Needs Assessment & Care Allocations in Alberta The Right Care in the Right Place Presentation at the Care Assessment Congress March 26 2010 by Donna Stelmachovich
Discussion Content Alberta Demographics Alberta s Continuing Care System Continuing Care Clients and Care Provision Coordinated Access process Service Needs Determination / Allocation 2
About Alberta One of 13 provinces/territories in Canada 4 th Largest Province Spans 661,185km 2 3x the size of Great Britain In size, equals France, Switzerland, Belgium and the Netherlands combined Population of 3.5 million 370,000 Seniors 1 in 10 Albertans is a Senior Year 2030 880,000 Seniors 1 in 5 Albertans will be a Senior Senior is defined as a person 65+ years 3
Strategic Policy outlines broad governmental direction for future change. Directional Policy is a network of interrelated statements that together outline a consistent provincial approach to change. Alberta Health and Wellness Standards describe the minimum requirements that need to be met based on best available evidence/practice. Operational Policy aligns with and flows from directional policy and identifies the key strategies and actions needed to achieve change. Alberta Health Services
AHS Operational Strategy System Solutions will be built on five pillars 1. Meeting needs of an aging population 2. Standardized assessments to ensure that seniors get the right care 3. Supporting independence through choice of options for care 4. Assuring quality of care 5. Equitable funding to providers 5
Alberta s Continuing Care System Coordinated Access to Publicly Funded Continuing Care Health Services Policy Continuing Care Services Home and Supportive Living: Directional & Operational Policy Admission Guidelines for Publicly Funded Continuing Care Living Options Case Management Framework in Continuing Care RAI Instruments 6
Tools in Alberta interrai information system CAPs MAPLe RUG-III/HC Evaluate Best Practices MDS Assessment Quality Improvement Accreditation Outcome Measures Supports Data Quality Quality Indicators Adapted from J. Hirdes et al., Integrated Health Information Systems Based on the RAI/MDS Series of Instruments, Healthcare Management Forum 12, 4 ( 1999): pp. 30 40. 7
Alberta s Continuing Care System Home Living Supportive Living Facility Living Independent Living (eg: house, apartment, condominium) Level 1 Level 2 Level 3 Level 4 Assisted Living Enhanced Assisted Living Long-Term Care Facility (Nursing Homes And Auxiliary Hospitals) Home care Through Home Care Programs Health care services through home care programs Variety of accommodation services provided Health care and accommodation Services provided Home living 95,000 Albertans receive publicly funded Home Care Services Supportive Living (SL) 18,500 units 5,607 Designated, or health subsidized units are SL3 Assisted Living SL4 Enhanced Assisted Living Long-term Care Facility 14,500 spaces 8
Home Living and Supportive Living Levels 1 & 2 Person (Client) Largest population served by home care are seniors but includes all age groups Not intended to replace informal support Clients are provided scheduled care and support in their own homes based on assessed unmet need Unscheduled care available short-term Care provision: Personal Care & Support Contracted Agencies Health Care Aides (HCAs) Professional Services AHS Home Care Case Management Registered Nurse Services On call 24/7 Allied Health Expert consultation 9
Supportive Living Level 3 Assisted Living Person (Client/ Resident): Require supportive and personal care assistance in at least one area Need scheduled and ongoing unscheduled care May require assistance to get to the dining room May need assistance to participate in social, recreational and rehabilitation programs Care provision: Personal Care & Support HCAs on-site Professional Services AHS Home Care Case Management Registered Nurse Services on-call 24/7 Allied Health Expert consultation 10
Supportive Living Level 4 Enhanced Assisted Living Person (Client/ Resident): Require supportive and personal care in at least one or more areas Need for professional care and assessment at the LPN level Need scheduled and unscheduled care May need transfer with a mechanical lift May need assistance to participate in social, recreational and rehabilitation programs An alternative to traditional Long-term Care Facility Care provision: Personal Care & Support HCAs on-site Professional Nursing LPNs on-site Professional Services AHS Home Care Case Management Registered Nurse Services on-call 24/7 Allied Health Expert consultation 11
Supportive Living Level 4 - Dementia Enhanced Assisted Living - Dementia Person (Client/ Resident): In addition to the Supportive Living Level 4 description, Moderate dementia that may progress to later stages or other forms of cognitive impairment May have unpredictable behaviours which may include elopement Care provision: Personal Care & Support HCAs on-site Professional Nursing LPNs on-site Professional Services AHS Home Care Case Management Registered Nurse Services on-call 24/7 Allied Health Expert consultation 12
Long-term Care Facility Person (Client/ Resident): Medically fragile Complex medical conditions that are unpredictable Require 24-hour on-site unscheduled registered nursing assessment / care Care provision: Personal Care & Support HCAs on-site Professional Nursing LPNs on-site (optional) Registered Nurses (RNs) on-site Professional Services Allied Health on-site or contracted Expert consultation 13
Inquiry for Information Intake & Screening Assessment Service Needs Determination Negotiation of Individual Service Options Service Recommendation & Referral Service Delivery, Monitoring, Reassessment Transition Discharge Waitlist Management Case Management Integrated Information Management 14
Assessment / Re-assessment Available 7 days per week Conducted by an AHS Home Care healthcare professional working in a Case Management role Standardized assessment tools Client / Family negotiation Consultation with an Interdisciplinary Team Professional judgement Standardized frequency for re-assessment 15
Service Needs Determination / Negotiation / Recommendation / Referral Supplement and complement, not replace, care provided by individuals, families and communities Based on determination of unmet need Policy and tools consistent province-wide Coordinated Access to Publicly Funded Continuing Care Health Services: Directional and Operational Policy Service needs determined by Home Care Case Managers using RAI-HC assessment outputs and professional judgment 16
Service Needs Determination / Negotiation / Recommendation / Referral Client and family input / negotiation Interdisciplinary team input Panelling process for living option determination Service Allocation Tools Home Care Service Parameters Continuing Care Service Provision Guidelines Admission Guidelines for Publicly Funded Continuing Care Living Options Decision Making Tool 17
Service Needs Determination Assessment Outputs of RAI Outcome Measures (examples include) Cognitive Performance Scale (CPS) Activities of Daily Living (ADL) Scales Changes in Health, End-stage Disease, Signs & Symptoms (CHESS) Depression Rating Scale (DRS) Instrumental Activities of Daily Living (IADL) Scales Pain Scale 18
Service Needs Determination Outputs of RAI MAPLe Method for Assigning Priority Levels Predicts risk of adverse health outcomes Determines urgency Identifies clients at risk of admission to a living option One of several key outputs for consideration of living option eligibility 19
Service Needs Determination Outputs of RAI Clinical Assessment Protocols (CAPs) provide the clinician with valuable information to determine client strengths and identify areas that could be problems or potential problems and are used in developing a plan of care and service 20
Transitions and Discharge Minimizing transitions Service option enhancements Transitions within AHS coordinated and seamless Short-term Community Support Beds Case Management supports transitions Consistent discharge process 21
Waitlist Management / Monitoring Consistent provincial criteria, processes and policies Common electronic waitlist management system Consistent policies for Charges for Alternate Level of Care (ALC) Clients Waiting (in Acute Care) For Continuing Care Facility Placement First Available Appropriate Bed Continuing Care Charges Reduction For Demonstrated Financial Hardship 22
Continuing Care Service Needs Flowchart Inquiries Coordinated Access Case Manager conducts Intake & Screening Process Case Manager completes appropriate assessments No Long Term Supportive or Maintenance Client Type Care Plan developed and services implemented guided by Home & Supportive Living Services Parameters Yes Case Manager completes RAI HC Assessment with client/family involvement Case Manager reviews RAI Outputs including MAPLe Case Manager reviews Continuing Care Service Guidelines and recommends service needs with client/family involvement. Document MAPLe and rationale for recommendation Case Manager reviews Living Option Guidelines No Home living, SL1 or SL2 Case Manager recommends Living Option and documents MAPLe and rationale for decision Yes Case Manager develops Care Plan and arranges for Home Care services guided by Home & Supportive Living Services Parameters Client admitted to Living Option and receives services Client receives Home Care services Case Manager conducts regular RAI Assessments and documents MAPLe and other service information by level of care and location Seniors Health conducts retrospective reviews to establish benchmarks and plan future services 23
Service Needs Determination / Allocation CONTINUING CARE SERVICE PROVISION GUIDELINES Factors MAPLe Score Scheduled Formal Care Needs only Unscheduled Formal Care Needs Socialization Client s Preferences and Family Preferences regarding how care is delivered and level of care Caregiver Needs Cognition Mental Health Altered Behaviours including Wandering, Exit Seeking, Aggression and Agitation Physical Functioning and Chronic Health Issues Hospitalization and Emergency Room Visits Chronic Unmanaged Incontinence Safety 24
Service Needs Determination / Allocation CONTINUING CARE SERVICE GUIDELINES Decision Client can remain in existing living situation Client requires Supportive Living Level 1 or 2 It is determined client needs to consider Supportive Living Level 3, 4 or Long Term Care Rationale Why can client manage What interventions need to be implemented What is status of caregiver Why is Supportive Living Level 1 or 2 required Interim interventions to maintain client until SL 1 or 2 available Why must client consider Supportive Living Level 3, 4 or Facility Living What interventions have been trialed What is the status of the caregiver 25
Service Needs Determination / Allocation Home Care Service Parameters Services are fair, defensible and consistent across Alberta Responsive Assessed unmet need Respect client choice Services available include Case Management Professional Health Services Personal Support Caregiver Support Parameters of funded resources are based on client type End of Life Long-term Supportive Acute Maintenance Rehabilitation Wellness 26
Service Needs Determination Admission Guidelines for Publicly Funded Continuing Care Living Options Supportive Living Levels 3 & 4 and Long-term Care Facility Intent of Living Option Guidelines Provides a support tool Assists with consistent living option referrals to Supportive Living levels 3, 4 and Long-term Care. Ensure long-term care beds are used by those who most need them. Clients with complex, unpredictable medical needs requiring 24- hour unscheduled Registered Nurse assessment and services. Guides the professional without being overly rigid or prescriptive 27
Living Options Guidelines for Decision Making (March 5, 2010) Supportive Living Level 3 Assisted Living (SL3) Health Care Aide - 24 hour on-site Registered Nurse - 24 hour on-call availability Medical Conditions: Medical condition is stable and appropriately managed without a 24 hour on-site RN or LPN PRN medication assistance available if client capable of making request Cognitive Status: May have mild dementia but behaviourally stable May require unscheduled reassurance No known risk of elopement but may wander is easily redirected Social behaviour does not induce fear and anxiety in other residents No known risk of self-harm or harm to others Note: site may have a secured environment Functional Status: Mobilizes independently or with oneperson transfer Requires unscheduled personal care (assistance with management of incontinence, cueing and/or assistance with meals, transportation to meals, direction and/or cueing for initiation and completion of activities, assistance with pre-packaged scheduled medications) Able to call for help using a call system Exclusion Considerations: Complete meal assistance if dietician support / consultation is not available Mechanical lift transfers Two-person transfers Unmanaged incontinence RAI-HC Outcome Scales Expected Range: Cognitive Performance Scale: 0-3 ADL Hierarchy: 0-3 IADL Difficulty: 4-6 CHESS Scale: 0-3 MAPLe Scale: Mod, High or Very High Supportive Living Level 4 Enhanced Assisted Living (SL4) Licensed Practical Nurse and Health Care Aide - 24 hour on-site Registered Nurse - 24 hour on-call availability Supportive Living Level 4 Dementia Enhanced Assisted Living (SL4-D) Medical Conditions: May be complex but is stable and appropriately managed safely through an interdisciplinary person-centred plan of care Unscheduled professional assessments may be required to adjust the plan of care which may include medication management Cognitive Status: May have varying levels of dementia but are behaviourally stable May require unscheduled reassurance Minimal risk for elopement but may wander is easily redirected Social behaviour does not induce fear and anxiety in other residents Minimal risk of self-harm or harm to others Functional Status: Will have complex physical care needs that cannot be met at home or in a lower level of supportive living May require the following types of assistance with ADLs: o Complete meal assistance including tube feeding o Mechanical lift transfers o Two-person transfers o Total assistance to mobilize including portering o Medication assistance or administration o Unmanaged incontinence Cognitive Status: Will have moderate dementia that may progress to later stages or other forms of cognitive impairment (CPS 3 or greater) Lacks awareness of personal space of others Will have unpredictable behaviours which may include risk for elopement May have unpredictable behaviours placing self and others at risk but manageable in this environment. Functional Status: May have complex care needs that cannot be met at home or in other supportive living environments May require the following types of assistance with ADLs: o Complete meal assistance including tube feeding o Mechanical lift transfers o Two-person transfers o Total assistance to mobilize including portering o Medication assistance or administration o Unmanaged incontinence Exclusion Considerations: Unpredictable behaviour placing self and others at risk (may not be an exclusion consideration in some settings) Require 24-hour on-site RN professional services Requires intensive and/or extensive rehabilitation services that cannot be easily accessed RAI-HC Outcome Scales Expected Range: Cognitive Performance Scale: 2-4 ADL Hierarchy: 2-4 IADL Difficulty: 5-6 CHESS Scale: 0-3 MAPLe Scale: Mod, High or Very High RAI-HC Outcome Scales Expected Range: Cognitive Performance Scale: 3-5 ADL Hierarchy: 1-3 IADL Difficulty: 5-6 CHESS Scale: 0-3 MAPLe Scale: High or Very High Long-term Care Facility Living Registered Nurse, Licensed Practical Nurse and Health Care Aide - 24 hour on-site Medical Conditions: Will have complex unpredictable needs but is clinically stable and can be managed safely with 24 hour on-site RN and regularly scheduled and unscheduled on-site physician support for complex end of life care needs, complex medication management, or complex nursing interventions Unscheduled assessments are often required to address changing resident care issues Cognitive Status: May have any stage of dementia May have unpredictable behaviours placing self and others at risk Note: facility may have a secured dementia care unit Functional Status: Will have complex physical needs with care requirements that cannot be met at home or in a supportive living environment May require the following types of assistance with ADLs: o Complex nutritional intake requirements o Intensive and extensive rehabilitation requirements o Complex elimination requirements Social Support: There may be complex family dynamics requiring on-site RN interventions Exclusion Considerations: Clients with unstable acute medical or psychiatric conditions who require acute care hospitalization RAI-HC Outcome Scales Expected Range: Cognitive Performance Scale: 2-4 ADL Hierarchy: 2-5 IADL Difficulty: 5-6 CHESS Scale: 2-4 MAPLe Scale: High or Very High 28
System Costs Health System Costs Stream Home Living Supportive Living Level 3 Supportive Living Level 4 Long-term Care Funded per diem Direct AHS Cost per diem Total Combined (Canadian $) Total Combined (Euro ) $362,203,000 ( 259,289,300) annually for 95,000 clients $40.50 $9.50 $50.00 35.80 $107.00 $13.00 $120.00 85.95 $170.00 Indirect $170.00 121.75 Client Costs Stream Accommodation Rate range Accommodation Rate per diem (Canadian $) range per diem (Euro ) $26.47 46.03 18.95 32.96 Supportive Living Level 3 Supportive Living Level 4 Long-term Care Private Room $54.25 Semi-private Room $47.00 $32.88 54.25 25.54 38.84 38.84 33.65 29
Coordinated Access Glossary End of Life In one s best clinical judgment, a client with and end-stage disease who is expected to live less than six months. Judgment should be substantiated by welldocumented disease diagnosis and deteriorating clinical course. Acute Home Care A client who needs immediate or urgent time limited (up to three months or less) intervention to improve or stabilize a medical or post-surgical condition. Rehabilitation A client with a stable health condition that is expected to improve with a time-limited focus on goal-orientated, functional rehabilitation. The rehabilitation plan specifies goals and expected duration of therapy. Long-term Supportive A client who is at significant risk of institutionalization due to unstable, chronic health conditions, and/or living condition(s) and/or personal resources. Maintenance A client with stable chronic health conditions, stable living conditions and stable personal resources, who requires ongoing support to remain at home. Wellness A client with stable chronic health conditions, who is stable independently in the community and is able to self-manage their care with minimal ongoing home care monitoring (every three months). 30
Supportive Living Level 3 Case Scenario Situation Background Assessment Recommendation Louise is an 89 year old currently living in her own home with support from her son and daughter. Her memory is deteriorating placing her at risk of injury due to unsafe behaviours within the home. Diagnosis Chronic Heart Failure, Pacemaker, Hypertension, Osteoarthritis, Alzheimer s Type Dementia Louise and her husband came to Canada as a young couple with small children. Louise stayed home to raise their 6 children while her husband worked away from home. Eventually they divorced and she was left alone to support her young family. She worked as a housekeeper until she retired at age 65. Louise is extremely proud of her ability to provide for her family despite challenging circumstances. Currently she is very proud of her independence and ability to manage her own affairs. She has little insight into her declining memory problems and refuses any formal assistance despite concerns with meal preparation, medication management and safety within the home. Family report finding pills and unfinished medication packages in her house. Louise has been known to leave windows open despite very cold weather, or leave space heaters turned inappropriately high posing a safety risk. Personal care assistance has been arranged through Home Care but Louise refuses to open the door for caregivers. Her daughter has tried to support her mother s insistence on remaining in her home and currently provides up to 3 hours of support daily. Louise is very upset if her daughter is not readily available to assist her. Family recognize that it is not safe for her to remain at home. Her PD had been enacted and family are exploring options for supportive housing. - independent with transfers and mobility - 1 assist with bathing for safety in and out of tub - cue and assist for dressing, grooming, hygiene to ensure completion - continent and independent with toileting - cue for meal times - requires MAP for medication, requests prn analgesia for pain RAI HC Outcome Measures: Cognitive Performance Scale: 3 Depression Scale: 4 Pain Scale: 2 ADL Hierarchy: 2 IADL Difficulty: 5 CHESS Scale: 1 MAPLe Scale: High Louise recently spent time on a geriatric assessment unit and adapted well to routines in this environment. She requires unscheduled personal care assistance for safety and cueing which can be met in Designated Supportive Living Level 3.
Supportive Living Level 4 Case Scenario Situation Background Assessment Recommendation Glen is a 51 year old man with Multiple Sclerosis. Mobility is declining and 1-person transfer is no longer feasible. Unscheduled incontinence care is also required. He is experiencing a slow, progressive, predictable decline in physical functioning related to MS. Diagnosis - Multiple sclerosis, Chronic pain and numbness from chest down related to MS Glen lives at home with his spouse and school age daughter. He has four grown children from a previous marriage who live in another province. He has received personal care services in his home for the past 3 years. Care needs are now exceeding what 1 caregiver can provide in the home on a scheduled basis due mainly to his declining mobility. During a recent exacerbation of MS he was admitted to a respite bed located in an Designated Supportive Living Level 3. He was very satisfied with the care received which met his physical needs, allowing him to function as independently as possible. His spouse is very supportive and involved in his care; however, she works full time and the stress of his increasing care needs is impacting her ability to cope. Glen recognizes that as his disease progresses, his needs are increasing, and access to personal care on an unscheduled basis is necessary to meet his physical needs. He is independent once up in his wheelchair and enjoys daily outings, attending his daughter s sporting events, and spending time with friends and family. He has slow recall with short term memory but is able to direct his care. - non-weight bearing, mechanical lift for all transfers - total assist with all dressing, bathing, grooming, hygiene - total assist with incontinence bladder and bowel, wears condom catheter and incontinent pads - occasional assistance with eating meals during MS exacerbation - manages medication independently, requires assistance with bowel routine RAI HC Outcome Measures: Cognitive Performance Scale: 2 Depression Scale: 0 Pain Scale: 3 ADL Hierarchy: 3 IADL Difficulty: 5 CHESS Scale: 1 MAPLe Scale: Moderate 2-person transfer/mechanical lift is exclusion criteria for Designated Supportive Living Level 3 therefore Designated Supportive Living Level 4 is recommended for unscheduled personal care and transfer needs.
Situation Background Assessment Recommendation Supportive Living Level 4 Dementia Case Scenario Sylvia is a 79 year old who was brought to hospital by police after threats to kill her daughter and an attempt to flee her residence. She is currently in a secured Geriatric assessment unit. Her daughter refuses to take her home as she fears for her personal safety. Diagnosis Alzheimer s type dementia, Fractured Left hip 2 years ago, Arthritis Left knee and hip, previous history of Alcohol abuse Sylvia is a widow who lives alone in her own home. She has had dementia for many years with strong frontal lobe features. Her ability to remain independent was compromised 2 years ago when she fell and fractured her hip. Upon recovery she was resistive to any caregivers coming into her home. Her daughter feels extremely guilty about having her mother placed and recently been spending up to 6 hours per day assistance her with meals, household management, and care needs. Sylvia has poor short term memory and extremely poor insight. She is aggressive and verbally abusive towards her daughter which escalated into rage and threats of violence the night she was brought into hospital. Since coming to hospital, Sylvia is much more calm, pleasant and cooperative. She has a prn antipsychotic which has been used less than weekly once she settled on to the unit. She interacts well with staff and caregivers and responds well to humour and a kind approach. She continues to demonstrate negative thoughts and behaviours towards her daughter and expresses her fear that family are taking me for everything I have. She is a high elopement risk requiring one-to-one care at times to redirect her from the door. - independent with transfers and mobility, could use a walker for support but she refuses - stand-by assist and cueing for bathing and hygiene, refuses tub bath - 1 assist with dressing - independent with toileting but requires monitoring to ensure pad has been changed and clothing adjusted - has been losing weight and requires supervision and encouragement to eat meals - requires medication management RAI HC Outcome Measures: Cognitive Performance Scale: 3 Depression Scale: 4 Pain Scale: 1 ADL Hierarchy: 2 IADL Difficulty: 5 CHESS Scale: 4 MAPLe Scale: Very High Due to high elopement risk, Sylvia requires a secured environment. She is medically stable with progressive dementia that requires professional nursing to intervene if behaviours start to escalate. Her needs can be met in Designated Supportive Living Level 4 Dementia with on site LPN and consultation of a community Registered Nurse.
Long-term Care Facility Case Scenario Situation Background Assessment Recommendation Lucy is a 99 year old Chinese lady previously living alone in her own home with the support of friends. She is legally blind. She was sent to the ED after a fall, and is currently waiting for placement from hospital due to significant change in health status requiring on site monitoring by a Registered Nurse. Diagnosis Subdural hematoma, Subarachnoid hemorrhage, DVT, Atrial Fib., Hypertension, Osteoporosis, Anxiety, Macular Degeneration, Neurodermatitis, Bilat. Cataracts with abnormal Right lens Lucy lived independently in her own home receiving twice weekly bath assist through Home Care. She refused all other assistance. She has one son who is not involved. Members of her church were supportive and assisted with meals, yard work, house maintenance, and appointments. She speaks old Cantonese and has limited understanding of English. She recently fell on her way to the mailbox and was admitted to hospital with subdural hematoma and subarachnoid hemorrhage. Two weeks after admission to hospital she was diagnosed with an extensive DVT. Usual treatment for DVT was initiated with caution due to the recent bleed and her advanced age. During her hospital stay she became unresponsive for a period of several days and was deemed comfort care. She regained consciousness and is currently bright and alert, however her physical functioning has deteriorated significantly and she is total care and immobile, unable to sit up without support. She is also experiencing periods of confusion and occasionally does not recognize familiar friends which is a change from pre-hospitalization. Currently she appears content and responds to smiles and friendly gestures. Her medical status continues to be unstable with fluctuating INR s and level of consciousness. - mechanical lift for all transfers, unable to sit without support in place - total assist with all bathing, grooming, dressing, hygiene - indwelling catheter requires total management, pads for bowel incontinence - meal set up and occasional assist with eating, intake poor which may improve if traditional food brought in - requires medication management RAI HC Outcome Measures: Cognitive Performance Scale: 5 Depression Scale: 3 Pain Scale: 2 ADL Hierarchy: 5 IADL Difficulty: 6 CHESS Scale: 3 MAPLe Scale: Very High Due to RN monitoring of unstable medical condition she is Long Term Care Facility Living level. She requires a higher level of assessment skills due to fluctuating medical status.
Contact Information Donna Stelmachovich, Vice President Seniors Health Alberta Health Services donna.stelmachovich@albertahealthservices.ca Documents / Tools referred to in this presentation may be obtained by contacting Patti Vandervelden patti.vandervelden@albertahealthservices.ca 35