) who experience an acute illness or traumatic event Their health is compromised in other ways with many living with physical disabilities, developmental delays, and communications issues. While chronic mechanical ventilation is a life supporting service, it is usually not the only health related issue with which these people are living. 4

5 Who are the people? Perspectives from Jim and his family Jim experienced many transitions throughout his care journey. He is now living in his own home with chronic mechanical ventilation needs. In December 2013, Jim and his family consented to telling their story in order to help others learn about what is important for patients when looking for change in the health care system. 5

6 Jim s Journey Date of Surgery July 29, 2012 Venue Support Date Days in Venue CSRU IV July 29, EICU IV August 7, September 5, Home NIV EICU IV October 5, Parkwood CCC IV January 9, EICU IV May 13, Tillsonburg CCC IV May 21, Home IV October 26, April 23, 2014 IV = invasive ventilation NIV = Noninvasive ventilation CSRU = Cardiac Surgery Recovery Unit (UH) EICU = Extended ICU (UH) CCC = Complex Contiuing Care 6

7 Jim s Journey 1 (Interview with Jim and family) Emotions Transition Description July 2012 LHSC Bypass Surgery, ICU couldn t breathe very well so they tried putting him on a BiPAP first. Like, when he had his surgery his diaphragm collapsed and his vocal cords are weak (Carol, Jim s wife) It was really hard (travel for family, Jim couldn t see outside) we [family] were welcome in the ICU It took a while [to get here ] (Jim) Home with BiPAP for 3 ½ weeks October 2012 Outpatient clinic LHSC University until January 2013 couldn t breathe, couldn t swallow and I had to go back for the trach (Jim) Dr. didn t like the way he was breathing they put the trach in (Carol) It took a while [to move to Parkwood] (Jim) Parkwood until end of April

8 Jim s Journey 2 (Interview with Jim and family) Emotions Transition Description LHSC (University Hospital) for 2 weeks when he got the vent for Tillsonburg changed the size of the trach because he had a 7 and he was having a lot of trouble (Carol) well, I wanted to come back (Jim) felt prepared (Jim) got to adjust to people around you (Jim) scared at first (Carol) May 2013 Tillsonburg Hospital October 2013 Home with mechanical ventilation at night I think I could have come straight home [rather than come to Tillsonburg], you know with the support I ve got but there was nobody trained in the community (Jim) we ve got the vent and then the suction machine and then we have the CCAC the nurses come in at night (Carol) I was scared (Carol) Tillsonburg Emerg. I cleaned it and everything, but it plugged right up couldn t get a catheter in, so right away we phoned the ambulance (Carol) yeah, some downs, yeah. It seems alright, I don t worry (Carol) Home with mechanical ventilation at night Yeah, he looked really depressed there [in Christmas time picture while in hospital], but now you see he is a lot happier. (Carol) 8

9 Background What is Chronic Mechanical Ventilation? Mechanical ventilation is a method to mechanically assist or replace spontaneous breathing. This involves a machine called a ventilator. There are two main types of mechanical ventilation: invasive ventilation and non-invasive ventilation. Chronic Mechanical Ventilation (CMV) includes the following: Prolonged Mechanical Ventilation (PMV) - The actual or anticipated need for mechanical ventilation (invasive or noninvasive; 12 hours per day) in a critical care unit for 21 days or longer. Long-Term Mechanical Ventilation (LTMV) - The actual or anticipated need for any mechanical ventilation (invasive or noninvasive; nocturnal only or continuous) beyond the critical care unit for survival or quality of life. Delivery of air from a ventilator may be either through a mask firmly held to the face, or through a tube inserted into the trachea toward the bottom of the throat. A mask is called non-invasive ventilation, while a tracheostomy tube is called invasive ventilation. 9

10 Background Alignment with Access to Care Access to Care is an approach to care focused on supporting people, specifically seniors and adults with complex needs, in their homes for as long as possible, with community supports. Phase 1 Report regarding Adults Living with CMV recommended a model of care to transition and support these individuals with complex needs to live at home. 10

11 Background Alignment with South West Integrated Health Services Plan Within the Current IHSP, one of the actions listed is to: Implement redesign recommendations to improve access to Assisted Living, Supportive Housing, Adult Day Programs, Complex Continuing Care and Rehabilitation beds to obtain the right service at the right time by the right provider With the long term outcome being to: Increase access to community supports so people can leave hospital to live safely and independently in their homes (7100 more days at home instead of in hospital) Implementation of the vision and recommendations for a systems model of care for adults living with CMV needs will contribute to this outcome. 11

12 Background Funding Support from the South West LHIN for Adults Living with Chronic Mechanical Ventilation Needs In the last number of years, the South West LHIN has targeted funding to specific Health Service Providers to improve services for individuals living with Chronic Mechanical Ventilation needs including the following: London Health Sciences Centre $125K one time funds to LHSC for planning for the chronic mechanical ventilation population (Dec 2009) Participation House $250K annually to increase access to supportive housing, $10K one time for staff training (Dec 2012) St. Joseph s Health Care, London $76,844 annually to convert 1 Complex Continuing Care bed to a Long-Term Ventilation bed and to support Registered Respiratory Therapist (RT) outreach services to clients living at Participation House, $17K one time funding for ventilator equipment (Dec 2012) South West CCAC $92,375 in one time funds to have clients receive RT support in their homes (Dec 2013) 12

13 Background Description of Phases of Work to Support Adults Living with Chronic Mechanical Ventilation needs in the South West LHIN Phase 1 Completed Fall of 2013 An agreed upon vision and guiding principles A Transitions Model to guide system and individual care planning Determination of Patient Volume Projections Phase 2 October 2013 to May 2014 Development of an implementation plan for recommendations in the 2013 report Development of methodology to capture planning information to ensure resource needs are understood Phase 3 Future Work Plan Recommendations to complete implementation of a systems model to support adults living with CMV in the South West 13

14 Phase 1: A Systems Model to Support the Needs of Adults Living with Chronic Mechanical Ventilation Needs in the South West LHIN The model of care was developed over the 2012/13 and 2013/14 fiscal year by the Planning Group with direction and oversight of the Steering Committee and a full description can be found in the following report: 0Commitment%20to%20Excellence%20and%20Partnerships%20FINAL%20-%20Nov% pdf The Vision To create a coordinated and integrated system of health and supportive care services for Adults living with CMV needs that: Provides safe, high quality standards-based care Supports people to live in the most appropriate, least restrictive setting possible Supports individuals/families/loved ones through transitions of life Is responsive, adaptable and able to reflect changing needs, and Applies best practices 14

15 Phase 1: Guiding Principles 1. Providers work together to provide an integrated system of health and supportive care 2. The system of services is responsive, adaptable and innovative 3. High quality consistent standards of care are provided regardless of the setting or service 4. Transitions are planned and executed in a coordinated manner 5. People are supported to live at home whenever possible 6. Families are partners 7. Transition to Home is supported by: Acute Care for: Medical stabilization Specialized ventilator care to transition out of hospital Specialized scheduled outpatient care to support community living Complex Continuing Care for: Regular physician care and specialized staff intervention Home for: Specialized professional support 8. Technology is leveraged to provide a high quality of life 15

16 2013 Transitions Working Model 16

17 2013 Transitions Working Model 17

18 Data Element Non- Invasive Invasive Comments Current volume Based on UH volumes (invasive) and UH and VH volumes (non-invasive) Annual new cases Based on UH data (invasive) and UH data (non-invasive) Increased annual new cases Annual death rate/100 persons Reduced annual death rate/100 persons Annual population growth Patient Volume Projections (Calculations by Carol Mulder, SW LHIN, for the CMV Steering Committee, Fall 2013) 48 0 Based on clinical judgment and knowledge of program operations Non-invasive death rate was based on expected life span of 5 years (i.e. 20%/year for 5 years) Arbitrarily reduced death rate for calculation of contingency projections to estimate impact of error in death rate estimates 1% 1% Based on Ministry of Finance estimates 18

19 (Calculations by Carol Mulder, SW LHIN, for the CMV Steering Committee, Fall 2013) 19

20 (Calculations by Carol Mulder, SW LHIN, for the CMV Steering Committee, Fall 2013) 20

21 Phase 1 Patient Volume Projection Conclusion The data in the previous two graphs is presented to provide some sense of the cumulative impact on health care system resources. However, as the gap between the projections based on differing assumptions about new recruitment and death rates show, it is difficult to predict with certainty the precise volumes over a long term. In addition, there are a wide variety of reasons that cause people to become dependent on mechanical ventilation and affect their survival rates once they become dependent. This is particularly true for non-invasive ventilation; the patterns for invasive patient volumes appear to be more stable. 21

22 The purpose of Phase 2 work was to position the many recommendations outlined in the Phase 1 report, to implementation. Phase 2 work is presented here in the following categories: Timelines Administrative Oversight Patient Experience Clinical Metrics Business Case and Monitoring Coordinated Access Funding Options Phase 2

23 General Schedule/ Report/ATC Adults Living with CMV Oversight Structure RT and Other Professional Work Group Adults Living with Chronic Mechanical Vent Phase 2 Timelines Q3 13/14 Translate recs into work plan Jan 2014 Submit rept to LHIN Board Feb 2014 Mar 2014 Apr 2014 May 2014 Jun 2014 Establish recs for how Impl. Plan Summarize funding for equip CCC will serve those with CMV & Service Gap to ATC Core Ops Draft Terms of Reference for CMV Oversight Structure and CMV Management Group Organize clinical standards manual electronically for posting on LHSC website Approve accountability Framework, TOR; Recruit members for CMV Oversight Structure and CMV Management Group July 2014 Post clinical standards manual on LHSC website; define CCAC-based Community RT role, including LTC Homes (pending CCAC RFP process) Aug 2014 Sept 2014 Inaugural meetings of CMV Oversight Structure and CMV Management Group Notes/ Comments CMV Oversight Committee to include patients/families; Need to determine what reporting structure will have to the LHIN and accountability (e.g. H-SAA, M-SAA) Metrics Work Group Transition Team Select indicators and determine data sources for monitoring and determining need; draft metrics for monitoring performance Draft process and documentation for team Draft metrics report to ATC Core Ops Finalize process/doc; Determine how to maintain master contact list Implement process and documentation Participation House Create current process maps for SALH, day program, and respite Establish plan for future planning and establish process map Evaluate need and apply for Priorities for Investment, if appropriate Transitional Respiratory Care Unit Work Group CCAC Parkwood RT Outreach Fully implement coordinated access for AL, ADP, Respite for MFTD at PH Complete Parkwood RT Evaluation This work is embedded in Level 2 Bed Strategy for LHSC project timelines TBD Award Contract Fully implement coordinated access for CCC/Rehab to Community RT Operationalize Community RT, Impl. cough assist training Provider for Community PTs, establish referral protocols to CCAC Define future role and direction of Parkwood Outreach Service in supporting those with CMV Adults living with CMV have been established as group for CCAC Complex and Chronic Care Teams; training imbedded in internal CCAC project charter timing TBD Develop process/screening tool for referring to CCAC timing TBD Respite in LTCH previously implemented; overnight respite at ADPs accessed via ADP provider Critical Care Network Confirmed as lead for establishing partnerships and disseminating CCSO Toolkit Confirm GBHS/LHSC Leadership and Level 3 ICU support of those in their communities; Schedule education and planning day with CCSO Timing for CCSO Long Term Mechanical Vent Toolkit webinar TBD SW LHIN Hospice and Palliative Network Facilitate OTN presentation re: Consent, Capacity and Care Planning Include CMV in Adoption of proactive palliative and end-of-life strategies, including Speak Up dissemination Long Term Care Council Survey LTCHs re: current and historical service for those living with CMV Identify LTCHs to serve those living with CMV Need to ensure that appropriate supports are in place to support Creation Date: Feb 7/14 Revision date: Apr 9/14 LEGEND: = task complete = task not complete 23

24 Adults Living with Chronic Mechanical Ventilation Phase 2 Administrative Oversight for Implementation Planning South West LHIN Adults living with CMV Implementation Planning Steering Committee Area Provider Tables/ Geographical Teams Parkwood RT Outreach Evaluation SW LHIN Hospice Palliative Care Network Critical Care Network Adults living with CMV Planning Group ATC-CCC/Rehab Multi- Community Working Group CCAC LTC Home Network Council RT and Other Professionals Working Group Metrics Working Group Transition Team Working Group Participation House Working Group Transitional Care Unit Working Group = existing group with links to CMV = temporary group, in place for Planning Phase (Phase 2) only = group will transition as move into Phase 3, implementation and sustainability Created: November/13 Last updated: April 13/14 24

25 Adults Living with Chronic Mechanical Ventilation Oversight Structure 2013/14 Team Members Adults Living with CMV Implementation Planning Steering Committee Judy Kojlak, Director, Critical Care, Trauma & Patient Access, LHSC; Elaine Gibson, Vice President, Complex, Specialty Aging and Rehabilitative Care, St. Joseph s - Parkwood Hospital & Mount Hope; Brian Dunne, Executive Director, Participation House Support Services; Donna Ladouceur, Senior Director, Client Services, South West CCAC; Lois Beamish-Taylor, Senior Director, Performance Management and Accountability, South West CCAC; Carrie Jeffreys, System Design & Integration Lead, South West LHIN; Mark Landy, Director, Medicine and Oncology at Grey Bruce Health Services; Brian Orr, Vice President, Participation House Board Adults Living with CMV Implementation Planning Group Asha Rawal, Social Worker, ICU, LHSC; Brian Dunne, Executive Director, Participation House Support Services ; Carmell Tait, Chief Operating Officer, Participation House Support Services ; Carrie Jeffreys, System Design & Integration Lead, South West LHIN; Cathy Mawdsley, Clinical Nurse Specialist LHSC; Danielle Heibein, Nurse Practitioner Pediatrics, Pediatric Complex & Intermediate Care, Pediatric Cardiology, Children s Hospital; Dr. David Leasa, Respirologist, LHSC; Erin Fleischer, Pediatric NP with Respirology at Children s Hospital; Jane Wheildon, Manager of Critical Care, Respiratory Therapy and Dialysis, Grey Bruce Health Services; Joanne Smith, Registered Respiratory Therapist, LHSC; Lindsey Declercq, Health Data and Performance Analyst, South West LHIN; Lisa Gardner, Integrated VP/CNE for TDMH (Tillsonburg District Memorial Hospital) and AHI (Alexandra Hospital, Ingersoll); Lisa Malbrecht, Director, Complex Care, St. Joseph s Parkwood Hospital; Margo Collver, AL/SH/ADP Co-Lead, Access to Care; Mary Jo Dunlop, Cheshire Homes South West LHIN Access to Care Assisted Living Special Populations; Megan Nichols, Regional Quality Manager, South West CCAC; Michele Pegg, AL/SH/ADP Co-Lead, Access to Care; Michelle Vermeeren, General Manager, Village of Glendale Crossing, Schlegel Villages; Sherry Fletcher, Regional Client Services Manager, South West CCAC; Shirley Koch, AL/SH/ADP Co-Lead, Access to Care; Corresponding member: Dr. Marc Newton, Respirologist, Grey Bruce Health Services RT & Other Professionals Working Group Led by Joanne Smith (LHSC) Metrics Working Group Led by Lindsey Declercq (SW LHIN) and Martin Bauwens (SW CCAC) Transition Team Working Group Led by Cathy Mawdsley (LHSC) Participation House Working Group Led by Carmell Tait (Participation House) Transitional Care Unit Working Group Led by Dr. David Leasa (LHSC) Parkwood RT Outreach Evaluation Key contact is Lisa Malbrecht (St. Joseph s) Critical Care Network Key contact is Carrie Jeffreys (SW LHIN) CCAC Key contact is Megan Nichols (SW CCAC) SW LHIN Hospice Palliative Care Network Key contact is Patrick Shanahan (SW CCAC) ATC-CCC/Rehab Multi-Community Working Group Key contact is Elaine Gibson (St. Joseph s) LTC Council Key contact is Anita Cole (SW CCAC) Staff Support: Amber Alpaugh-Bishop, Project Manager, Access to Care; Steve Elson, Regional Integration Specialist, LHSC & St. Joseph s; Sue McCutcheon, Project Lead, Access to Care; Wendy Benson, Executive Assistant, Access to Care 25

26 Phase 2 Administrative Oversight for Implementation Planning Role of Planning Committee and Implementation Planning Steering Committee Adults Living with CMV Planning Committee Development of the draft implementation plan Detail of the work to be done Determination of who would be best to do the work Drafting of timelines for completion of the work Oversight of Working Groups who developed the detailed implementation plan and begin implementation (December 2013-June 2014) Adults Living with CMV Implementation Planning Steering Committee Review and endorsement of the implementation plan to go forward to Access to Care Core Operations Review and advice on further opportunities to develop measurement and evaluation strategies 26

27 Phase 2 Administrative Oversight for Implementation Planning Leveraging Existing Groups for Implementation Planning The following groups who are in existence were asked to participate in detailing the work plan and implementation of the model of care: South West Critical Care Network South West LHIN Hospice and Palliative Care LTC Council St. Joseph s Health Care Parkwood Access to Care Complex Continuing Care/Rehab Steering Committee Access to Care Assisted Living/Supportive Housing and Adult Day Program Steering Committee (Coordinated Access implementation) The work that organizations across the South West were implementing to change care for this population was also leveraged. 27

28 Phase 2 Patient Experience 1. Administrative Structure committed to recruit individuals and their families to be part of ongoing implementation 2. James Triska and his family were interviewed to build understanding of the experience of transition for individuals living with chronic mechanical ventilation needs The questions used were consistent with other experience based design work within Access to Care. These questions came as a result of consultation with Dr. Carol McWilliam and are as follows: Tell me about yourself and what happened to you What helps you to live your life? What obstacles are most challenging to you? What supports are most important to you? What is the most important message you want to share? The interview was audio recorded and transcribed. Two team members listened to or read the transcript to ensure all aspects of the story were captured. 28

29 Phase 2 Perspectives from Jim and his family he came home on Thursday, then on Friday, our grandson; he was coming and he says, Dad, I d like a fresh baked apple pie and Grey [Jim s son] was telling his dad, so he said, maybe I got apples here, maybe I ll make him one so Jim hadn t saw him in a long time, so he s 10, so he went and made him an apple pie. So, Julian [grandson] was tickled to death over it that Grandpa could make him a pie - Jim s wife 29

30 Phase 2 Perspectives from Jim and his family Getting and giving help are both important they got him all set in a routine and if I have to work a whole day, they [home care] come and do the breathe stacking (Carol, Jim s wife) because Tillsonburg never dealt with anything like that before either so, once they got there, Jim more or less taught them, because they just saw the video and they had a little bit of training... (Carol) In the hospital, I had to train all my nurses in Tillsonburg (Jim) 30

31 Phase 2 Perspectives from Jim and his family Independence to go places I can go anyplace I want to go I can drive too (Jim) to the horses and the farm shopping too (Carol) it was hard on Jim, you know he couldn t come home at all because he was in ICU and, you know, you don t see out (Carol) Privacy It is our home Pretty good, they have been letting us know what time. They phone ahead Except the first day when what's her name came out we did not know she was coming and she just walks into our house but otherwise, they ve been really, really [good] (Jim, his wife and son) 31

32 Phase 2 Perspectives from Jim and his family Staying in touch The only thing I found, in London, I couldn t phone my family because I had trouble talking. So, I had my tablet and my and I could communicate with them [family]. (Jim) Everybody would send him pictures. (Carol) I would Skype them [grandchildren] too. (Jim) Staying active he had to learn [the tablet] and he did the crosswords, that s what kept him going was the cross not the crosswords Word Search (Carol) I did bowling on the Wii at Parkwood (Jim) I made more friends in Tillsonburg. We used to play cards every day. (Jim) 32

33 Phase 2 Perspectives from Jim and his family Knowing there is support makes it more comfortable they told us everything and they told us who his doctor would be and if I had any concerns, they told me to phone right back what to do if something goes wrong Yes, the training and understanding what to do so, if something goes wrong (Carol) the vent hook-up she had us all do that, [4 family members] so that we understood it (Carol) the third night, the nurse phoned in sick that was a little bit of panic I was scared at first oh, what are you going to do? Well, I sort of thought, well we can do it Someone s got to stay up, so we will work around it. (Carol) when we had trouble with his breathing, we just called the ambulance (Carol) 33

34 Phase 2 Advice from Jim and his family If you want to go home I think it s how well the patient really wants to be at home. If they get it in their mind and the family gets it in their minds that it can be done, it can be done. (Carol) just got to adjust to people around you, make sure of your care, got to learn it yourself. I can do my own suctioning. (Jim) It s alright. I guess I ve just gotten used to it. If you want him home, you re just going to have to expect this [a nurse in the home every night]. (Carol) Well, if you want the person home, they got to be willing to help out and make sure there is someone with the person at all times, because you never know if it plugs up or whatever. (Carol) 34

35 Phase 2 Clinical Standards Respiratory Therapy (RT) and Other Professionals Working Group Purpose: To establish standards of care and disseminate to all stakeholders including patients and families Respirologists in London and Owen Sound have agreed to support community RTs and physiotherapists who are working with patients with CMV needs in their respective areas Implementation of CCAC-based Community RT role has been confirmed provider name is pending announcement of the outcome of RFP process 35

36 Purpose: Phase 2 Clinical Standards Transitions in Care Working Group To establish standard processes for patients and their families in transition between care settings (including documentation) Cross sector process flow maps and documentation for short and long-term as well as planned and unscheduled transitions have been approved for use (Appendix 1a) Have consulted with the Transition to Adult Care Clinic at Children's Hospital to ensure processes address pediatric to adult transition needs A contact list has been compiled of key individuals who have agreed to come together around a specific client/patient situation when a complex transition is being contemplated Documentation will be case specific and will utilize the CCAC Complex Client Conference template (Appendix 2) Commitment made to ensure patients/clients and families are actively involved in all aspects of transition planning, execution and review 36

37 Purpose: Critical Care Network will support implementation of integrated model of care for adults living with CMV Critical Care Secretariat of Ontario (CCSO) has released a Long-Term Mechanical Ventilation Toolkit ( ilation_toolkit_december% pdf ) and it has been adopted as a standard of care in the South West Agreement in principle reached for the South West LHIN Critical Care Network to support Phase 2 - Clinical Standards Critical Care Network Grey Bruce Health Services (GBHS) and London Health Sciences Centre (LHSC) as leads for serving this population and All Level 3 Intensive Care Units (ICU) to provide care as needed to those living with CMV in their community Agreement to involve provincial CCSO leaders in increasing awareness of this work Respirologists in London and Owen Sound have agreed to consult with other ICUs in their area as needed 37

38 Phase 2 Clinical Standards South West LHIN Hospice Palliative Care Network Purpose: All persons who live with CMV are engaged in an early conversation about their palliative care and end of life wishes Speak Up resources were identified and distributed as tools for health service providers, patients and families to use for initial conversations about end of life wishes South West LHIN Hospice Palliative Care Network hosted an OTN Presentation re: Consent, Capacity and Care Planning in June/14 for health service providers to increase general knowledge on end of life care (Appendix 3) 38

39 Purpose: Long-Term Care (LTC) homes will be willing and able to accept older Adults living with CMV into their facilities LTC Council has agreed to continue to work with stakeholders to ensure that funding options for respiratory equipment and RT services are available to residents of LTC LTC Homes surveyed to determine current state of adults with CMV living in LTC (detail is mapped on following slide and the full report can be found in Appendix 4) Current state: Phase 2 Clinical Standards Long-Term Care Council 9% (3/35) had experience with a resident using a tracheotomy 51% (18/35) had served residents that required nocturnal positive airway pressure (nasal mask continuous positive airway pressure (CPAP)) 9% (3/35) had residents who needed nocturnal non-invasive ventilation (full mask bi-level positive airway pressure) 11% (4/35) had a resident that needed intermittent non-invasive ventilation 3% (1/35) had a resident that required continuous non-invasive ventilation 39

40 40

41 Phase 2 Clinical Standards South West CCAC (Community RT and PT) Purpose: Respiratory therapist (RT) and physiotherapist (PT) services are available in the community to support adults living with CMV in community South West CCAC services are expanding to include community respiratory therapy with a focus on individuals who are dependent on CMV living in the community Complex discharge screening tool is in place in acute care to identify patients who will need a in depth stakeholder engagement to facilitate discharge 41

42 Phase 2 Business Case Development and Monitoring Participation House Working Group Purpose: To explore opportunities to predict future client volumes for assisted living and/or minimizing time from referral to transition to the community for individuals able to live in the community Current state process flow maps for short and long-term as well as planned and unscheduled transitions have been approved for PDSA at Participation House (see Appendix 1a) Partners explored opportunities for flexible funding in order to decrease time between referral and transition to the community Able to accurately track time from referral to transition to community through coordinated access Confirmation reached that $150K-$180K (2013/14) is the cost per annum for each individual with invasive ventilatory needs living in the community 42

43 Phase 2 Business Case Development and Monitoring Metrics Working Group Purpose: Establish metrics for both understanding the needs for this population and for tracking the success of system improvements ICES confirmed in December 2013 that OHIP Billing data and Ventilator Equipment Pool data was not available as recommended in Phase 1 due to inaccuracy of OHIP Billing data for this population and the degree of manual data capture in the Ventilator Equipment Pool Regional Integrated Decision Support (RIDS) was determined to be able to describe the population, monitor ongoing improvement and trending demand over time Individual organizations identified patients (CCAC, GBHS, LHSC, SBGHC and HDH) Each patient flagged in the RIDS system so their care journey can now be followed Driver Diagram Completed (detailed on slide 44) Draft Quarterly Metrics report developed 43

44 Phase 2 Business Case Development and Monitoring Metrics Working Group Adults Living with CMV Needs Driver Diagram AIM Primary Drivers Secondary Drivers Support people to live in the most appropriate, least restrictive setting possible across the South West Reduce ALC Build Community Capacity Minimize Hospital Days* Support people with integrated care across transitions of life and daily living Minimize ED Visits* Increase access to Community Clinical Services Increase access to Assisted Living, Respite & Day Programs Engage all Individuals and Family as lead decision makers in their care Transition Team(s) implement best practice clinical transitions Integrated system of care in place # outpatient and community health care encounters* # of adults living with CMV on AL, Respite and Day programs Ongoing Qualitative Evaluation re: Quality of Life # of transitions per year* Shared Agreement in place and active * Key Performance Indicators for 2014/15 Future indicators for consideration Population health Quality of Life 44 44

45 Phase 2 Business Case Development and Monitoring Metrics Working Group Adults Living with CMV Current Population Description The SW CCAC, LHSC, GBHS, SBGHC and HDH identified current patients with CMV needs and submitted RIDS patient identifiers to the South West LHIN for flagging these patients in RIDS. Patients requiring both invasive and noninvasive ventilation needs were identified. In the South West, a total of 214 patients with CMV needs have been identified as receiving health care from a hospital or the CCAC in the time frame that RIDS is available (fiscal 2010/11- end of third quarter 2013/14). Note that the hospital visit could be to any South West LHIN Hospital. It is not known what date during this time frame these patients started to have CMV needs. 45

46 Phase 2 Business Case Development and Monitoring Metrics Working Group Adults Living with CMV Current Population Description 46

47 Phase 2 Business Case Development and Monitoring Metrics Working Group Adults Living with CMV Current Population Description 47

48 Phase 2 Business Case Development and Monitoring Metrics Working Group Adults Living with CMV Current Population Description Number of Male CMV Patients by Age 48

49 Phase 2 Business Case Development and Monitoring Metrics Working Group Adults Living with CMV Current Population Description 49

50 Number of CMV patients Phase 2 Business Case Development and Monitoring Metrics Working Group Adults Living with CMV Current Population Description Number of unscheduled ER visits by hospital, FY 2013/

51 Hours Phase 2 Business Case Development and Monitoring Metrics Working Group Adults Living with CMV Current Population Description Average LOS for unscheduled ER visits by hospital, FY 2013/

52 Phase 2 Business Case Development and Monitoring Metrics Working Group Adults Living with CMV Current Population Description Discharge destination description for unscheduled ED visits, FY 2013/14 Transferred to another acute care facility directly from an Amb MIS FC Patient left at his/her own risk following registration and triage Intra facility transfer to day surgery Discharged to place of residence (NH,RH, Jail) 18 Discharged Home 60 Death after arrival (DAA) 1 Admit to Reporting Facility as an in-patient to critical care unit or OR directly from an Amb MIS FC 14 Admit to Reporting Facility as an in-patient to another unit directly from an Amb MIS FC Number of discharges 52

53 Number of transfers Phase 2 Business Case Development and Monitoring Metrics Working Group Adults Living with CMV Current Population Description Transfers to institution type for unscheduled ED visits, FY 2013/ Acute Care Treatment Hospital Ambulatory Care Home Care Program (Community Care Access Centres) 1 2 Mental Health Unit Nursing Home (Long Term Care Beds) 53

54 Number of discharges Phase 2 Business Case Development and Monitoring Metrics Working Group Adults Living with CMV Current Population Description Number of non-elective inpatient discharges by hospital, FY 2013/ ALEXANDRA HOSPITAL GREY BRUCE HEALTH SERVICES HANOVER AND DISTRICT HOSPITAL LONDON HEALTH SCIENCES CENTRE NORFOLK GENERAL HOSPITAL SOUTH HURON HOSPITAL ST THOMAS- ELGIN GENERAL HOSPITAL STRATFORD GENERAL HOSPITAL STRATHROY MIDDLESEX GENERAL HOSPITAL WOODSTOCK GENERAL HOSPITAL 54

55 Days 26.0 Phase 2 Business Case Development and Monitoring Metrics Working Group Adults Living with CMV Current Population Description Average length of stay for non-elective inpatient discharges by hospital, FY 2013/ ALEXANDRA HOSPITAL GREY BRUCE HEALTH SERVICES HANOVER AND DISTRICT HOSPITAL LONDON HEALTH SCIENCES CENTRE NORFOLK GENERAL HOSPITAL SOUTH HURON HOSPITAL ST THOMAS- ELGIN GENERAL HOSPITAL STRATFORD GENERAL HOSPITAL STRATHROY MIDDLESEX GENERAL HOSPITAL WOODSTOCK GENERAL HOSPITAL 55

56 Phase 2 Business Case Development and Monitoring Metrics Working Group Adults Living with CMV Current Population Description Discharge destination description for non-elective inpatient discharges, FY 2013/14 Transferred to other 1 Transferred to an acute care inpatient institution 5 Transferred to a continuing care 20 Discharged to a home setting with support services 52 Discharged Home 32 Died Number of discharges 56

57 Phase 2 Implementation of Coordinated Access Purpose: Establish coordinated access to CCC, Rehab, Assisted living, Supportive Housing and Adult Day Programs Coordinated Access implemented for adults living with CMV to LTC Homes (Completed summer 2013) Assisted Living, Supportive Housing and Adult Day Programs across the South West (completed March 30/14) Complex Continuing Care and Rehabilitation services at St. Thomas Elgin General Hospital, Tillsonburg District Memorial Hospital, Alexandra Hospital in Ingersoll and Woodstock Hospital (Completed October 2013) 57

58 Phase 2 Build Understanding of Funding Options Purpose: Build one document with funding options outlined Funding options mapped into one document (Appendix 5) 58

59 Phase 3 Adults Living with CMV Recommendations for Implementation Recommendations are presented in the following categories Timelines Administrative Oversight/CMV System Organization Clinical Standards and Operations Monitoring System Performance Business Case Development Coordinated Access 59

60 Phase 3 Adults Living with Chronic Mechanical Vent - Timelines Jun 2014 Jul 2014 Aug 2014 Sep 2014 Oct 2014 Nov 2014 Dec 2014 Jan 2015 Feb 2015 Mar 2015 Notes/ Comments Administrative Oversight/CMV System Organization Sign Accountability Agreement; Finalize Terms of Reference for Oversight Committee & Operations Management Committee; Recruit members for both committees Hold inaugural meetings of CMV Oversight Structure and CMV Operations Management Group CMV Oversight Committee to include patients/families Clinical Standards and Operations Post clinical standards on the internet Transitions in Care Team to initiate use of Care Conferencing Template and process maps Phased Implementation CCAC-based community RT support role and define future role, in collaboration with Parkwood Outreach Service; Community PTs offer cough assist and assessment services Education and Planning day with CCSO Spring/2015 Include adults living with CMV in the adoption of proactive palliative and end-of-life strategies, including Speak Up dissemination as per the Palliative Care Network work plan Critical Care Network to monitor the application of the clinical guides as outlined by CCSO by SW LHIN ICUs Long Term Care Council to monitor and plan to support adults living with non-invasive chronic mechanical ventilation Investigating the possibility of CCSO doing a webinar on the CCSO Long-term Mechanical Ventilation Toolkit recently released; timelines to be determined Draft metrics report to ATC Core Ops Business Case Development and Monitoring System Performance Establish metrics report format and process to build quarterly report Plan for level 2 transitional respiratory care defined at University Hospital Coordinated Access Incorporate CCC/Rehab RM&R form into coordinated access (CA) at TDMH, AH, WH, STEGH Expand CA to remaining CCC beds at AH Implement CA to CCC/Rehab beds across Huron Perth and Grey Bruce sites Implement CA to CCC/Rehab at Parkwood Expand CA to remaining CCC/Rehab beds at STEGH, WH, TDMH Coordinated access has been fully implemented for Assisted Living/Supportive Housing/Adult Day Programs for High Risk Seniors and Special Populations (inclusive of those living with Chronic Mechanical Ventilation) Creation Date: Jun 5/14 Revision date: Jun 27/14

61 Adults Living with Chronic Mechanical Ventilation Oversight Structure Phase 3 - Implementation South West LHIN CMV System Oversight Committee Area Provider Tables/ Geographical Teams Critical Care Network SW Rehabilitative Care Committee CCAC CMV Operations Management Committee SW LHIN Hospice Palliative Care Network LTC Home Network Council Metrics Working Group Transitions in Care Team = existing group with links to CMV = group will transition as move into Phase 3, implementation and sustainability Created: November/13 Last updated: June 23/14

62 Location of CMV Oversight Structure during Phase 3 - Implementation Location of CMV Oversight Structure during Sustainability Phase 6/27/2014 3:22 PM

63 Phase 3 Administrative Oversight/CMV System Organization Recommendations for Implementation 1. Recruit Patients and families to be members of the CMV System Oversight Committee 2. Develop and approve Terms of Reference for the: CMV System Oversight Committee to provide system-level governance and leadership CMV Operations Management Committee to effectively addresses system-wide operational issues and needs 3. CMV System Oversight Committee to develop and get agreement on a shared accountability agreement to support cross-sector monitoring and decision making determine future alignment with related initiatives, groups (e.g. medically complex, technologically dependent special population; youth to adult transition group) Determine, in collaboration with South West LHIN Partners, when to move to sustainability reporting mechanism outlined on slide 63) 63

64 Phase 3 Clinical Standards and Operations Recommendations for Implementation 4. Make new clinical standards available online for all clinicians as they are developed 5. Promote clinical standards through leveraging the expertise of Respirologists in London and Owen Sound 6. Ensure community respiratory therapists and physiotherapists are aware of clinical back-up available through the Respirologists in London and Owen Sound 7. Ensure clarity of community physiotherapist and respiratory therapist roles for all stakeholders 8. Establish training and maintenance of competency for community PT for airway clearance management 9. Use newly developed process flow maps and documentation templates to plan, execute and review transitions 10. Request key clinical individuals come together for transition planning and execution around a specific client/patient when a complex transition is being contemplated 64

65 Phase 3 Clinical Standards and Operations Recommendations for Implementation 11. Maintain a list of key clinical contacts (Transitions in Care Team), to be consulted as appropriate, for future transitions 12. Document transitions for each patient using the SW CCAC Care Conference template (Appendix 2) 13. Actively involve patients and families in all aspects of transition planning, execution and review 14. When the date is available, market the Webinar on the Long Term Mechanical Ventilation Toolkit by the Critical Care Secretariat of Ontario (CCSO) to all stakeholders 15. Consider Grey Bruce Health Services and London Health Sciences Centre as the clinical leads from a Critical Care perspective 16. Expect all Level 3 ICUs to support those living with CMV in their community when this level of care is required 17. Hold an Invitational Education and Awareness day in the South West for members of the CCSO prior to the end of March

66 Phase 3 Clinical Standards and Operations Recommendations for Implementation 18. Include the following in the 2014/15 Hospital Palliative Care Network work plan: All persons who live with CMV are engaged in an early conversation about their palliative care and end of life wishes, using proactive palliative and endof-life strategies including ongoing dissemination of Speak Up resources to patients, families and health care professionals 19. Continue to identify LTC Homes as a suitable residential option for people living with respiratory problems including people living with non-invasive mechanical ventilation 20. Use LTC Homes current state survey (Appendix 4) to build common understanding of clinical care and funding of respiratory equipment in Long-Term Care 66

67 Phase 3 Clinical Standards and Operations Recommendations for Implementation 21. Implement community respiratory therapy with a focus on individuals who are living with CMV needs SJHC Parkwood and SW CCAC will collaborate to ensure community RT service for this population is synergistic 22. Community professionals will maintain competency for caring for this population including airway clearance management 23. All adults living with CMV who are actively being cared for in an outpatient clinic setting are to be referred to CCAC for care coordination if they have not already done so 24. Patients requiring complex continuing care and inpatient rehabilitation will get individualized care through care planning that is coordinated with them and their health care team at the time of need in any CCC or Rehab bed in the South West (see Appendix 6 for detailed report) 25. All partners will work together to provide care that is based on best practices for each specialized population when the situation arises 26. Exploration of the hospital based ambulatory care needs of adults living with CMV needs is recommended 67

68 Phase 3 Monitoring System Performance Recommendations for Implementation 27. Use the Adults Living with CMV driver diagram (Slide 44) to build understanding of the system changes expected and the measurements that will change as a result 28. CMV System Oversight Committee and the CMV Operations Management Committee will review quarterly metrics report Metrics Group to Oversee the process to sustain production of the quarterly report Annually review the process and indicators for potential improvement Make recommendations for change to the CMV System Oversight Committee 29. Over fiscal 2014/15, the CMV System Oversight Committee will work to understand measures both qualitative and quantitative that reflect the quality of life of adults who are living with CMV needs. It is the vision that this information will be used to continue to co-design the system with individuals and their families to enhance their quality of life. 68

69 Phase 3 Business Case Development Recommendations for Implementation 30. Incorporate support for people who have CMV needs to transition to less intensive care post level 3 ICU care into the Level 2 Bed Strategy at LHSC 31. Incorporate learning gained from the respite spaces funded at Participation House in 2013/14 for adults with complex medical needs into future planning 32. Spread learning from the implementation of the Participation House-based process maps as appropriate 33. As there are approximately 2.5 new people with invasive CMV needs identified each year and a projected death rate which is similar, Participation House and other partners will work with South West LHIN staff to fund residential care on a case by case basis Current respite funding is suggested as an option for more flexibility in funding spaces in the short-term 34. Offer specialized adult day programs, respite and residential care to Adults living with CMV throughout the South West 35. CMV System Oversight Committee will monitor assisted living demand for this population annually to determine other funding options 69

70 Phase 3 Coordinated Access Recommendations for Implementation 36. Implement Coordinated Access to CCC and Rehabilitation in alignment with resource Matching and Referral standards in: STEGH, TDMH, AH, and WH in July 2014 Huron Perth and Grey Bruce Hospitals in November 2014 London Middlesex in the fourth quarter of fiscal 2014/ Include adults living with CMV in the Complex and Chronic CCAC Teams; supported by CCAC 70

71 Planned Next Steps Phase 3 Administrative Oversight Structure to be in place by September 2014 First Quarterly report to be available for review by Phase 3 Administrative Oversight Structure in September 2014 Sustainability actions for Phase 3 to be delineated and accepted prior to the end of June 2014 through the Access to Care Transition to Maintenance checklist

72 Acknowledgements South West LHIN Implementation Planning Steering Committee Members Judy Kojlak Elaine Gibson Brian Dunne Donna Ladouceur Lois BeamishTaylor Carrie Jeffreys Susan Warner Mark Landy Brian Orr Director, Critical Care, Trauma & Patient Access, LHSC Vice President, Complex, Specialty Aging and Rehabilitative Care, St. Joseph s Parkwood Hospital & Mount Hope Executive Director, Participation House Support Services Senior Director, Client Services, South West CCAC Senior Director, Performance Management and Accountability, South West CCAC System Design & Integration Lead, South West LHIN System Design & Integration Project Lead, South West LHIN Director, Medicine and Oncology, GBHS Board Director, Participation House Support Services 72

73 Pictured: Dr. David Leasa Lisa Malbrecht Carmell Tait Margo Collver Joanne Smith Michelle Vermeeren Mary Jo Dunlop Amber Alpaugh-Bishop Sue McCutcheon Michele Pegg Sherry Fletcher Shirley Koch Asha Rawal Carrie Jeffries Acknowledgements South West LHIN Planning Group Members Not Pictured: Steve Elson Cathy Mawdsley Jane Wheildon Dr. Mark Newton 73

74 Appendices 1. Transition Flow Maps a) Transitions in Care Team b) Participation House 2. SW CCAC Complex Care Conference Template 3. Hospice Palliative Care Webinar a link to the education session 4. LTC Home Survey Briefing Note 5. Table of Funding Opportunities 6. CCC/Rehab Multi-community Briefing Note 7. Community RT service Schedule 74

75 Key References for Further Information 1. Commitment to Excellence in Care: A Systems Model to Support the Needs of Adults Living with Chronic Mechanical Ventilation needs in the South West LHIN (2013) tives/mechanical_vent/a%20commitment%20to%20excellence%20and%20partne rships%20final%20-%20nov% pdf 2. LTC Ventilation Manual ation/ccso_long%20term%20mechanical%20ventilation_toolkit_december% pdf 3. Speak Up Palliative Care Resources 75