Short Stay Convalescent Care Program and RAI-HC Assessment Evaluation Demonstrating improved patient outcomes and care transitions June 10, 2014 OACCAC Achieving Excellence Together Jennifer Scott, Director, Patient Services - Placement Services Debbie Taciuk, Supervisor, Patient Services Central CCAC Outstanding care every person, every day
Agenda Short Stay Convalescent Care (SSCC) Overview Resident Assessment Instrument Home Care (RAI-HC) Analysis: Data Overview Demographics Outcome Measures Client Assessment Protocols (CAPs) SSCC Outcomes & Transitions Summary Appendices 2
Short Stay Convalescent Care Program Overview CCAC/Long-Term Care Home (LTCH) partnership Provided within LTCHs funded by MOHLTC 690 beds in Ontario 105 beds in Central LHIN Requires access to 24-hour care, and rehabilitation goal(s) Medical, therapy and support services Patient and family education Maximum 90 days length of stay Based on attaining rehabilitation goal(s) Discharge to community setting 3
Ms. C s experience 77 years old Fractured knee post-fall SSCC improved pain, independence with ADLs and most IADLs Hospital Referral Day 7 RAI Admit Day 7 Rehab Goals SSCC Admit Day 12 Rehab Goals met RAI Discharge Day 44 Discharge Home Day 49 CCAC assesses & determines eligibility CCAC reassesses & coordinates CCAC & Community Service (s) to support transition home 4
RAI Outputs Ms. C: RAI Data Comparison ADL (0-6) ADL Long (0-28) Pain (0-3) CHESS (0-5) MAPLe DRS (0-14) RAI Admit 4 18 3 1 Moderate- 2 7 3 RAI Discharge 0 2 2 0 Mild 0 4 Medication Review RAI Admit (4) RAI Discharge (4) CAPs Tylenol PRN at least two/day Zopiclone (Imovane) PRN taken daily (sleep) Coversyl daily (blood pressure) Fragmin daily Tylenol at Bedtime Calcium daily Centrum Vitamin daily Vitamin D daily 5
Data Overview Includes 1681 Central CCAC patients with a SSCC Referral Start and End date between January 2007 and February 2014 All patients had a RAI-HC completed upon starting the SSCC referral (RAI Admit) All patients had a RAI-HC completed prior to SSCC referral discharge (RAI Discharge) Average Length of Stay: 64 days 6
Demographics/Living Arrangement 74% women and 26% men Average age: 81 years 40% 35% 30% 25% 20% 15% 10% 5% 0% 20% live alone 31% live with spouse and/or family 20% 13%13% 6% 7% 3% 39% Alone Spouse/Life Partner With Family With Spouse and Family Other Arrangement Non Private Residence Not Available Note: Not Available Living Arrangement information part of initial referral assessments to CCAC only 7
Demographics: Marital Status 54% Widowed 30% Married 60% 54% 50% 40% 30% 20% 10% 6% 30% 1% 2% 7% Divorced Married Other Separated Single Widowed 0% 8
RAI-HC Outputs Compared: Admission vs Discharge Changes in Health, End Stage Disease and Signs and Symptoms (CHESS) Pain ADL Hierarchy (ADL) ADL Long (includes all ADLs) Method for Assigning Priority Levels (MAPLe) Client Assessment Protocols (CAPs) Depression Rating Scale (DRS) 9
CHESS Comparison between RAI Admit and RAI Discharge 60% 50% 51% 51% 68% improved on RAI Discharge 40% 30% 20% 10% 0% 31% 29% 13% 13% 5% 4% 1% 1% 0% 0% 0 1 2 3 4 5 Admit Discharge CHESS scale is a predictor of risk of adverse outcomes such as mortality, hospitalization, pain and caregiver stress, as well as medical complexity. 10
Pain Scale Comparison between RAI Admit and RAI Discharge 60% 50% 40% 30% 20% 10% 0% 0= No Pain 18% 29% 1/3= Less than Daily Pain 8% 12% 58% 50% 16% 0 1 2 3 2/3 = Daily Pain (mild OR moderate) 3/3=Daily Severe Pain 9% Admit Discharge Frequency and intensity of reported pain improves 35% on RAI Discharge More % improvement possible, as score of 2 varies in pain intensity 11
60% 50% 40% 30% 20% ADL Comparison between RAI Admit and RAI Discharge 51 % require limited to weight-bearing assistance on RAI Admit vs 14% on RAI Discharge Admit Discharge 10% 0% 0 1 2 3 4 5 6 Admit 7.50% 11.24% 30.46% 18.62% 25.64% 6.48% 0.06% Discharge 56.34% 15.29% 14.40% 7.38% 4.52% 1.61% 0.48% ADL hierarchy includes personal hygiene, locomotion, toileting and eating ADL = 1-2 = Light Physical Care Needs ADL = 3-4 = Medium Physical Care Needs ADL = 5-6 = Heavy Physical Care Needs 12
70% 60% 50% 69% ADL Long Comparison between RAI Admit and RAI Discharge 87% improved on RAI Discharge 40% 30% 20% 10% 0% 27% 28% 10% 17% 16% 14% 8% 5% 3% 2% 1% 0% 1% 0 4 5 8 9 12 13 16 17 20 21 24 25 28 Admit Discharge ADL Long includes all ADLs within RAI-HC 90% scored 5-24 on RAI Admit vs 32 % on RAI Discharge 13
MAPLe comparison between RAI Admit and RAI Discharge 80% 70% 60% 50% 40% 30% 20% 10% 0% 16% 18% 0% 1% 73% 24% 2% Low Mild Moderate High Very High 97% Moderate to High on Admit 62% Moderate to High on Discharge 41% 21% 4% Admit Discharge A shift to the left indicates decreased risk for LTC placement and reduced resource allocation in home care services. 14
RAI Discharge Score Improvements vs. No Change 90% 80% Depression Rating Scale 70% 60% 50% 40% 30% 20% 10% 0% CHESS Pain Maple DRS ADL ADL long Improvements 68% 35% 43% 43% 75% 87% No Change 23% 53% 40% 40% 17% 5% CHESS, ADL, and ADL Long score prove to be areas with the most significant improvements in score on the RAI Discharge. 15
100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Top Triggered CAPs at Admit vs. Discharge 97% 82% 79% 71% 63% 57% 48% 48% 38% 36% 23% 15% 19% 17% 6% 7% Admit Discharge 16
RAI-HC Rehabilitation Admit Criteria: Criteria Based on Data Review: Ms. C meets criteria Description RAI Scale Admit Score Check Medically CHESS 0-2 Stable ADL Needs ADL Hierarchy 2-4 ADL Long 5-20 ADL/IADL Needs/ Cognition Intact- Mild Impairment MAPLe Moderate- High CPS 0-2 Motivation & Potential ADL Rehab CAP triggered 17
80 70 60 50 72.9 72.4 SSCC Outcome by LTCHs January 2011- January 2014 64.7 64.9 70.4 Overall 85% go home or to other destination % Discharged Home % Discharged to Hospital 40 30 20 10 5.1 14.2 20.4 22.2 18.3 % Discharged to LTCH % Discharged to Other Destinations 0 Hawthorne Place Maple Health Centre Newmarket Health Centre Senior's Health Centre Unionvilla Other destinations include: Rehabilitation Respite/Return to Retirement Home Supportive Housing/Assisted Living 18
Care Transitions after SSCC 66% of patients did NOT receive Central CCAC home care and/or LTC services 34% of patients received Central CCAC home care and/or LTC services 19
Summary Patients experienced functional improvements and transitioned back to community setting Significant improvements on RAI Discharge: ADL Hierarchy, ADL Long, CHESS Scale and MAPLe Falls and ADL Rehab Potential CAPs The number of CAPs triggered decreased after completing SSCC program Review areas for greater improvement Pain, Falls, Urinary Status, Psychotropic Medications, Depression Validate falls coding with assessors 20
Data Limitations Falls Coding Need to ensure NOT over coded if last RAI-HC assessment completed within last 90 days Discharge Destination not consistently captured over time of program Length of Stay used the referral dates in CHRIS admission to discharge date Required both Client Health and Related Information System (CHRIS) and RAI records to be included in data review for consistency Implemented CHRIS in 2009, RAI in 2003 21
Questions Josian Petgrave, Decision Support josian.petgrave@central.ccac-ont.ca Jennifer Scott, Director, Placement Services Jennifer.Scott@central.ccac-ont.ca Debbie Taciuk, Supervisor, Placement Services Debbie.Taciuk@central.ccac-ont.ca Jennifer Wright, Senior Manager, Patient Services - Projects Jennifer.Wright@central.ccac-ont.ca 22
Appendix A: Primary Language/ Use of Interpreter 2% 3% 11% English Italian Chinese Russian 1600 1400 1200 75% 1000 800 600 400 No Yes 200 0 Needs an Interpreter 23
Appendix B : MAPLe MAPLe Level Service Direction Need to Review: 1. LOW Generally I&R light homemaking 2. MILD Likely to need personal care & homemaking 3. MODERATE Require a range of services almost none appropriate for I&R only NOTE: Convalescent Care usually Moderate 4. HIGH May require intensive in-home services and # of patients appropriate for LTC 1. Poor Stamina 2. Prior Self Rated Health 3. Hospitalization 4. Emergency Visits 5. Caregiver Status 6. Hours of Informal Care 7. Hours of Formal Care 8. Family Preferences 9. Patient Preferences 10. CHESS Score Medical Complexity 11. 24 hr supervision 12. Mental Health 5. VERY HIGH Highest # appropriate for LTC or remain in home with intensive services 24
Appendix C: MAPLe: Moderate-3 Patient Characteristics: Moderate - Sublevel 3 Present Cognition Performance Scale (CPS) = 2 or less ADL Hierarchy score = 1 or greater Absent No behaviour problems No falls problems No for few meals No swallowing problems 25
Appendix D: MAPLe level: Moderate- Sublevel 3 80% 64% 60% 40% 20% 0% 36% Yes No MAPLe Moderate-3 means the patient has ADL deficit(s) (ADL>1) and is cognitively intact (CPS<2) Possible predictive criteria for SSCC program 26
80% 70% 60% 50% 40% 30% Appendix E: Diagnosis (Based on sample of 267 patients in 2011) Average Number of Diagnoses per patient: 4 Top 8: 1. HTN 2. Arthritis 3. Other Fracture 4. Osteoporosis 5. Diabetes 6. Hip Fracture 7. CAD 8. Emphysema/COPD /Asthma 20% 10% 0% Admit Discharge 27
Appendix F: % Falls Admit vs Discharge 70 66 60 50 50 40 30 20 10 0 30 22 13 8 5 2 4 2 0 1 2 3 4+ Admit Discharge 28
Appendix G: Number of Falls 800 700 600 500 400 300 200 100 0 765 747 177 Fewer falls No change More falls Falls Frequency After Discharge 29
Appendix H: SSCC Outcome Overall by LTCHs Review based on data captured to date: January 2011-2014 80.0 60.0 40.0 20.0 0.0 69.4 % Discharged Home 15.6 % Discharged to Other Destinations % Discharged to Hospital 7.5 7.5 % Discharged to LTCH Discharge Destination 30