Helping Patients Find Their Way Managing Patient Transitions in the Health Care System
Helping Patients Find Their Way Opening Remarks Laurie Zimmer ED/ALC Manager
Patient Experience Video Shelley Dobson A Daughter s Experience
Helping Patients Find Their Way Panel Discussion #1
Helping Patients Find Their Way Keynote Katharine Byrick Partner Health Law Group
ESC LHIN Managing Transitions: Legal Framework for Discharge planning and Decision Making Katharine L. Byrick Partner, Health Law Group June 9, 2015
Overview Insured Services, when a patient is Ready for Discharge, and Alternative Level of Care Chronic care co-payments and per diem charges for Hospital beds. 7
What is an insured service Prescribed services of hospitals and health facilities are insured services. Health Insurance Act, R.S.O. 1993, c. H.6., s.11(2). 8
Entitlement to an Insured Service An insured person is not entitled to insured services in a hospital unless the person has been admitted as in-patient on the order of a physician. Regulation 552 to the Health Insurance Act, s.11(1)(a). 9
Admission to Hospital A hospital shall accept a person as an in-patient they require the level or type of hospital care provided, and on the order / authority of a physician who is a member of the medical staff at that Hospital. Public Hospitals Act, R.S.O. 1993, c.p.40. s.20. Regulation 965 to the Public Hospitals Act, s.11(1)(2). 10
Entitlement to an insured service The in-patient services to which an insured person is entitled without charge include accommodation and meals at the standard or public ward level. Health Insurance Act, s.12. Regulation 552 to the Health Insurance Act, s.7. 11
Ready for Discharge If a patient is no longer in need of treatment in the hospital, the attending physician shall make an order that the patient be discharged and shall also communicate the order to the patient. Public Hospitals Act, Hospital Management Regulation, s.16. 12
Ready for Discharge Where an order has been made with respect to the discharge of a patient, the hospital shall discharge the patient and the patient shall leave the hospital on a date set out in the discharge order. Public Hospitals Act, Hospital Management Regulation, s.16. 13
Ready for Discharge The administrator may grant permission for a patient to remain in the hospital for a period of up to twenty-four hours after the date set out in the discharge order. Public Hospitals Act, Hospital Management Regulation, s.16. 14
Patients without a specific destination when ready for discharge A wide range of patients can fall into this category. The options for dealing with these patients will depend to a large degree on the situation of a particular patient. 15
Alternative Level of Care When a patient is occupying a bed in a hospital and does not require the intensity of resources/services provided in this care setting (Acute, Complex Continuing Care, Mental Health or Rehabilitation), the patient must be designated Alternate Level of Care (ALC) at that time by the physician or her/his delegate. 16
Alternative Level of Care (2) The ALC wait period starts at the time of designation and ends at the time of discharge/transfer to a discharge destination (or when the patient s needs or condition changes and the designation of ALC no longer applies) please see the provincial definition for complete statement, with notes. 17
Alternative Level of Care (3) Discharge destinations under the provincial ALC definition include: Home, with or without services Rehabilitation, Complex continuing care, long-term care Transitional care bed, convalescent care bed, palliative care bed Group home, retirement home, shelter, supportive housing 18
Alternative Level of Care (4) The definition does not apply to patients: Waiting at home Waiting in an acute care bed for another acute care bed. Waiting in a tertiary care bed for transfer to a non tertiary care bed (repatriation) 19
Co-Payments A co-payment for accommodation and meals that are insured services shall be made by or on behalf of an insured person who meets certain criteria. A chronic care co-payment IF the hospital is entitled to charge a copayment. Regulation 552 to the Health Insurance Act, s.10. 20
Co-Payments The criteria: Patients are those who, in the opinion of their attending physician, require chronic care and are more or less permanently resident in a hospital or other institution. Regulation 552 to the Health Insurance Act, s.10. 21
Co-payments v. per diem charges They are not the same! ALC patients may be charged a co-payment. ALC patients who refuse to fully participate in the discharge planning process may be charged a copayment. Per diem charges only apply when specific criteria is met. 22
Per Diem charges A Hospital may charge a per diem rate after the effective date of a discharge order, when a patient has refused to leave and/or declined to accept a long-term care bed from one of their facility choices. A discharge planning policy that contemplates a per diem charge should include certain elements. 23
Elements for policy of per diem charges 1. The attending physician has: a) discharged the patient, or b) is aware that a patient to be discharged is in receipt of a long-term care bed offer from among his or her facility choices and discharges that patient effective the date that the bed becomes available. 24
Elements for policy of per diem charges 2. The per diem rate for uninsured services that will be charged to a patient who remains in the Hospital past his or her discharge date is set out. 3. A rational explanation of the per diem rate for uninsured services is included. 25
Elements for policy of per diem charges 4. Any in-patient that is put on long-term care waiting lists shall be immediately notified of the Hospital s policy that s/he will be discharged as of the date that a bed becomes available at any one of his or her facility choices and that s/he will be charged the per diem rate for uninsured services from that date forward. 26
Dealing with Difficult Discharge Situations THE KEY IS COMMUNICATION All involved in the discharge planning process, and in the discharge plan, should be working together to form an appropriate plan. First question WHO makes the decision? Second question WHAT to consider in making a decision? 27
Capacity - HCCA A two-part test based on s. 4(1) HCCA: a) Is the person able to understand information relevant to making the decision? b) Is the person able to appreciate consequences of a decision or lack of decision? If the answer is yes to both questions: person is capable. Can apply to treatment, admission to a care facility or a personal assistive service. 28
Determining Capacity A patient is presumed to be capable The onus is on the evaluator to prove incapacity Evaluator may rely on this presumption unless reasonable grounds to believe otherwise Capacity can change! 29
Determining Capacity Test for capacity is objective two parts CCB: there must be cogent and compelling evidence of incapacity It is not enough to disagree with a person s decision to refuse to consent. 30
Doubts about capacity? If in doubt, the evaluator proposing a treatment / admission should conduct an evaluation and consider whether: a) The person is able to understand information relevant to making decision; and b) The person is able to appreciate the reasonably foreseeable consequences of treatment or lack of treatment 31
Follow up required on finding of incapacity Follow-up to finding of incapacity: a) In accordance with professional guidelines, evaluator must provide to the incapable person information about the consequences of the finding; b) Identify a Substitute Decision Maker (SDM) who may consent on the incapable person s behalf; and c) Document the capacity assessment and consent discussion in the patient s chart 32
Substitute Decision Makers (SDMs) and consent More on these in a few minutes!!! 33
Role of the Consent and Capacity Board, the CCB The CCB is an independent provincial tribunal that has been established to provide fair and accessible adjudication of consent and capacity issues, balancing the rights of vulnerable individuals with public safety. Consent and Capacity Board Website, online: Ontario Consent and Capacity Board, www.ccboard.on.ca; A Practical Guide to Mental Health and the Law in Ontario, October 2012, page 63. 34
What does the CCB do? The CCB holds hearings under the: Health Care Consent Act Mental Health Act Personal Health Information Protection Act Substitute Decisions Act A complete list of the types of applications that may be made to the CCB can be found in Appendix C in the OHA s A Practical Guide to Mental Health and the Law in Ontario and on the CCB website. 35
Who can be a Substitute Decision-Maker? Guardian of the Person, if so authorized: SDA Attorney for Personal Care, is so authorized: SDA CCB appointed representative Spouse or Partner A child or custodial parent or CAS A parent with right of access only A brother or sister Any other relative None of the above: the Public Guardian and Trustee 36
SDM the essential ingredients Qualifications Person on the list of potential SDMs: s. 20(1) Capable with respect to the treatment At least 16; unless the parent Not prohibited by court order or separation agreement from having access or giving consent Available Willing to assume responsibility No higher ranking SDM 37
Public Guardian and Trustee Where there is no SDM who meets the requirements in s. 20(2), the PGT shall make the decision to give or refuse consent PGT also acts where two equally ranking SDMs are in conflict over a decision Investigations to determine need for guardianship of mentally incapable persons 38
Duties of the SDM SDM shall give or refuse consent according to certain principles: Must act in accordance with a prior capable wish, expressed by person > 16 years of age If no known prior, capable wish, must act in accordance with the incapable person s best interests 39
What are Best Interests? Values and beliefs held when person was capable; Any wishes expressed that are not P.C.W. ; The following factors: Will improve person s condition or well being Will prevent or reduce the rate of deterioration Will the patient improve, remain the same or deteriorate without Benefits of weighed against risk of harm Comparative benefit of a less restrictive or less intrusive, including no. 40
Consent for Admission to Long-Term Care This is often part of the discharge planning process. The definition for capacity with respect to admission to a care facility is the same as for treatment: a) Is the person able to understand information relevant to making the decision? b) Is the person able to appreciate consequences of a decision or lack of decision? 41
Consent in Discharge Planning Discharge planning is not limited to admission to a care facility. All aspects of a comprehensive discharge plan should be considered / reviewed in this process. Will likely involve several members of multidisciplinary team. 42
Elements of Consent Must relate to the admissions / proposed treatment Must be informed Must be given voluntarily Must not be obtained through fraud or misrepresentation 43
Informed Consent - Admission What the admission entails The expected advantages and disadvantages of admission Alternatives to admission The likely consequences of not being admitted 44
Informed consent things to remember Ensure that all of the person s questions about the treatment are answered. Following an informed consent discussion, the capable person or SDM is entitled to either consent or refuse to consent to the proposed treatment / admission. Refusal of treatment / admission by a capable person is lawful, even when the refusal jeopardizes life. 45
The role of the patient, SDM, family and health care providers What is the proposal for which consent is being sought? Who should be making the decision? What factors should be considered? How quickly should a decision be made? 46
Thank you!! 47
Helping Patients Find Their Way Keynote Dale Clement Chief Executive Officer Waterloo Wellington CCAC
Lunch
5-Minute Countdown Video Calendar Girl
Patient Experience Video Robert Falconer
Helping Patients Find Their Way Presentation Daniel Ball Director of Patient Care & Clinical Analytics Central West CCAC
Innovative Health Care Without Boundaries Daniel Ball, June 9 th, 2015 Central West CCAC 53
Background Our Team Central West LHIN Is home to over 840 thousand residents living in one of the fastest growing and most culturally diverse regions of Canada 23 Long-Term Care Homes (LTC) providing an estimated 750,000 resident days/year Over 600 Primary Care Physicians 2 hospital corporations (William Osler Health System and Headwaters Health Care Centre), operating 3 hospital sites attending over 70,000 hospital admissions and 233,500 unscheduled ED visits/year 54
Need for Our Team Change In April 2013, 13.3% of Ontario s hospital beds were patients deemed as Alternate Level of Care (ALC) the equivalent to over 116,000 ALC days. In Central West, ALC patients accumulated over 3,400 days (12.5%) which dramatically impacted the efficiency of patient flow. As the majority of these patients were identified as waiting for long-term care (LTC), CW CCAC and WOHS partnered to redesign Home First Strategies. 55
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Intro- Home first Redesign Formulating strategy is one thing. Executing Formulating it throughout strategy the entire is one organization thing.... well, that s the really hard well, part. that s Without the effective really hard execution, part. no business strategy can succeed. Executing it throughout the entire organization... Without effective execution, no change strategy can succeed. 57
Home First Philosophy The principle of a Home First philosophy is that patients should, where clinically appropriate, return to a home environment in the community following an acute care admission. Home First is not a mandatory program, it is a philosophy intended to promote the Ministry s overarching goal of providing appropriate care in the appropriate setting. There may be some ALC patients for whom a discharge home, even on an interim or transitional basis, is not an appropriate option. 58
Patient Flow Objectives Vision Exceptional Patient Experience High Quality Patient Care Smooth Transitions Improved Patient Flow/ Reduced ALC volumes Standardized Processes and Communication Minimize errors in the consent process Integrated Team Optimize roles and minimize duplication 59
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Key Success Our Team Factors Strong Partnerships, Collaboration and Shared Accountabilities to improve the Patient Experience 62
Home first Redesign -Approach and Key Success factors- 63
System Wide Collaboration and Engagement How can we work together differently? 64
System Wide Collaboration and Engagement Hospital Physicians Discharge Care Coordinators CCAC Care Coordinators Professional Practice (Allied Health) Ethicist Legal Counsel LTC Senior Leadership Clinical Management Finance Access & Flow Nursing Community Partners IT/ Decision Support Primary Care 65
Review, Identify and Share Performance Our Opportunities Team 66
Cause and Effect PEOPLE PROCEDURES Hospital Physicians Allied Discharge Cord CCAC Primary Care Patient/SDM BSO Contracted Service Providers Escalation Med rec Consent Joint Meetings LHIN Boundaries Escalation Team Community Partners Decision Support/IT LTC Health Reports Pathways/Scripts Service bundles ALC Rates Delays Not ordered Hoyer Hospital Bed Not available Consent and Capacity SDM LTC Legislation Hospital Policy/Act EQUIPMENT POLICY Different people own different parts of this problem
Cause and Effect PEOPLE PROCEDURES Hospital Physicians Allied Discharge Cord CCAC Primary Care Patient/SDM BSO Contracted Service Providers Escalation Med rec Consent Joint Meetings LHIN Boundaries Escalation Team Community Partners Decision Support/IT LTC Health Reports Pathways/Scripts Service bundles ALC Rates Delays Not ordered Hoyer Hospital Bed Not available Consent and Capacity SDM LTC Legislation Hospital Policy/Act EQUIPMENT We often look for person(s) responsible for the delays rather than looking at the big picture POLICY
Build on Our Best Team Practice Research and consult provincial leaders Evidence based LEND (=give) BORROW (=take) 69
Provide Role Clarity: Who is doing what on discharge? Patient Choosing where he/she would like to go after discharge Consenting or withholding consent if something is proposed, and he/she is capable Hospital Team Discharging & developing recommendations to help patient achieve his/her discharge goals The designation of ALC is determined by the physician in collaboration with the interprofessional team CCAC Proposing long term care and/or home care, assisted services Substitute Decision Maker (if required) Providing or withholding consent to what is proposed, in accordance with the principles of substitute decision making from the Health Care Consent Act 70
Standardized Processes and Pathways 71
Optimize Technology Optimize Technology to improve efficiencies Referral Processes Patient lists/census/triage Reporting and monitoring * Optimize roles and minimize duplication 72
Documentation Standards Review Documentation Standards Identify and share common errors Create checklists Develop documentation templates 73
Minimize Errors in the Consent Process Health care professionals may: 1. seek consent for decisions that do not require it 2. take direction from a family member when the patient is capable 3. take direction from the wrong substitute decision-maker (SDM) when the patient in incapable 4. not always meet documentation standards to support actions/decisions (i.e. capacity assessments) 5. know of a prior expressed wish but ignore that wish when considering a placement plan 6. wait for an SDM who is not available, willing and capable, instead of proceeding down the hierarchy of decision-makers 7. not use an interpreter when is required 8. identify a POA without seeing/obtaining the POA document 74
Consent to Long-Term Care Exploration of patient values, wishes and beliefs around LTC Only CCAC can propose LTC to a capable patient or, in the event of their incapacity, his/her substitute decision-maker (SDM) SDM has legal obligations to: Act on behalf of the patient and not based on his/her own preferences Consent/refuse in accordance with prior expressed, capable wishes Consent/refuse in best interests of patient 75
Standardized Communication Scripts developed for staff; Accurate, clear and coordinated communication are key to successful discharge planning. Equips staff with tools to engage in appropriate conversations with patients. Enables staff to meet legal and ethical obligations and avoid common consent errors. Facilitates consistency in messaging and encourages one voice, one team philosophy 76
Customized Training and Communication Our Team Customized Training and Communication Hospital CCAC Care Coordinators and Discharge Care Coordinators Allied Professionals Nursing Clinical Managers Hospital Physicians Primary Care LTC Community Support Partners (i.e. assisted living, Retirement Homes) CCAC staff and Contracted Service Providers 77
Leadership Create Support Teams Created to support staff (all levels) Meets weekly to review/strategize complex discharges Leadership presence Walk the talk 78
Leadership 79
Our Metrics, Team Anyone keeping score? Leadership Support Team Created to support staff (all levels) Meets weekly to review/strategize complex discharges jjjjj jjjjj jjjjj jjjjj jj 80
Performance outcomes Home First- Number of Patients Enrolled 2013/14-396 2014/15-593 Readmission Rates 2013/14-14% 2014/15-9 % ALC 2013-12.5% 2014-6.8% 2015-6.8% (February) 81
Monitor, Adjust and Sustain 82
Performance outcomes Monthly Budget vs Actual 5,300,000 5,100,000 4,900,000 4,700,000 4,500,000 4,300,000 4,100,000 3,900,000 Apr '14 May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Proj'n** Actual Gold and Budget Green Updated Budget Feb '15 In Home excluding PT/E&F Actual Feb 2015 per GL In Home excluding PT/E&F 83
Testimonies When staff were asked about the impact of the revised Home First framework on their patients and practice, here s what staff had to say: Having more specific points of contact and knowing exactly who/how I can ask for additional support is a vital component that has improved the process. The new improvements to the Home First process have been beneficial for various reasons such as: -Adding structure to the process making planning and implementation move more smoothly and efficiently. -Allowing Discharge Coordinators to better understand the Home First process through clarification of our role, in addition to the clarification of the roles of other disciplines. We are all talking now from the same book! 84
Leading Change 85
Our Summary Team Strong Partnerships, collaboration and shared accountabilities to improve the Patient Experience Engage all key Stakeholders Research and consult provincial leaders Identify and share performance opportunities Evidence based Standardize Processes Define Roles & Accountabilities Standardized Communication Staff Training and Resources Minimize errors in the consent process Create Support Teams-Leadership Presence Optimize Technology Monitor, adjust, and sustain 86
Take away messages One team, one voice. Build processes around the patient. Don t work patients around the processes. Nothing about me without me- talk with the capable patient Capable patients can choose to live at risk When patients are incapable, ensure the SDM(s) understand their role and that they are making decisions in the best interest of the patient. CCAC s are the placement co-ordinators for admission to long term care homes in Ontario. This role is designated in legislation and cannot be delegated. 87
Thank You For your time 88
Patient Experience Video Kathryn Brooker
Helping Patients Find Their Way Presentation Jane Meadus Barrister & Solicitor Institutional Advocate Advocacy Centre for the Elderly
Patient Experience Video Madeline Kerr
Helping Patients Find Their Way Panel Discussion #2
Helping Patients Find Their Way Closing Remarks Laurie Zimmer ED/ALC Manager
Questions
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