An Integrated Program for Complex Care in the Hamilton Niagara Haldimand Brant Local Health Integration Network

An Integrated Program for Complex Care in the Hamilton Niagara Haldimand Brant Local Health Integration Network Final Report from the Task Group on Coordinated Strategy for Complex Care to the Hamilton Niagara Haldimand Brant Local Health Integration Network Board of Directors The Model for an Integrated Program for Complex Care in the HNHB LHIN Page 1 of 27

Table of Contents EXECUTIVE SUMMARY 3 1. BACKGROUND 6 1.1. 6 1.1.1. Hamilton Niagara Haldimand Brant Local Health 6 Integration Network s Integrated Health Service Plan and Clinical Services Plan 1.1.2. Clinical Program Integration 6 1.2. Complex Care Task Group and Process 7 1.2.1. Project Scope and Objectives 7 1.2.2. Task Group Process 8 1.3. Inpatient Complex Care in HNHB LHIN Current State 8 2. COMPLEX CARE PROPOSED INTEGRATED PROGRAM 11 2.1. Service Delivery Model 11 2.1.1. Common Definitions and Admission Criteria 11 2.1.2. Patient Flow Processes 13 2.2. Configuration Model 14 2.2.1. Configuration Model Criteria 14 2.2.2. Sizing the Inpatient Complex Care System 14 2.2.3. Siting the Inpatient Complex Care System 17 3. TRANSITION PLAN AND NEXT STEPS 20 3.1. Transition Agenda 20 3.2. Next Steps 21 4. APPENDICES 23 A. Task Group Terms of Reference 23 B. Complex Care Task Group Membership 25 C. Task Group s Planning Advisory Group Subgroup Membership 26 D. Snapshot Audit (March 2010) 26 E. Task Group Proposed Staffing Principles 27 Page The Model for an Integrated Program for Complex Care in the HNHB LHIN Page 2 of 27

EXECUTIVE SUMMARY In January 2010, the Hamilton Niagara Haldimand Brant (HNHB) Local Health Integration Network (LHIN) established a Complex Care Task Group (Task Group) to develop the elements of a LHIN-wide integrated program in complex care (CC). The Task Group built on the planning work for CC that was completed by the Planning Advisory Group (PAG), during the Clinical Services Plan (CSP) development process. Over the course of a three month period, the Task Group developed a service delivery model, configuration model, and transition plan for an integrated program in CC. The Task Group s service delivery model includes common definitions for CC and its substreams. The definition of CC and the subspecialty streams represent a relatively new way of thinking about CC. The CC bed is not intended as a final destination for the patient a plan for discharge is required on admission. Individuals appropriate for CC are medically stable (diagnosis and acute phase complete), but have multiple complex chronic conditions requiring daily skilled assessment by an interprofessional team. Lengths of stay are targeted in a range of 45-90 days, with clear goals set, in order to enable appropriate care to be provided at home or at a different level (e.g. long-term care (LTC) or supportive housing). The Task Group also recommends an expanded role for the HNHB Community Care Access Centre (CCAC) with respect to patient flow processes. This will include the management of a centralized wait list and the implementation of common assessment, referral, and placement processes. Recommendations about the configuration of CC beds in the HNHB LHIN were made based on a set of criteria established by the Task Group. The criteria were based on the work of the PAG and are organized according to the three broad aims guiding all of the clinical program integration work: improving the health of the population enhancing the individual s experience of care reducing, or at least maintaining cost. The Task Group developed a logic model to determine the future number of CC beds required in the HNHB LHIN. The steps in the logic model adjust utilization for population growth, unmet need, and alternate level of care (ALC) and occupancy rates. This process results in a right-sizing of the inpatient CC system from 686 beds to 628 beds. Finally, the Task Group considered transition and implementation planning. In order to get from the current state and current utilization of CC beds to the new model proposed in this report, a number of implementation activities will need to be coordinated simultaneously. Much of the operationalization work will be carried out by the individual hospitals within existing funding with the assistance of the CCAC. While it is anticipated that much of the transition work can be completed by April 2011, full implementation of the integrated program will require a phased process, targeted for completion by April 2012. For example, most hospital sites will need to realign their current complement of CC beds to a right-sized complement of beds, following the new stream definitions. In many cases, this will require a reduction in surplus CC beds (currently occupied by ALC patients), with focused programming and staffing to coincide with the programming. Discussions with the LHIN will enable these changes to take place within each hospital corporation, in the context of the Hospital Service Accountability Agreement (H-SAA). Each site would then work in partnership with the CCAC to make the changes that will transition the system to the new role. The Model for an Integrated Program for Complex Care in the HNHB LHIN Page 3 of 27

The following summarizes the immediate next steps to be taken once the CC report has received LHIN Board of Directors (Board) approval: Hospitals work with the CCAC on the appropriate placement of individuals currently designated ALC begin to admit new patients to the new definitions and streams reconfigure beds to comply with the plan using existing funding. CCAC work with hospitals on the appropriate placement of individuals designated ALC implement enhanced role in wait list management, assessment, referral and placement. LHIN establish a LHIN-wide coordinating group to monitor transition work in parallel towards the enhancement of community-based alternatives (community-based capacity project in process) discuss funding and accountability arrangements with each hospital and CCAC facilitate ongoing work with the hospital CEO group and subgroups towards the development of a longer-term leadership model which will oversee the implementation of: leading practice guidelines and targets incorporation of academic and research components ongoing evaluation, quality improvement, and performance measurements. The Model for an Integrated Program for Complex Care in the HNHB LHIN Page 4 of 27

Complex Care Task Group Recommendations: 1. That by Fall of 2010, the following definition of CC be formally adopted by all CC providers in the HNHB LHIN: Complex care is a specialized, time-limited program providing patients with complex medical conditions who require a hospital stay with ongoing onsite assessment and active care by an interprofessional team with a goal to enhance the health and quality of life. 2. That the CC admission criteria and streams be adopted and implemented by all CC providers in the HNHB LHIN by Fall 2010. 3. That the CCAC take on an enhanced role for CC beds starting in the Fall of 2010, including: centralized wait list management standardized assessment, referral and placement processes. 4. That the HNHB LHIN adopt the proposed allocation of 628 CC beds by stream and geography as the post-transition target (April 2012). 5. That the HNHB LHIN direct hospitals to reconfigure existing beds to comply with the plan, using existing funding. Hospitals should identify what changes will be made immediately; by April 2011; and by April 2012. 6. That the HNHB LHIN follow-up with each CC hospital provider and the CCAC to formalize funding, accountabilities, and performance requirements, including timelines for implementation, for incorporation in the next service accountability agreement. 7. That the HNHB LHIN establish a LHIN-wide coordinating group to facilitate and monitor transition towards the integrated program in CC. The Model for an Integrated Program for Complex Care in the HNHB LHIN Page 5 of 27

1. BACKGROUND 1.1. 1.1.1. s Integrated Health Service Plan and Clinical Services Plan The HNHB LHIN encompasses Brant, Burlington, Haldimand, Hamilton, Niagara and most of Norfolk County, covering approximately 7,000 square kilometres. The HNHB LHIN is home to more than 1.4 million people, with more than 70% of the population residing in the City of Hamilton and the Regional Municipality of Niagara. The HNHB LHIN works to ensure the availability of, and access to, linked services to improve the health of the population and the continuity of health care. This is consistent with the HNHB LHIN Vision of a health care system that keeps people healthy, gets them good care when they are sick, and will be there for our children and grandchildren. In anticipation of the development of the LHIN s second Integrated Health Service Plan (IHSP), the LHIN undertook the development of the CSP. The CSP is a population-based planning study, focusing on three key questions: 1. What are the health needs of the population? 2. What services are required to meet those needs? 3. How should those services be organized? The purpose in addressing these questions was to assist the LHIN in achieving its vision by improving the health of the population, enhancing the experience of quality and care of individuals in the system, and maintaining or reducing costs. The key themes arising from the CSP - clinical program integration (CPI); community-based health service capacity (CBHSC), and interprofessional care (IPC) were incorporated into the IHSP, providing a three-year roadmap for health system change in the HNHB LHIN. 1.1.2. Clinical Program Integration Through CPI, the LHIN wants to achieve integrated service delivery for selected clinical areas on a LHIN-wide, coordinated, program basis. The goal is to improve efficiency, access and quality. Integrated clinical programs will allow the system to maximize resources on a LHIN-wide basis, while at the same time, focusing those resources on improving health and quality. This will involve, for each selected clinical area, the development of service delivery models with elements of common definitions, assessment, admission, discharge, referral, clinical care pathways, etc.; population-based sizing and siting of resources; and consideration of leadership and accountability mechanisms, along with other implementation issues. The CSP identified 18 clinical program areas where potential exists to develop LHIN-wide integrated programs. Each of these clinical program areas may require a slightly different approach, however, in each case, the process, tools and outcomes will be the same. This report outlines the proposed integrated program plan for CC, formerly referred to as complex continuing care. The Model for an Integrated Program for Complex Care in the HNHB LHIN Page 6 of 27

1.2. Complex Care Task Group and Process 1.2.1. Project Scope and Objectives In January 2010, the HNHB LHIN established a Task Group to develop the elements of a LHINwide, integrated program in CC. Complex care was identified as the first clinical program area for the development of a LHIN-wide integrated program, in part, to provide guidance to hospitals in their plans for service delivery. In early discussions about the 2010-12 H-SAA process, several hospitals identified a potential closure of CC beds as a means to balance budgets. The Task Group was comprised of individuals with expertise in CC, administration, planning, epidemiology and community care. The Task Group was charged with developing, by mid-april 2010, the following: a service delivery model, including a: consistent, standardized, LHIN-wide definition for CC patients standardized admission and discharge criteria definition of bed types/services delivered at the LHIN-wide level, the sub-lhin or district level, and the local or community level. recommendations regarding the appropriate locations for and sizing of CC beds in the HNHB LHIN that is advised by the PAG model. a transitional plan that will: identify steps for incorporating the use of common admission and discharge criteria in all hospitals across the LHIN, ensuring that CC beds are being used for the appropriate patients identify accountability mechanisms to support the coordinated LHIN-wide model identify a LHIN-wide Human Resource (HR) staffing model that identifies scope of practice, skill mix, and policies. The Terms of Reference and Membership are attached as Appendices A and B. Based on the Terms of Reference, the Task Group further outlined the scope of work, goals, objectives and deliverables for the project. The Task Group agreed that, given its relatively short mandate, the project scope would be limited to inpatient CC bed utilization, configuration, and distribution within the HNHB LHIN. In limiting the scope to inpatient CC resources, the Task Group recognized the importance of viewing CC beds as part of a broader continuum, and its recommendations reflect the need for further emphasis on other parts of the continuum in subsequent work. The goals, objectives and deliverables of the Task Group, based on the Terms of Reference and project scope, are outlined in Table 1. The Model for an Integrated Program for Complex Care in the HNHB LHIN Page 7 of 27

Goals Coordinated LHINwide model for CC beds Recommendations for locations and sizing of CC beds Table 1: Task Group Goals, Objectives and Deliverables Objectives/Deliverables consistent, standardized definition of CC patients (and cohorts) standardized admission discharge exclusion criteria. update bed utilization audit and estimation of future needs identify need for CC beds now and in future identify configuration model based on cohorts. Transitional plan steps to implement common admission and discharge criteria - enablers and barriers leadership model including recommended accountability mechanisms HR staffing that identifies scopes of practice, staffing, skill sets and principles for implementation. 1.2.2. Task Group Process The Task Group reviewed, as a starting point, the planning work for CC that was completed by the PAG during the CSP development process. The Task Group then reconvened the PAG in order to further build on their model and definitions, and ensure alignment (see Appendix C for membership). As a result, the Task Group was able to quickly articulate CC definitions, streams and admission criteria. The Task Group also reviewed the CC work of several other LHINs and organizations, including South West (SW) LHIN, Waterloo Wellington (WW) LHIN, North Simcoe Muskoka (NSM) LHIN, and the Ontario Hospital Association (OHA). The Task Group met 12 times over the course of its three month mandate, and maintained contact with hospital stakeholders throughout the process through the PAG and direct communication. In addition, as the work progressed, the Task Group consulted with the HNHB Hospice Palliative Care Network, the Executive Council of the Long-Term Care Home (LTCH) Network, the Acquired Brain Injury (ABI) Network, the LHIN Chronic Kidney Disease Committee, as well as referring to previous LHIN work such as the HNHB LHIN Report on Chronic Ventilation Services. The draft report was reviewed for input by the HNHB LHIN hospital and CCAC CEO s group. 1.3. Inpatient Complex Care in HNHB LHIN Current State Capacity In December 2009, 10 HNHB LHIN hospital corporations reported 809 CC beds in operation across 14 sites. Sixty of these beds are temporarily serving as Assess/Restore beds (35) and Slow Stream Rehab beds (25) as part of the LHIN ALC strategy. The total number of CC beds has further decreased to 686 as of May 2010, based on planned closures (see Table 2). The Model for an Integrated Program for Complex Care in the HNHB LHIN Page 8 of 27

Table 2: Complex Care Bed Numbers as of December 2009 and April/May 2010 by Hospital Site* Municipality / CC Beds as of Hospital Site County April / May 2010 Niagara Niagara Health System (NHS) Douglas Memorial 40 Port Colborne 46 Niagara-on-the-Lake 18 St. Catharines General 0 Welland 35 Greater Niagara General 36 West Lincoln Memorial Hospital (WLMH) 16 Hotel Dieu Shaver Health and 82 Rehabilitation Hospital (HDSRH) Haldimand West Haldimand General Hospital 0 (WHGH) Haldimand War Memorial Hospital 13 (HWMH) Norfolk Norfolk General Hospital (NGH) 16 Hamilton Hamilton Health Sciences (HHS) St. Peter s 238 St. Josephs Healthcare Hamilton (SJHH) 52 Brant Brant Community Healthcare System 58 (BCHS) Burlington Joseph Brant Memorial Hospital (JBMH) 36 Total 686 * excluding Assess/Restore and Slow Stream Rehab Beds The distribution of CC beds per population 75+ years of age varies by area in the LHIN. The map (Table 3) illustrates the wide variation in CC beds per population, ranging from 2.6 to 8.5 beds per 1,000 75+ years of age. Utilization In the HNHB LHIN, there were about 2,800 admissions to CC beds in the LHIN s hospitals during the 2007 and 2008 fiscal years with an average age of admission of 77 years (Source: IntelliHealth Ontario, Ontario Ministry of Health and Long-Term Care). Approximately 96% of the admissions were residents of HNHB LHIN. About 98% of the admissions of HNHB LHIN residents are at HNHB LHIN facilities (only two percent of residents CC admissions are made to facilities outside the LHIN). There were over 262,000 CC days for patients discharged from CC in the HNHB LHIN during the 2008 fiscal year. Patients who require an ALC account for some of the CC days. For example in February 2010, ALC days accounted for 35.8% of all CC days at HNHB LHIN hospitals with a large variation by hospital site (Table 4). ALC patients, by definition, do not require CC, but may best be served through other settings such as LTCH or supportive living environments. The Model for an Integrated Program for Complex Care in the HNHB LHIN Page 9 of 27

Table 3: Number of CC Beds in the HNHB LHIN as of April / May 2010 with CC Beds per 1000 Population 75 years+ Number (CC Beds per 1,000 Population 75+ years) 36 (2.6) 290 (7.4) 58 (6.3) 290 (7.4) 58 (6.3) Table 4: % Complex Care ALC Days as of February 2010 by Hospital Site Hospital Site % ALC Days in Complex Care (February 2010) Haldimand War Memorial Hospital 90.3 West Haldimand General Hospital 84.9 Norfolk General Hospital 84.0 NHS Port Colborne 77.7 NHS Niagara on the Lake 60.6 NHS Douglas Memorial 56.1 NHS Greater Niagara 53.3 NHS Welland 52.4 West Lincoln Memorial Hospital 48.5 Hotel Dieu/Shaver Health and Rehabilitation 35.5 Hospital Joseph Brant Memorial Hospital 35.1 Brant Community Healthcare System 33.8 HHS St. Peter s Hospital 10.1 St. Joseph s Healthcare Hamilton 5.5 TOTAL HNHB LHIN 35.8 % Source: HNHB CCAC: Hospital ALC Summary Report - February 2010 The Model for an Integrated Program for Complex Care in the HNHB LHIN Page 10 of 27

2. COMPLEX CARE PROPOSED INTEGRATED PROGRAM 2.1. Service Delivery Model 2.1.1. Common Definitions and Admission Criteria Through the reconvened PAG, the Task Group polled all inpatient CC programs in the LHIN for their current definitions, streams and admission criteria. The PAG collated and integrated the current definitions, which the Task Group vetted. The Task Group adopted and recommends the following overall CC definition, based on the OHA s recognized work: Recommendation #1: That by Fall of 2010, the following definition of Complex Care be formally adopted by all CC providers in the HNHB LHIN: Complex care is a specialized, time-limited program providing patients with complex medical conditions who require a hospital stay with ongoing onsite assessment and active care by an interprofessional team with a goal to enhance the health and quality of life. The definition of CC and the subspecialty streams represent a relatively new way of thinking about CC. The CC bed is not intended as a final destination for the patient a plan for discharge is required on admission. Individuals appropriate for CC are medically stable (diagnosis and acute phase complete), but have multiple complex chronic conditions requiring daily skilled assessment by an interprofessional team. Lengths of stay are targeted in a range of 45-90 days, with clear goals set, in order to enable appropriate care to be provided at home or at a different level (e.g. LTC or supportive housing). The proposed definitions and admission criteria were circulated to all inpatient CC programs, and are presented in Table 5 as the Task Group s recommendation. Recommendation #2: That the complex care admission criteria and streams be adopted and implemented by all CC providers in the HNHB LHIN by Fall 2010. In addition, the Task Group reviewed staffing models from other jurisdictions and discussed potential principles for staffing related to the new definitions. These principles are attached in Appendix E. The Model for an Integrated Program for Complex Care in the HNHB LHIN Page 11 of 27

Table 5: Complex Care Admission Criteria and Streams Overall Admission Criteria: General Exclusion Criteria: General Discharge Criteria: Streams: Targeted Average Length of Stay: Need daily skilled assessment by an interprofessional team. Medically stable: The major portion of diagnostic tests for the patient has been completed and the patient is not requiring acute daily medical intervention by a physician. The patient has completed the acute phase of illness. Clearly defined goals have been established (including a date of discharge). Criteria identified in the definition have been met. Care needs can be met at a different level of care. Care can now be provided at home or different level of care. Goals have been met. These streams are not mutually exclusive as patients may require the expertise of multiple care teams. There is a preference to cohort the young and old separately because of psychosocial differences. Medically Complex Behavioural Health End of Life Care Restorative Care People with multiple medically complex conditions such as complex wounds, ALS, MS, bariatric or COPD who require unique programming. Some distinct cohorts of this group include but are not limited to: a) Ventilator-dependent: People with CC needs that require specialized care and equipment to support their long term ventilation needs. This patient group requires highly specialized care and equipment b) Dialysis: People who have medically complex conditions and care needs that include hemodialysis c) ABI: People who require ongoing medical and therapeutic intervention to optimize and sustain their functional ability d) Life expectancy of > 3 months. People with dementia and challenging behaviours who require skilled interventions in a controlled environment to facilitate their transition to the appropriate level of care. People with a life limiting illness who are at the end stage of that disease process and who require pain and symptoms management and skilled interventions delivered by an interprofessional team. This may include people who require chemotherapy as part of their treatment regime to maintain comfort a) Life expectancy of < 3 months b) Patient is on an established treatment regime with a focus on pain and symptom management and end of life care c) Social supports have been depleted or are no longer available d) Palliative Performance Scale 50% or less e) Patient may be experiencing complexities associated with the end stage of their disease including delirium, aggression, agitation etc. People with a multiple medical and/or functionally complex condition(s) who are expected to benefit from low intensity, long duration interventions provided by an interprofessional team, with clearly articulated functional improvement goals that can be attained within the average length of stay a) Mini-mental state exam (MMSE) score of >16 b) Presence of significant physical/functional impairments c) Physical tolerance that permits participation in programming d) Goal to go home or to a retirement home. 60-90 days 45-90 days 60-90 days 45-60 days The Model for an Integrated Program for Complex Care in the HNHB LHIN Page 12 of 27

2.1.2. Patient Flow Processes Regulation 554/06 of the Ontario Community Care Access Act enables the CCAC to play an enhanced role as system navigators. Currently, the CCAC plays this role with respect to assessment and referral to home care services and placement into LTCHs and residential hospices, but not CC. Currently, admissions to CC beds are managed by individual hospitals. With the new regulation, the CCAC is able to assess and refer to other types of care including CC beds in public hospitals. The Task Group viewed this new regulation as an opportunity to advance an integrated program for CC. Common definitions and admission criteria represent one key building block in the service delivery model. Equally important, however, are common processes to operationalise those definitions. The implementation of a centralized assessment, referral, and placement process, along with centralized wait list management process, represents the other key building block in the service delivery model. The Task Group recommends that the HNHB CCAC take on the assessment, referral, placement, and wait list management role in the new integrated program for CC. Implementation of these processes will require further detailed work to develop centralized best practices, processes, and protocols, to ensure consistent and streamlined access to CC. The Task Group also recognized that the role of hospital discharge planners and CCAC case managers must change with the implementation of a CCAC-administered, centralized assessment, referral, placement and centralized wait list management process. Based on its review of this role in other LHINs, most notably NSM LHIN, the Task Group developed five principles to guide the development and implementation of the CCAC s enhanced role: 1. Acknowledge that the new CCAC role will have a staffing and financial impact which must be assessed and addressed. 2. Use of a standardized, reliable tool for clinical assessments as the initial step in determining eligibility for CC. 3. Move towards the goal of referrals, admissions and discharges occurring seven days a week. 4. Establish benchmarks for admission, referral and discharge process times. 5. Maximize the use of technology (e.g. electronic referral). Recommendation #3: That the CCAC take on an enhanced role for complex care beds starting in the Fall of 2010, including: centralized wait list management standardized assessment, referral and placement processes. The Model for an Integrated Program for Complex Care in the HNHB LHIN Page 13 of 27

2.2. Configuration Model 2.2.1. Configuration Model Criteria Recommendations about the configuration of CC beds in the HNHB LHIN were made based on a set of criteria established by the Task Group (Table 6). The criteria were based on the work of the PAG and are organized according to the three broad aims guiding all of the clinical program integration work: improving the health of the population enhancing the individual s experience of care reducing, or at least maintaining cost. 2.2.2. Sizing the Inpatient Complex Care System Determination of the Baseline Number of CC Beds The Task Group developed a logic model to determine the future number of CC beds required in the HNHB LHIN. The steps in the logic model adjust utilization for population growth, unmet need, and ALC and occupancy rates. This process, which is outlined in Table 7, results in a right-sizing of the inpatient CC system from 686 beds to 628 beds. The Model for an Integrated Program for Complex Care in the HNHB LHIN Page 14 of 27

Table 6: Criteria for Sizing and Siting the CC Beds 1. Improve Health of Population (Accessibility) 2. Enhance Individual s Experience of Care (Quality) 3. Maintain or Reduce Cost (Sustainability) Criteria Definition/Description proximity of CC beds across the LHIN principle of closer to home region to the patient population matches the needs/service requirements of the CC population wait times for admission (adjustment centralized waiting list for unmet need) wait times from referral to admission equitable access across the LHIN addresses uneven access/gaps in service bed ratios per population services matched to patient need (e.g. designation under French Language Health Services Act) responsive to patients diversity (e.g. aboriginal, Francophone, marginalized, cultural/linguistic and visible minority populations; and, all age groups: children/youth, adults and the elderly) critical mass 26-32 CC bed units for clinical excellence and staffing efficiencies* clinical coherence / adjacencies supports continuity of care across care settings; leverages other resources (e.g. medical subspecialties, rehab allied health) minimizes CC patient transfers existing patients stay in CC beds in the short-term (compassionate grounds) integration with education and build capacity for education and research research leverage existing capital projects take into account current and proposed capital projects that include CC utilize existing specialized cost-efficient to use existing resources infrastructure (e.g. dialysis units, behavioural units) contribution to clinical efficiency critical mass administrative savings centralized assess, refer and wait list management use of information technology (telemedicine, information systems for drugs/labs, tests) maximizes bed throughput with target and maximum length of stay efficient use of scarce HHR; reduced duplication of clinical tests and streamline care processes goal-centered approach not a final destination * based on Task Group expertise The Model for an Integrated Program for Complex Care in the HNHB LHIN Page 15 of 27

Table 7: Complex Care Sizing Logic Model Steps Step 1. Determine current utilization of Complex Care at HNHB LHIN hospitals Remove CC ALC days from Total CC days: Patients requiring ALC were removed from the total CC days. The calculation was based on available data provided by the hospitals for total CC days and CC ALC days from HNHB LHIN ALC Trigger Report for Q3 2009-10. Step 2. Adjust for population growth Population growth for HNHB LHIN residents 75+ years was used for projecting population growth of CC beds as an analysis of current CC data indicated that approximately 70% of admits among residents in the HNHB LHIN over the past two fiscal years were 75 years of age and older. In the 1990s, the Health System Restructuring Commission (HSRC) also used the population 75+ years of age for projecting the need for CC beds. Step 3. Address Unmet Need 5% The purpose of including an overall unmet need adjustment is to take into consideration patients who are not currently receiving CC (e.g. may be on a waiting list or at home in the community) but meet the definitions and criteria for CC from both the community-based and acute hospital sectors. Five percent was chosen as a reasonable estimate of unmet need. The Task Group recognized that this will need to be re-examined over time as the continuum of care for patients with complex needs changes. Step 4. Apply a 12% ALC rate The HNHB LHIN ALC rate in CC ranges from approximately 35-38% by month. The goal of a 12% ALC rate was selected as a target based on the current provincial ALC rate within acute care beds. The Task Group recognized that this would not be achievable within the first year of implementation of the integrated program, but would occur over the three year time frame. Step 5. Calculate bed equivalents at 92% Occupancy Rate A 92% occupancy rate was selected by the Task Group based on the expected decreased length of stay within CC (new admissions to CC will be goal oriented) and increased bed turnover that will occur within CC. The occupancy rate will act as a buffer for infection control issues (restrictions on CC semi-private beds due to isolation requirements) and organization of a centralized intake and referral process. Although the methodology uses 92% occupancy, the Task Group expects the occupancy rate at each site to be optimized and best practice achieved. Result: 628 beds This bed number provides a baseline bed number for CC in the HNHB LHIN. Determination of the Future Distribution of CC Beds by Stream of Care Each hospital site provided a current one-day snapshot of CC patients based on the new definitions for CC streams of care (see Appendix D). The results show that on that day, there were 590 patients occupying CC beds who would meet the admission criteria for the proposed new streams. Using information from the snapshot audit as a starting point, the Task Group made adjustments for future demand in each of the streams. This was done based on the Task Group s knowledge of current practice in The Model for an Integrated Program for Complex Care in the HNHB LHIN Page 16 of 27

leading trends, both locally and provincially. Table 8 summarizes the current distribution of CC beds across the streams of care; the Task Group s adjustments for future distribution; and the resulting CC bed numbers, by stream of care. 1. The need for restorative care and general medically CC is expected to increase in the future based on the aging population and increasing prevalence of chronic conditions. Bariatric patients were included in the general medically complex numbers, however there are specific requirements for this patient population, therefore, these beds have been separated out for siting purposes. 2. Future investments in community-based palliative care settings (in-home and hospice) are needed to enable a shift in the demand for end of life care for CC. A decrease in the distribution of end of life care in CC is anticipated, given an increasing trend to alternative community settings. 3. No significant change in distribution of CC beds is expected for ventilator-dependent, dialysis, acquired brain injury, and behavioural health streams. Table 8: Current and Future Distribution of CC Beds by Stream Stream Current distribution of CC beds Future distribution of CC beds Future CC bed numbers 1 Total Medically Complex (1=1a+1b+1c+1d) 1a # Ventilator-dependent 1.2% 2% 10 1b # Dialysis 3.6% 4% 25 1c # Acquired Brain Injury 2.9% 2% 13 141 general 1d # All other medically complex (including Bariatric) 22.7% 24% & 10 bariatric 2 Behavioural Health 17.8% 18% 113 3 End of Life Care 19.0% 15% 95 4 Restorative Care 32.9% 35% 221 Total 100.0% 100% 628 2.2.3. Siting the Inpatient Complex Care System Bed to Population Ratios Population ratios were examined in the interest of creating more equitable access to beds across the HNHB LHIN. Bed ratios per HNHB LHIN population 75+ years were applied to CC streams where local access is key. These streams general medically complex, restorative, and end of life represent the largest number of CC beds and are the most geographically dispersed across the LHIN. For these streams, ratio of beds per population 75+ years was equally applied across areas within the HNHB LHIN to determine the number of CC beds that are required to serve the geographic area within the LHIN. The Model for an Integrated Program for Complex Care in the HNHB LHIN Page 17 of 27

Specialized Sub-Populations The remainder of the CC beds are intended to serve CC patient population groups with more specialized care needs. As such, these beds were centralized at one or two sites within the LHIN area. The configuration of CC beds by stream, and number of sites is summarized below in Table 9. The rationale for the siting of beds is described below and is consistent with the Task Group s sizing and siting criteria. Table 9: Configuration of Complex Care Beds by Stream by Sites Streams 1. Medically Complex a. Ventilatordependent b. Dialysis c. Acquired Brain Injury d. All Other Medically Complex e. Bariatric Bed Numbers Number of Hospital Sites 10 2 sites 25 2 sites 13 1 site 141 10 sites 10 2 sites 2. Behavioural Health 113 2 sites 3. End of Life Care 95 11 sites 4. Restorative Care 221 8 sites Rationale for Number of Sites Two sites are currently established to care for these patients (one in Hamilton and one in Niagara). This should continue in the future; consistent with the LHIN s Long-Term Ventilation Working Group Report (October 2009). Dialysis patients within CC should be co-located with HNHB LHIN chronic kidney disease (CKD) regional centres to ensure efficient access to dialysis services. A small number of patients will require these services within CC. Specialized care for these patients is required and should be sited at one location (preferably co-located with rehabilitation services for this patient population). Local access to general medically complex services should be available. Specialized equipment and care is required for this medically complex patient population and co-location with an acute care facility is recommended. Specialized care and access to a geriatric psychiatrist is required for this patient population. Centralizing to two sites one in Hamilton and one in Niagara, will allow efficient use of resources. To support caregiver/patient interaction, local access to end of life care is needed. Use of telemedicine is important to maximize availability of medical expertise. Local access to restorative care should be balanced with the specialized care that is required for this patient population. Siting of CC Beds by Stream and Geography The following Table summarizes the proposed siting of CC beds by stream and by sub-lhin geography (see Table 10). The Model for an Integrated Program for Complex Care in the HNHB LHIN Page 18 of 27

Table 10: Siting of CC Beds by Stream and Geography HNHB LHIN Area CC Beds as of Apr/ May 2010 excluding Assess Restore & Slow Stream Rehab in CC Beds 1a. Ventilatordependent 1b. Dialysis 1c. Acquired Brain Injury 1d. All other medically complex Hamilton 290 5 15 13 49 6 63 35 80 266-24 Niagara 273 5 10 0 50 4 50 34 79 232-41 Haldimand/ Norfolk 29 0 0 0 10 0 0 6 15 31 2 Brant 58 0 0 0 13 0 0 8 19 40-18 Burlington 36 0 0 0 19 0 0 12 28 59 23 Total 686 10 25 13 141 10 113 95 221 628-58 Within Hamilton, ventilator-dependent, dialysis, acquired brain injury, bariatric and behavioural streams will each be centralized. The remaining streams will be distributed between HHS and SJHH. Within Niagara, ventilator-dependent, dialysis, bariatric and behavioural streams will each be centralized. In distributing the remaining beds, the Task Group recommends that the distribution of beds reflect the distribution of the population, with general medically complex, end of life, and restorative stream beds located in both north Niagara and south Niagara. In 2009-10, one of the three CC bed sites (WHGH) in Haldimand-Norfolk requested, and were granted approval, to close their 10 CC beds. The remaining two sites (NGH and HWMH) will continue to provide medically complex, end of life, and restorative CC. The Task Group noted that Burlington is significantly undersized in CC beds. The hospital has included the proposed increase of 23 beds in their capital redevelopment plans. The timing of this development and its impact on the transition to an integrated program for CC will need to be taken into account. 1e. Bariatric 2. Behavioural Health 3. End of Life Care 4. Restorative Care Total Change from April/ May 2010 Recommendation #4: That the HNHB LHIN adopt the proposed allocation of 628 CC beds by stream and geography as the posttransition target (April 2012). The Model for an Integrated Program for Complex Care in the HNHB LHIN Page 19 of 27

3. TRANSITION PLAN AND NEXT STEPS 3.1. Transition Agenda With the approval of this report, the building blocks will be in place for the integrated program in CC in the HNHB LHIN. These building blocks include: common definitions and admission criteria a process for managing a centralized wait list processes for common assessment, referral, and placement future configuration of inpatient CC beds, reflecting optimal use and distribution of resources according to the new definitions in response to population need. In order to get from the current state and current utilization of CC beds to the new model proposed in this report, a number of implementation activities will need to be coordinated simultaneously. Much of the operationalization work will be carried out by the individual hospitals within existing funding with the assistance of the CCAC. While it is anticipated that much of the transition work can be completed by April 2011, full implementation of the integrated program will require a phased process, targeted for completion by April 2012. Hospitals will need to admit new patients to the new definitions, and adjust their bed complements and staffing. The CCAC will provide assistance to hospitals in placement of individuals currently designated ALC into more appropriate settings. The CCAC will also assist in the transition to the new model through the implementation of a centralized wait list and common assessment, referral and placement processes. At the same time, the LHIN will have an enabling role, setting expectations and finalizing funding and accountability arrangements with individual providers. In addition, the LHIN will work towards the enhancement of community supports and, on an ongoing basis, work with the hospitals to determine longer-term leadership strategies. A key success factor in transitioning to the integrated model is agreement on the concept of closing beds as individuals are relocated to more appropriate settings. Funding from the closed beds may then be used to implement the changes required to transition to the new model. For example, most hospital sites will need to realign their current complement of CC beds to a rightsized complement of beds, following the new stream definitions. In many cases, this will require a reduction in surplus CC beds (currently occupied by ALC patients), with focused programming and staffing to coincide with the programming. Discussions with the LHIN will enable these changes to take place within each hospital corporation, in the context of the H-SAA. Each site would then work in partnership with the CCAC to make the changes that will transition the system to the new role. Enhancement of other community resources will also be a key success factor in transitioning to the new integrated model. In order to allow the more appropriate streaming of CC resources, other parts of the continuum will require enhancement. Specifically, investments in home supports, assisted living services in home and community settings, as well as hospice and community-based palliative care services will be required to offset the reduced capacity in the hospital sector. The LHIN, in partnership with the CCAC, has initiated a project that will guide the enhancement of community-based health service capacity. The Model for an Integrated Program for Complex Care in the HNHB LHIN Page 20 of 27

Finally, while this maps out the immediate steps for transitioning to the integrated program in CC, the Task Group also noted the importance of an ongoing leadership mechanism, or structure. LHIN-wide leadership will be required to ensure that the integrated program is exactly that integrated and coordinated across sites. A LHIN-wide leadership mechanism will oversee the implementation of: leading practice guidelines and targets incorporation of academic and research components ongoing evaluation, quality improvement and performance measurement. The LHIN is committed to working collaboratively with the hospitals and CCAC to arrive at an appropriate leadership mechanism, and will do this through the CEO group. 3.2. Next Steps The following summarizes the immediate next steps to be taken once the CC report has received LHIN Board of Directors approval. Hospitals work with the CCAC on the appropriate placement of individuals currently designated ALC begin to admit new patients to the new definitions and streams reconfigure beds to comply with the plan, using existing funding. CCAC work with hospitals on the appropriate placement of individuals designated ALC implement enhanced role in wait list management, assessment, referral and placement. LHIN establish a LHIN-wide coordinating group to monitor transition work in parallel towards the enhancement of community-based alternatives (community-based capacity project in process) discuss funding and accountability arrangements with each hospital and CCAC facilitate ongoing work with the hospital CEO group and subgroups towards the development of a longer-term leadership model which will oversee the implementation of: leading practice guidelines and targets incorporation of academic and research components ongoing evaluation, quality improvement, and performance measurements Recommendation #5: That the HNHB LHIN direct hospitals to reconfigure existing beds to comply with the plan, using existing funding. Hospitals should identify what changes will be made immediately; by April 2011; and by April 2012. The Model for an Integrated Program for Complex Care in the HNHB LHIN Page 21 of 27

Recommendation #6: That the HNHB LHIN follow-up with each complex care hospital provider and the CCAC to formalize funding, accountabilities, and performance requirements, including timelines for implementation, for incorporation in the next service accountability agreement. Recommendation #7: That the HNHB LHIN establish a LHIN-wide coordinating group to facilitate and monitor transition towards the integrated program in complex care. The Model for an Integrated Program for Complex Care in the HNHB LHIN Page 22 of 27

4. APPENDICES Appendix A Coordinated Strategy for Complex Care in the Task Group Terms of Reference Purpose The (HNHB LHIN) is seeking to confirm the current distribution and role of complex care (CC) beds and to plan for the future needs of the region s population. The Task Group would be required to: 1. Review the planning work for CC that was completed by the Planning Advisory Group (PAG) during the Clinical Services Plan (CSP) development process, and build on recommendations to determine a co-ordinated LHIN-wide model for CC beds. 2. Evaluate and approve a common definition, admission and discharge criteria for CC beds across health care providers in the HNHB LHIN. 3. Develop a transitional plan to implement common admission and discharge criteria for CC, in order to achieve the appropriate level and distribution of CC beds required in the HNHB LHIN. Background The need to determine the role of CC has arisen in response to a number of recent developments in the HNHB LHIN that require informed direction from a co-ordinated LHIN-wide strategy. Specifically, the HNHB LHIN needs to understand the current and future needs of the CC population so that, from a system-wide perspective, it is possible to effectively guide hospitals in their plans for service delivery. During the 2010-12 H-SAA process, many hospitals identified closure of CC beds as a means to balance budgets. The HNHB LHIN is concerned that these closures may have a negative impact on access to appropriate health care resources for residents. Alternatively, other hospitals are planning capital expansions of CC beds. The HNHB LHIN must ensure that these decisions are coordinated, maximizing utilization of resources. In order to identify whether these actions are in the best interest of the HNHB LHIN s residents, the LHIN is establishing a task group that will work to determine the most appropriate utilization, configuration and distribution of CC resources within the LHIN. The development of a coordinated LHIN-wide model for CC is aligned with HNHB LHIN and Ministry of Health and Long-Term Care s (ministry) strategic priorities. An evaluation of the current CC population will provide information about the needs of residents, ensuring that they are getting the right care, in the right place, at the right time. A coordinated system that directs residents who require CC to appropriate, The Model for an Integrated Program for Complex Care in the HNHB LHIN Page 23 of 27

standardized care across the health care continuum addresses the LHIN s priorities of equal access and improved patient flow, and facilitates the ministry s priorities of reducing emergency department wait times and alternate level of care (ALC) rates. Finally, the development of a coordinated CC model today will ensure that the local health care system is prepared for facilitating the future demands of the LHIN population. As identified by the PAG during the CSP development process, the need for CC beds is intensifying for specialty population groups such as bariatric patients, the elderly with complex conditions, residents with behavioural issues, patients on ventilators and those on dialysis. Health care providers in the LHIN must work efficiently to provide the optimal care for these growing populations. Assumptions 1. On September 18, 2009, regulations under the Community Care Access Corporations Act came into effect that enable Community Care Access Centres (CCACs) to take on a broader role in supporting residents. The regulations create the potential for CCACs to place people in complex continuing care beds. Given this opportunity, the HNHB LHIN is currently in discussions with the HNHB CCAC to develop the role of the CCAC as the coordinator of the CC admission process across the LHIN. 2. The coordinated LHIN-wide CC model will be aligned with ehealth strategies, and will incorporate technology to improve processes such as wait list co-ordination and resource matching. 3. All project deliverables will build on work that was completed by the CC PAG during the CSP development process. Scope of Work The task group will be required to produce the following project deliverables: 1. A coordinated LHIN-wide model for CC beds that includes: o o o a consistent, standardized LHIN-wide definition for CC patients standardized admission and discharge criteria a definition of bed type/services delivered at the LHIN-wide level, the sub-lhin or district level, and the local or community level. 2. Recommendation regarding the appropriate locations for, and sizing of, CC beds in the HNHB LHIN that is advised by the PAG model. CC beds should be distributed based on resource utilization requirements of CC patients in eight categories: 1. Ventilator-dependent 2. Acquired Brain Injury 3. Medical Complex Adults (non-geriatric) 4. Behavioural 5. Medically Complex Geriatric 6. End-of-Life Care 7. Dialysis 8. Reactivations (low intensity, long duration rehab) The Model for an Integrated Program for Complex Care in the HNHB LHIN Page 24 of 27