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Access to the Best Care Urgent Care Centre Overview Earlier this year, Hamilton Health Sciences (HHS) introduced 'Access to the Best Care.' This is a multi-faceted, four-year plan designed to ensure the best outcomes for patients, optimize resources, and enhance access to care by realigning clinical services and introducing new services where need has been identified. This plan also incorporates the Ministry of Health and Long-Term Care s (MOHLTC) key priorities of reducing wait times with a focus on emergency care and improving access to quality family health care. In keeping with this, HHS is proposing the creation of a dedicated pediatric Emergency Department (ED) at McMaster University Medical Centre (MUMC) on Main Street West in Hamilton. This means that the adult emergency care now provided at MUMC will shift to the two other EDs operated by HHS and the one ED operated by St. Joseph s Healthcare Hamilton (SJHH). In addition, and in a further effort to provide improved access for patients, HHS is proposing the establishment of a new Urgent Care Centre (UCC) in the west end of Hamilton. Ideally, HHS would like to open this UCC by fall 2009 at 690 Main Street West (currently The West End Clinic), well in advance of the change of the MUMC ED to care for pediatric patients only. In all, when the proposed changes are fully implemented, people in Hamilton and the surrounding region will have more places to go for urgent and emergency care: Today 4 EDs (three old, one revitalized) 1 UCC (east side - SJHH) 5 Total No dedicated pediatric department (unlike most major centres in Canada) Four years from now 3 revitalized EDs 1 new pediatric specialty ED 2 UCCs (east side SJHH, west side HHS) 6 Total This document has been prepared to provide further context and rationale related to the new UCC for HHS Board members and the HNHB LHIN. The UCC is just one component of the 'Access to the Best Care' plan, however, if approved, it will play an important role in helping HHS meet the immediate health care needs of this community and relieve current pressure on the city's EDs. Ultimately, by providing an additional 2
point of access to urgent care, HHS will be offering the community a much needed, valuable health care resource. The need for change Like communities across Canada, Hamilton has a shortage of health care professionals. Patients and families experience challenges accessing primary care, urgent care and emergency services in a timely way. Whether they are having difficulty seeing a family physician quickly, or find themselves facing significant wait times in the ED, a new centre for non-emergent, urgent care will be a welcome addition to the community. HHS believes the creation of a second UCC on the west side of the city (to complement the existing UCC on the east side), will provide a meaningful improvement to the system in two ways: it will provide the west side of the city with the same access to urgent care now enjoyed by residents on the east side; it will be a significant release valve for the overcrowded EDs and the ambulance service, which at times is challenged to off-load. Leaders at HHS and McMaster University also believe the new UCC represents a great opportunity for teaching future generations of family physicians, ED physicians and other health professionals. Emergency and Urgent Care volumes in Hamilton Currently, Hamilton hospitals (Hamilton General Hospital, Henderson General Hospital, MUMC and SJHH) see approximately 200,000 emergency/urgent patients each year (45,000 of these patients use the services of SJHH's UCC.) Last year, the ED at MUMC cared for 38,595 patients. A total of 24,126 were adults and nearly 60 percent of these patients could have been properly (and more quickly) cared for in an UCC. Interestingly, only 4,568 (or 19 percent) of all adult visits to the MUMC ED last year were admitted to the hospital. 3
The role of Urgent Care Centres Almost 30 years ago, Ontario's first UCCs were created to relieve pressure on hospital EDs by offering patients who have immediate, non life-threatening health care concerns an alternative to emergency care. UCCs treat illnesses or injuries that do not require the specialized attention of a hospital ED, but cannot wait for a scheduled appointment with a primary care physician. An UCC does not accept ambulances and cannot admit patients. If patients with lifethreatening illnesses such as heart attacks come to an UCC, they are stabilized and then transported to the appropriate ED by ambulance. UCCs can be built within existing hospital structures or as freestanding centres and are typically located in rapidly growing suburbs or in areas where augmented access is needed to meet community health care needs. There are a number of both hospital-based and freestanding UCCs in Ontario. By way of example, Trillium Health Centre operates a UCC in the Etobicoke that sees 40,000 patients annually. Similarly, Niagara Health System's Prompt Care Centre sees 33,250 patients annually while North York General Hospital's Branson Division UCC sees 30,000 a year. In Ottawa, the Orleans Urgent Care Clinic sees 70,000 patients a year and has almost doubled its volumes since it opened 12 years ago. This evidence suggests that once HHS UCC is up and running, non-emergency demands on local EDs should be notably reduced. Based on all assessments and examination of data, a conservative estimate would see this new UCC achieve at least 30,000 visits in its first year. Proposed Annual Visits to HHS new UCC Visits Source (where these patients would currently attend) 10,683 MUMC Adult ED 3,000 MUMC Pediatric ED 3,600 St. Joseph s Urgent Care Centre 1,000 Henderson Hospital ED 7,800 St. Joseph s Charlton Avenue ED 2,300 Hamilton General ED 3,000 New Visits 31,383 TOTAL Visits (For more information on the assumptions made to develop these figures, see Appendix 1) Based on a review of seven UCCs across the province, we would forecast the following breakdown of our 31,383 UCC visits by triage level. 4
Proposed Patient Visits by CTAS Level to HHS new UCC CTAS Levels (1 most urgent, 5 least urgent) Percentage of Patients Volume Split 1 0.02% 6 2 2.61% 818 3 19.21% 6,029 4 55.40% 17,385 5 22.77% 7,144 TOTAL 100.00% 31,383 Urgent Care Centre Planning Stakeholder Engagement HHS has sought broad stakeholder input and feedback while developing and refining the plan and location for the UCC. Our vision for this exciting new centre was developed in collaboration with the Department of Family Practice, McMaster University and representatives of local Family Health Teams. Throughout this planning, we have all been fully committed to improving access to high quality care while optimizing staff and physician resources and improving their quality of work life. The creation of the UCC will achieve both goals by offering more access to care for patients and a better working environment and conditions for staff. A variety of proposed models for collaboration between primary care and urgent care have been considered. The Chief of Emergency Medicine, HHS, who has represented the hospital s ED physicians, and the HHS Chief & Chair of Family Medicine representing the Faculty of Health Sciences, McMaster University, as well as family physicians and the interests of local Family Health Teams, have recommended an innovative integrated model. Integrated model enhances clinical care and education In this proposed model, the physical space of the new UCC will be co-located with a roster of family health teams, sharing infrastructure and amenities. Beyond the efficiencies associated with this sharing of space and non-clinical resources, there will also be significant clinical and teaching benefits. The integrated model will allow a combined facility for the Family Health Teams to operate their after-hours service alongside emergency physicians who are providing urgent care. This will allow for new synergies to develop as consultation between family physicians and emergency physicians happen in close proximity and in real time, providing the best care for patients. 5
The MOHLTC is very interested in pursuing opportunities to retrain family physicians in all levels of emergency medicine and this partnership will provide the appropriate environment to further this objective. Furthermore, an integrated environment will be novel and ideal for teaching tomorrow s health professionals since both family and emergency medicine physicians are actively involved in training all medical learners. The UCC will increase teaching opportunities and become an ideal environment for highquality learning and research. When opened, the UCC will be staffed by emergency physicians and nurses focused on providing urgent care but capable of treating serious medical conditions. The centre will be properly outfitted, including a fully equipped resuscitation room. Equipment on site will provide for effective treatment of other medical conditions such as lacerations, asthma, fractures, dislocations, etc. Most lab tests will be available quickly and on site. Basic diagnostic imaging, including ultrasound and X-ray, as well as an outpatient pharmacy, will also be readily available. Hours of Operation UCCs are typically open between 8 a.m. and 10 p.m. to accommodate patients during the busiest times of day. This schedule is supported by data gathered by the Canadian Institute for Health Information that reports, Patients were most likely to go to an ED between 8 a.m. and 8 p.m., with 11 a.m. recorded as the peak arrival time. The least busy time of day was recorded at 6 a.m. Visits to the ED by the most urgent cases and by the least urgent cases peaked at the same time, between 7 a.m. and 11 a.m. HHS UCC will be guided by a similar schedule; however we will remain flexible in our approach based on the flow patterns of the community we are serving. We will also take the needs of our family health team partners into consideration as we proceed. Proposed Location The recommendation of a location for the new UCC has been informed through extensive consultation and is a significant aspect of this proposal. Our top priority was ensuring maximum ease of access for patients and the broader community, today and in the future. HHS planners have considered the demographics of the community and the trends of age and illness among the people whom UCC will be built to serve. We also consulted with the City of Hamilton s urban development staff and were surprised to learn that growth in the population will not be to the south and west of the city. In fact, through provincial greenbelt legislation restrictions, as well as the City s own plan for intensification in the downtown and along major arterial routes, population growth in Hamilton will be closer to the core. It is further recognized that the UCC would be ideally located with strong access by public transit, major roads and highways. HHS has learned from other centres that ample parking and high visibility are fundamental to ensuring best possible access and utilization of the UCC. In addition, 6
HHS planners have been careful to pay close attention to the cost implications of the site choice. We are cognizant of the potentially high price of green field land ($2 to $3 million) and new construction ($4 to $5 million) for a project like this. That approach would also take time - time we don t have if we expect to keep up with the community s changing needs. After consulting with a wide range of stakeholders, we are recommending an option that involves the renovation of an existing hospital property where we have a long-term lease. That property, the West End Clinic on Main St. West, is an ideal location for a new UCC serving the broader Hamilton community. It meets all of the key criteria in that it has excellent proximity to Highway 403 and is easily accessible by public transit. It also has ample parking, good visibility and is located close to Hamilton s core. Since it is also currently being used for medical purposes, renovations to convert the space to an UCC would be minimal. Estimated Operating and Capital Costs HHS UCC Operating (estimate includes diagnostic imaging and laboratory services) REVENUES Total Revenues $600,000 EXPENSES Staffing and benefits 2,001,480 Medical/surgical supplies 110,000 Drugs 70,000 Supplies and other expenses 450,000 Annual maintenance and facilities 296,820 Total Expenses 2,928,300 NET OPERATING COSTS $2,328,300 Capital Costs (estimate includes diagnostic imaging and laboratory services) Renovation/construction $1,640,000 Construction contingency 348,000 Ancillaries 439,000 Furnishings and Equipment 1,502,000 TOTAL CAPITAL COSTS $3,929,000 Next steps HHS goal is to receive HNHB LHIN approval and begin working to prepare the West End Clinic location for a fall of 2009 opening. This ambitious timeline is purposeful. Not only will a fall 2009 opening achieve muchneeded access improvements for the community, it will provide important relief for the overburdened EDs. 7
Furthermore, this timeline provides maximum lead-time for HHS/McMaster Children s Hospital to put in place the changes necessary to create a dedicated pediatric facility in the MUMC ED. This lead-time will also be an important period for educating and communicating with the community about the changes taking place. 8
Appendix 1 Proposed Annual Planning Assumptions HHS Urgent Care Centre Volumes Visits Source (where these patients would currently attend) 10,683 MUMC Adult ED 3,000 MUMC Pediatric ED 3,600 St. Joseph s Urgent Care Centre 1,000 Henderson General ED 7,800 St. Joseph s Charlton Avenue ED 2,300 Hamilton General ED 3,000 New Visits 31,383 TOTAL Visits The following assumptions were made in the development of this chart: 80% of adult patients with CTAS scores of 4 or 5 who now come to the MUMC ED would attend the new HHS UCC 7,394 30% of adult patients with a CTAS score of 3 who now come to the MUMC ED would attend the new HHS UCC 3,289 20% of pediatric patients who now come to the MUMC ED would attend the new HHS UCC 2,893 90% of patients who now come to the SJHH UCC who live in northwest Hamilton, Ancaster, Dundas, and the northwest Mountain would attend the new HHS UCC 1,016 80% of patients who now come to the SJHH UCC who live on the west Mountain would attend the new HHS UCC 1,563 80% of patients who now come to the SJHH UCC who live in west Hamilton would attend the new HHS UCC 403 50% of patients who now come to the SJHH UCC who live in Burlington would attend the new HHS UCC 125 25% of patients who now come to the SJHH UCC who live in rural Hamilton would attend the new HHS UCC 500 10% of patients with CTAS scores of 4 or 5 who now come to the Henderson ED would attend the new HHS UCC 1,000 20% of patients with CTAS scores of 4 or 5 who now come to SJHH s ED would attend the new HHS UCC 7,800 15% of patients with CTAS scores of 4 or 5 who now come to Hamilton General s ED would attend the new HHS UCC 2,319 New visits (not currently accessing the ED system) 10% of 30,000 total visits 3,000 9
Appendix 2 10