Final Report from the Ontario Hip Fracture Care Forum: Removing Access Barriers to Return People Home 22 January 2010 Hyatt Regency, Toronto Prepared By: Janet McMullan, Project Manager, Bone & Joint Health Network Rhona McGlasson, Project Director, Bone & Joint Health Network Dr James Waddell, Chair, Orthopaedic Expert Panel Morgan Holmes, WordMeridian Communications Acknowledgement for Support and Funding to the Ontario Orthopaedic Expert Panel Canadian Orthopaedic Care Strategy Group
Final Report from the Ontario Hip Fracture Care Forum: Removing Access Barriers to Return People Home Executive Summary It is estimated that 9,500 people in Ontario will suffer a hip fracture that requires surgical intervention in the next year. Hip fracture is the most common type of injury requiring hospitalization for people 65 years and older, and is associated with significant rates of mortality (as high as 30%) and morbidity. For patients, a hip fracture can result in a loss of independence and decrease in their overall quality of life, and for the healthcare system, lengthy and costly hospital stays that contribute to significant challenges through alternative level of care days and streaming into long term care. On January 22 nd, 2010, the half-day forum Ontario Hip Fracture Care: Removing Access Barriers to Return People Home brought together health care leaders from acute care and rehabilitation hospitals, Ministry of Health and Long Term Care, Local Health Integration Networks [LHINs], and several interest groups from across the province and nationally. The aim of the day was to address access barriers and shape solutions to improve care for hip fracture patients across the Ontario health care system. These solutions would then be used to define the ongoing role and activities to be supported through the work of the Orthopaedic Expert Panel. The following recommendations have been consolidated from the group discussion as solutions to the access barriers for hip fracture patients. A. Health care system change 1. LHIN based regional planning for the provincial hip fracture model of care implementation to improve access to timely surgery within 48 hours and to facilitate access to rehabilitation in the patients home community. 2. Ensure an accountability framework for the effective regional management for patients. B. Health service provider/hospital change 3. Develop procedures, documentation (e.g. clinical care maps) and communication strategies to meet the clinical needs of hip fracture patients. 4. Establish local planning and communication with the necessary partnerships to support flow of patients across the health care continuum, including acute care, specialized services/consultation, rehabilitation, EMS and community support services. Report: Ontario Hip Fracture Care Forum 22 January 2010 2
C. Clinical practice 5. Implement clinical protocols to meet the needs of patients to optimize pre-operative, surgical and post-operative care using appropriate tools. 6. Address using education opportunities knowledge and skill gaps for surgeons, physicians and other health care providers about optimal pre operative, surgical and post operative management hip fracture practice. For successful change each of these programs needs leadership from the LHIN, health service providers and clinical providers. The Expert Panel can support the implementation of the changes required through their comprehensive clinical and operational toolkit as well as by linking to experts in the clinical and operational management of hip fracture patients. Report: Ontario Hip Fracture Care Forum 22 January 2010 3
Overview It is estimated that 9,500 people in Ontario will suffer a hip fracture that requires surgical intervention in the next year. Hip fracture is the most common type of injury requiring hospitalization for people 65 years and older, and is associated with significant rates of mortality (as high as 30%) and morbidity. For patients, a hip fracture can result in a loss of independence and decrease in their overall quality of life, and for the healthcare system, lengthy and costly hospital stays that contribute to significant challenges through alternative level of care days and streaming into long term care. Through the provincial implementation of the hip fracture model of care, the Orthopaedic Expert Panel has identified health care system issues that impact the ability of patients to access the care that is necessary for them to successfully return home again. Specifically, barriers occur in patient access to timely surgery and their access into appropriate rehabilitation care. On January 22 nd, 2010, the half-day forum Ontario Hip Fracture Care: Removing Access Barriers to Return People Home brought together health care leaders from acute care and rehabilitation hospitals, Ministry of Health and Long Term Care, Local Health Integration Networks [LHINs], and several interest groups from across the province and nationally. The aim of the day was to address access barriers and shape solutions to improve care for hip fracture patients across the Ontario health care system. These solutions would then be used to define the ongoing role and activities to be supported through the work of the Orthopaedic Expert Panel. Participants completed three important tasks: 1. Reviewed the Provincial Hip Fracture Model of Care in consideration of issues pertaining to access to care. 2. Identified strategies to enable consistent regional access for patients to timely surgery within 48 hours of admission to a hospital across all LHINs. 3. Identified strategies for improving access to appropriate rehabilitation for all patients coming from home. The format for the day included three presentations from leading experts and these were followed by four breakout group sessions. The presentations focused on 1) introduction to the Ontario Provincial Hip Fracture Model of Care; 2) the use of interrai comparative data to describe hip fracture care across the health care continuum and considerations in development of a system of care for these older, often frail patients; and finally 3), the issue of hip fracture care in the context of aging and care for the aged. A summary of these presentations can be found in Appendix A. The three presentations were videotaped. The presentation and recordings will be available on the Bone and Joint Health Network s website www.boneandjointhealthnetwork.ca. The breakout group used vignettes of potential patient cases to enable discussions on the topics of access to surgery (two groups) and access to rehabilitation (two groups). The groups reported Report: Ontario Hip Fracture Care Forum 22 January 2010 4
their findings and proposed solutions, and the floor was then opened to further comments from the other participants. The vignettes and group reporting are summarized in Appendix B. The information collected through the group discussion has been reviewed and analyzed to identify needs for health care system, organizational/hospital and clinical practice levels of change that are necessary to facilitate ongoing improvements in hip fracture care across the province. Responsibility for leadership in each of these areas was discussed at the meeting and is summarized under each section. The Orthopaedic Expert Panel role will be to provide leadership and expertise to facilitate change while working with the LHINS and organizations/hospitals across Ontario to implement the Provincial Hip Fracture Model of Care. Access to surgery recommendations The following recommendations have been consolidated from the group discussion as solutions to the access barriers to timely surgery for hip fracture patients. A. Health care system change 7. Development of LHIN based regional planning for provincial hip fracture model of care implementation to improve access to timely surgery within 48 hours, including: LHIN governance and accountability structures Centralized intake processes to manage waiting times from referring hospitals Considerations to critical mass and determination of responsibility to regional hospitals Appropriate funding/resources for regional centres to provide necessary care 8. Integrate clinical pathways across referring and regional hospitals through partnership and appropriate policy development, to support: Pre-operative preparation/work-up of patients in referring hospitals Seamless transfer to regional hospitals for surgery Repatriation processes to support seamless transitions back to referring hospitals for stabilization and rehabilitation care closer to home 9. Develop accountability frameworks for hospitals to provide timely hip fracture surgery by identifying and addressing the financial incentives and disincentives for effectively managing hip fracture patients. Leadership for Health care system change was identified as needing to be facilitated by the LHIN with support through the health service provider, surgeons, and the regional orthopaedic leadership. Report: Ontario Hip Fracture Care Forum 22 January 2010 5
B. Health service provider/hospital change 10. Develop policies for operating room priority management of hip fracture patients to support timely access to surgery within 48 hours, including consideration of: Orthopaedic trauma operating room to match trends/needs for urgent/emergent cases, support surgery occurring in daytime hours, and the promotion of patient safety and the prevention of complications. 11. Local planning to establish the necessary partnerships and communication processes to support flow of patients across the health care continuum, including acute care, specialized services/consultation, rehabilitation, and community support services. 12. Identify clear processes for coordination, supervision, and responsibility for hip fracture patient pre-operative preparation for timely surgery and post-operative flow including communication between referring and regional hospitals. 13. Establish transfer protocols including the role of EMS and other transportation systems. Leadership for Health Service Provider/hospital change was identified as needing to be facilitated by the Health Service Provider with support through the surgeons, and the regional orthopaedic leadership. C. Clinical practice change 14. Implement care pathways for hip fracture to optimize both pre-operative and post-operative care including: Early medical stabilization Delirium, dementia and depression screening, prevention and management Surgical procedures to maximize functioning through full weight bearing post operatively Early mobilization Discharge planning Transition across the health care continuum. 15. Consider opportunities of the use of standardized assessment tools to support care decisions, including the CHESS mortality scale, Confusion Assessment Method, Mini-Mental Status Examination, and others 16. Develop pre-operative and post operative order sets to support optimum hip fracture care. 17. Address using education opportunities knowledge and skill gaps for surgeons, physicians and other health care providers about optimal hip fracture practice, including: Pre-operative management of common medications (e.g. plavix, coumadin) Delirium, dementia and depression prevention, screening and management preoperatively and post-operatively. Leadership for Clinical Practice change was identified as needing to be facilitated by the local clinical leadership with support through the health service provider, and the regional orthopaedic leadership. Report: Ontario Hip Fracture Care Forum 22 January 2010 6
Access to rehabilitation recommendations The following recommendations have been consolidated from the group discussion as solutions to the access barriers to timely rehabilitation for hip fracture patients. A. Health care system change 1. Development of LHIN based regional planning for provincial hip fracture model of care implementation to improve access into rehabilitation, including: LHIN governance and accountability structures Rehabilitation system design with adequate capacity to address the rehabilitation needs of hip fracture patients, and to include when needed alternative care through slow stream rehabilitation and convalescent care Consideration of a centralized triage rehabilitation process using available technology to enhance communication Appropriate funding/resources for rehabilitation to provide necessary care to more complex hip fracture patients Integration planning to build stronger relationships between acute, rehabilitation and community care to promote patient flow and problem solving 2. Integrate care maps between acute care and rehabilitation hospitals to promote smooth transitions and care that is closer to home, including: Repatriation policy/principles to pre-arrange referrals to rehabilitation and opportunities for sub-acute patients to be readmitted to acute care when medically unstable Leadership for Health care system change was identified as needing to be facilitated by the LHIN with support through the health service provider, surgeons, and the regional orthopaedic leadership. B. Organizational/hospital change 1. Establish policies for rehabilitation beds use through standardized admission criteria and transfer processes that to promote access and do not select against hip fracture patients. 2. Local planning to establish the necessary partnerships and communication processes to support flow of patients from acute care to rehabilitation to community services, and including access to medical staff/ specialized geriatric services to manage potential complications that may occur with these complex patients. 3. Re-examine the health human resources required in rehabilitation setting to manage the complexity of hip fracture patients. 4. Develop appropriate policy and education resources to effectively manage patient and family expectations for hip fracture care and discharge planning. Report: Ontario Hip Fracture Care Forum 22 January 2010 7
Leadership for Health Service Provider/hospital change was identified as needing to be facilitated by the Health Service Provider with support through the surgeons, and the regional orthopaedic leadership. C. Clinical practice change 5. Implementation of care pathways for hip fracture to optimize rehabilitation care, including: Early and ability- focused mobilization Medical stabilization and prevention of complications Delirium, dementia and depression screening, prevention and management Falls risk/reduction Osteoporosis management Discharge planning Transition home with appropriate community support 6. Address using education opportunities knowledge and skill gaps for health care providers about optimal hip fracture care, including: Delirium, dementia and depression screening, prevention and management 7. Consider opportunities for an enhanced rehabilitation role for nurses. Leadership for Clinical Practice change was identified as needing to be facilitated by the local clinical leadership with support through the health service provider, and the regional orthopaedic leadership. Report: Ontario Hip Fracture Care Forum 22 January 2010 8
Appendix A Overview of Presentations Three presentations provide a focus for the group discussions and included 1) Ontario Provincial Hip Fracture Model of Care; 2) the use of interrai comparative data to describe hip fracture care across the health care continuum and considerations in development of a system of care for these older, often frail patients; and finally 3), the issue of hip fracture care in the context of aging and care for the aged. These presentations and group discussions are summarized below. The three presentations were videotaped and the recordings will be available on the Bone and Joint Health Network s Website (www.boneandjointhealthnetwork.ca). The Ontario Hip Fracture Model of Care Dr. James Waddell, chair of the Expert Panel for Orthopaedic Surgery for the Province of Ontario, began the Forum by reminding participants that approximately 10,000 Ontarians suffer a hip fracture each year. Hip fractures are the most common cause of hospitalization in Ontario and they are leading cause of death among patients over age 65. However, as Dr. Waddell pointed out, research conducted in Ontario and abroad shows that it is possible to bring about solidly beneficial outcomes for hip fracture patients by implementing a multi-faceted model of care. The majority of Dr. Waddell s remarks were devoted to discussing the new Ontario Hip Fracture Model of Care (see figure 1). This model of care for patients with a hip fracture was developed by the Bone and Joint Health Network, which worked under the direction of the Orthopaedic Expert Panel and with input from surgeons, nurses, physical therapists, and occupational therapists from across the province. Figure 1. Hip Fracture Model of Care PATIENT /FAMILY EDUCATION Hip Fracture Home With Follow up 10% Non Weight Bearing Patients 5% COMMUNITY Home/ Retirement Setting Independent Living LONG TERM CARE SURGERY Pre op Medical Stability Hip Fracture Fixation for wt. bearing <48 Hours ACUTE CARE Post Op Medical Stabilization LOS 5 Days LOS 24 28 Days INPATIENT REHAB A.C.T.E.D Program Assessment Client Centered Goals Treatment Evaluation Discharge Planning 80% of Home Stream Pts INPATIENT REHAB Continue Rehab care Geriatric program COMMUNITY Home/Retirement setting with followup care Homecare Outpatient Long term Care 75% Pts Return Home Long Term Care 20% Slow Stream Rehab 15% Adapted from Mahomed et al., 2008; McGilton et al., 2009; Scottish Intercollegiate Guidelines Network, 2002; British Orthopaedic Association, 2007 Report: Ontario Hip Fracture Care Forum 22 January 2010 9
The new Hip Fracture Model of Care has three main thrusts: Reducing wait times for surgery to 48 hours or less for 90% of patients Offering best-practice care after surgery, especially weight-bearing soon after surgery Providing earlier access to inpatient rehabilitation for medically-stable patients regardless of cognitive impairment. The model aims at a 5-day progressive transition for patients through surgery and recovery, followed by in-patient rehabilitation care for approximately 4 weeks. By accessing rehab in a timely fashion, patients will have the opportunity to return home or live in the most appropriate alternative settings. Ontario s LHINs, hospitals, and community care agencies will be able to focus their planning and plan-implementation activities in ways that ensure patients and their families in every corner of the province receive the best care possible. Implementing such a model of care across Ontario requires extensive face-to-face consultation at local and regional hospitals. To date, Janet McMullan, the Bone & Joint Health Network s project manager, has visited over half (71) of Ontario s hospitals to meet with physicians, nurses, occupational and physical therapists, administrators, and other concerned individuals and groups to explain the Hip Fracture Model of Care. Fifty of these hospitals have already implemented the model. The number-1 goal of the new Hip Fracture Model of Care, Dr. Waddell concluded, is to return patients to their homes as quickly as possible. Accomplishing that goal requires good surgical practices, care maps, and pre- and post-surgery order sets. It also relies on vision, commitment, belief, and new relationships among partners at both the local and regional levels. Participants comments Following Dr. Waddell s presentation, participants had an opportunity to voice their insights and concerns. Three issues in particular stood out: A widespread sense that the current system for hip fracture care is not working. Optimal hip fracture care and implementation of the Hip Fracture Model of Care require inter- and intra-hospital cooperation; for example, there must be policies and systems that ensure and facilitate cooperation between small local hospitals and larger regional facilities. Attitudes must change. Hip fractures must be made a top priority among policy-makers, hospital and LHIN administrators, health care providers, and others. Report: Ontario Hip Fracture Care Forum 22 January 2010 10
Hip Fractures across the Continuum of Care: Evidence Based on the interrai Assessment Instruments Dr. John P. Hirdes is a professor in the Department of Health Studies and Gerontology at the University of Waterloo. He introduced participants to interrai (www.interrai.org) and findings that have been generated using its assessment instruments, which he proposed as valuable components in the toolkits of those who care for people who have suffered from hip fractures. interrai is a collaborative network of approximately 60 researchers and health/social service professionals in over 30 countries. The network develops, implements, and evaluates research instruments and their related applications, as well as uses those instruments to collect and interpret data about the characteristics and outcomes of persons who are elderly, frail, or disabled. The goal of this research is to promote evidence-based clinical practice and policy decisions that can benefit such people by evaluating their strengths, preferences, and needs. The interrai system is integrated: all the instruments employ a common language (i.e., they refer to the same clinical concepts in the same way), common theoretical/conceptual bases, common measures, and common care-planning protocols. Forming an integrated health information system that reports on health care and status at a population level, interrai s assessment instruments address several important care types, including home care, complex continuing care, long-term care, and mental health services. In the case of examining hip fractures across the continuum, interrai researchers gather extensive data on aspects such as prevalence, sociodemographics, functional characteristics (e.g., cognitive performance, activities of daily living [ADL]), clinical assessment protocols, care planning, case mix, access to rehab, and outcomes. Dr. Hirdes presented extensive interrai comparative data relating to hip fractures across the continuum, including, for example, the following aspects: Rates of hip fracture diagnoses by care setting (e.g., long-term care, complex continuing care) Sociodemographic characteristics (e.g., youngest are in complex continuing care, oldest are in long-term care, high proportion of females) Distribution of the Cognitive Performance Scale (e.g., home care patients are highest cognitively intact) Distribution of the ADL hierarchy (e.g., more severe ADL impairment in long-term care) Distribution of the CHESS scale (measures health instability and medical complexity: higher score = strong predictor of mortality) Care protocol triggers, including pain, depression, pressure ulcers Resource-use intensity. Report: Ontario Hip Fracture Care Forum 22 January 2010 11
Access to rehab (e.g., new home-care admissions are more likely than follow-up cases to gain access to rehab) Dr. Hirdes concluded his presentation with three insights germane to the Forum s entire proceedings: Hip fracture patients comprise a complex population characterized by diverse social and medical needs. These patients receive care in different settings, but each setting serves somewhat different types of hip fracture patients, and therefore generalizing across care settings must be done cautiously. Access to rehab services for hip fracture patients depends on the care setting in which they find themselves. Hip Fracture Care: What Factors Make a Difference in Returning and Keeping Patients at Home? Dr. Rory Fisher, a professor emeritus in the Department of Medicine at the University of Toronto, addressed the issue of hip fracture care in the context of aging and care for the aged. Referring to a projected silver or grey tsunami about to cascade over Canada and much of the rest of the globe, Dr. Fisher echoed Globe and Mail health columnist André Picard s call (7 January 2010) to confront this phenomenon by offering choice, comfort, and dignity. Dr. Fisher s remarks emphasized the health care system s ethical duty to care for the frail elderly, people who are particularly vulnerable because they often have a multiple diseases. In this regard, he chastised the ageism that infects society and that can lead to under-treatment. When one speaks of chronic diseases such as Alzheimer s, osteoporosis, diabetes, osteoarthritis, and cancer, Dr. Fisher remarked, it is important to recognize that these so-called epidemics do not exist in isolation: a major common denominator is that they all afflict the frail elderly. Unfortunately, the care of such patients often must confront a hostile environment comprising severe challenges, including a cascade of dependency, functional loss, iatrogenic disease, adverse drug reactions, nosocomial infections, delirium, and malnutrition. On the matter of caring for people with hip fractures in particular, Dr. Fisher identified complications such as delirium, venous thrombosis, urinary problems, pneumonias, and worsening of co-morbidities. Hip fractures are costly to the health care system, are associated with increased mortality (especially among long-stay patients), reduce individuals independence, and increase the need for long-term care. Report: Ontario Hip Fracture Care Forum 22 January 2010 12
However, Dr. Fisher commented, the issue isn t insurmountable. The Hip Fracture Model of Care is an excellent example of what can be done. Dr. Fisher also emphasized that we can t do it all within the hospital system. On this account, he commended the work of various organizations and initiatives, including the following: Hospital Elder Life Program (HELP): www.hospitalelderlife.org The Regional Geriatric Programs of Ontario: www.rgps.on.ca The Regional Geriatric Program of Toronto: www.rgp.toronto.on.ca Inter-professional prevention of delirium Hip fracture nurses Geriatric orthopaedic rehab units Combined ortho-geriatric care Senior-friendly hospitals The Geriatrics, Interprofessional Practice and Interorganizational Collaboration (GiiC) Tool Kit: www.rgps.on.ca/giic-toolkit Ontario s Aging at Home Strategy: www.health.gov.on.ca/english/public/program/ltc/33_ontario_strategy.html Veterans Independence Program: www.vacacc.gc.ca/clients/sub.cfm?source=services/vip On Lok: www.onlok.org PACE (Program of All-inclusive Care for the Elderly): www.pace4you.org/website/article.asp?id=7 CHOICE: www.choiceadvisory.com/ Canadian Research Network for Care in the Community: www.ryerson.ca/cmcc/ Senate Report on Aging: Canada s Aging Population: Seizing the Opportunity (April 2009): www.parl.gc.ca. Looking to the future, Dr. Fisher believes several innovations will be essential for care: Family health teams Physician home visits (e.g., Available to all in the UK s NHS. However a majority are made to people over 75) Home care (e.g., free for all elderly in Scotland) Use of technology Support for informal caregivers Balance of Care. Report: Ontario Hip Fracture Care Forum 22 January 2010 13
Appendix B Breakout Sessions The second half of the Forum was devoted to breakout group discussions on the topics of access to surgery (two groups) and access to rehabilitation (two groups). Each group considered the issues by referring to a hypothetical patient case. The groups reported their findings and proposed solutions, and the floor was opened to further comments by the rest of the Forum participants. These breakout group sessions are summarized below. Blue Group Access to Surgery Patient Scenario Mr. Y. is an 87-year-old man who fell and sustained a fractured hip. He was taken to hospital and put on the list for surgery. During the intake process it was identified that he was taking medication that could pose a complication during surgery and medical clearance was required. The OR list was reviewed daily. Mr. Y. underwent his surgery after 8 days in hospital. Questions 1. Thinking about the scenario above, what are the specific factors that contribute to delays for patients in accessing surgery, and specifically for those requiring medical clearance? 2. For each factor identified, what is needed to achieve more timely access to surgery? Factors that delay access to surgery Lack of coherent systems between ER and the Orthopaedic Surgery department. Wait times for consultations differ by hospital and by profession. Access to the OR is limited, especially during the daytime. Fractures are lower on the OR triage scale, and thus problems of getting hip fracture patients into surgery can escalate as time goes by. When ORs are open after hours, issues often arise over nursing staff overtime: hospital administrators sometimes push back instead of considering best practices. The 48-hour clock begins ticking when a patient arrives in the ER, but is that a judicious measure if a patient arrives, for instance, at 11:00 p.m. in a rural hospital? Solutions to achieve more timely access Rural hospitals could assist by performing patient work-ups prior to transfer to regional hospitals. This would require enhanced rural regional facilities communication and policies. Review priority management policies regarding wait times in regional hospital ERs. Report: Ontario Hip Fracture Care Forum 22 January 2010 14
Establish repatriation agreements that take into account the needs of patients and their families (e.g., for care closer to home). Use the CHESS mortality scale. Clearly identify the person responsible for assessing and preparing patients for surgery. Establish policies on the completion of order sets. Revise and manage the financial incentives/disincentives for repeatedly signing on and off. Improve coordination inside the referring hospital. Build relationships within LHINs and develop pre-arrangements. Foster a two-way commitment to get patients the most appropriate timely care and to return them for care closer to home. The system requires strong leadership, clear protocols, and the commitment of all parties. Additional comments from the floor If a critical mass of hip fractures exists, hospitals ought to schedule hip fracture surgeries according to a fairly predictable pattern of occurrence (especially Monday-Friday). This helps with patient management. Daytime orthopaedic trauma rooms are a good idea, but hospitals have largely looked negatively upon that innovation because of the false sense that they are a money-losing solution. Organizing fracture care during the day has been shown to improve safety, complication rates, and other outcomes. Many fractures (e.g., ankle, wrist) do not require hospital admission, thus leading to a better use of hospital space. In urban centres, consolidate hip fracture care in one or two centres of excellence. Build capacity in those centres through a consolidation of expertise. Physicians lack knowledge about how to deal with patients who are on medications (e.g., cardiac drugs) in terms of safety windows prior to surgery. Addressing this shortcoming requires a focused education effort. Report: Ontario Hip Fracture Care Forum 22 January 2010 15
Green Group Access to Surgery Patient Scenario Mrs. B. lives in a small community where there is no access to orthopaedics within the local hospital. She fell and sustained a fractured hip. She was taken by ambulance to the local hospital where she was admitted and told she would need to go to the regional hospital for her surgery. Mrs. B. was placed on bed rest and transferred 7 days later when a surgery date came available. Questions 1. Thinking about the scenario above, what are the specific factors that contribute to delays in transferring patients between hospitals? 2. For each factor identified, what is needed to achieve more timely access? Factors that delay patient transfers Inadequate access to beds (resources): o Restricted by alternative level of care (ALC) patients o Beds held to support wait-time cases o Surgeon specialization. Absence or inadequacy of regional protocols and leadership around such critical issues as resources, referral, transfer, and priority-setting. Solutions to achieve more timely access A system-level solution is required. It is a regional issue. Therefore, regional hospitals need to take a lead role, which requires appropriate funding of regional facilities. Leadership must come from the LHINs and surgeons: Without question, the best outcome is when you have good leadership from LHINs and from surgeons. There must be commitment at the clinical, organizational, and management levels. Resources must be clearly mapped out (e.g., funding should follow patients). Protocols can drive the process (e.g., transportation, role of receiving organization, how to process returning referrals, role of EMS). Distribution of patients among multiple regional centres. Care pathways. Hospital leads/patient advocates to supervise patient flow through the system. Identification of regional orthopaedic leadership. Development of rehab programs at local hospitals. Post-hospitalization care in the home. Report: Ontario Hip Fracture Care Forum 22 January 2010 16
Yellow Group Access to Rehabilitation Patient Scenario Mrs. K. is a 79-year-old lady who had been living independently at home prior to the fall in which she sustained a hip fracture. She underwent surgery and was found to be mildly confused. Mrs. K. and her family were told she required a period of rehabilitation at a rehab centre to improve her functional ability. Referral papers were submitted to the rehab centre, but a bed was not immediately available. Daily phone calls were made to update the rehab centre about Mrs. K s walking ability and her family situation. After 5 days, Mrs. K. was refused by the rehab centre, with the explanation that they did not have the resources to meet her needs. Questions 1. Thinking about the scenario above, what are the specific factors that get in the way of patients like Mrs. K. being transferred to a rehab facility in a timely way? 2. For each factor identified, what is needed to achieve more timely access? Factors that obstruct timely transfer to rehab facilities Lack of a role for acute care in destination planning. Complicated referral process (e.g., multiple phone calls required). Rehab as the default destination: over-streamlined and lack of consideration of other options. Unlike acute care, rehab centres may refuse patients justified? Problems with incentives and resources: o Lead time to stock up on supplies o Rehab funding model = unavailability of resources o Medical consultation required to determine weight-bearing status o Lack of incentives to take/support more complex patients o Financial disincentives associated with consults and sign-offs o Varying resources and admission criteria across rehab centres, rehab programs, and LHINs. Lack of education and use of standardized assessment tools for dealing with delirium and dementia in rehab centres. Poor communication between hospitals and rehab centres. Wait times for CHESS scale evaluations and consultations. Multiple parties assessing and preparing elderly for surgery: o Hospitals o Internal medicine o Anaesthesia o Family physicians. Report: Ontario Hip Fracture Care Forum 22 January 2010 17
Solutions to achieve more timely access Care pathways. Begin rehab process at acute care admission. Standardize admission and transfer criteria. Enhance communication through technology. Centralize rehab triage in each LHIN, but avoid top-heavy bureaucracy that would slow down the process. Ensure each LHIN takes the lead to address rehab patients needs. Rehab as a process, not a destination: must occur at all stages of care. Co-operative effort between hospitals and rehab centres. Agree on protocols and anticipate when patients will be returning. Improve coordination within hospitals (e.g., main point of contact to manage and help to alleviate ER pressures). Enhance rehab role of acute care nurses. Completion of order sets: include agreement of levels of stabilization required before timely surgery can be achieved. Manage patient and family expectations. Build relationships in the system and have pre-arrangements. Leadership buy-in from the top down. Mutual commitment to take patients (rehab centres) and receive them back (hospitals). Additional comments from the floor Occupancy levels are challenging across the care continuum. We want to make the best use of our resources. If we accept patients who are not good rehab candidates, we cannot transfer them back to the referring institutions if they do not have the space to take them back (not just in fracture care but other medical areas, too). Timely transfers require clear incentives and agreements among partner institutions. Timely transfer is not just a take-back issue; it is also an ALC issue. To deal with it successfully requires flow-through across the health care system. If capacity exists at a rehab centre, it is feasible (e.g., St. John s Rehab) to implement a full-scale strategy that entails active solicitation of relevant patients from acute care partners. Report: Ontario Hip Fracture Care Forum 22 January 2010 18
Orange Group Access to Rehabilitation Patient Scenario Mrs. H. is a 77-year-old lady who has been living at home and has a diagnosis of early stage Alzheimer Disease. She lives with her husband who has been managing caring for her with family support. Following surgery for a hip fracture, Mrs. H. was accepted into rehab; however, on admission she demonstrated mild agitation. The rehab hospital immediately contacted the acute care hospital to return the patient. They stated that Mrs. H. needed placement in a longterm care facility. Questions 1. Thinking about the scenario above, what are the factors that limit access to rehab and successful return to home for patients with cognitive impairment? 2. For each factor identified, what is needed to achieve more timely access? Factors that limit access to rehab and return to home Inappropriate and inefficient patient assessment and management. Ageism: mistaken belief/predisposition that older patients will not benefit from rehab. Lack of expertise and tunnel vision. Lack of slow-stream and other rehab options. High occupancy levels. ALC issues in rehab, which lead to fear of taking a chance. Elevator-acquired pneumonia, etc. Lack of understanding about how cognitively-impaired patients can benefit from rehab (even patients with dementia can be considered stable ). Staffing models (e.g., RN/RPN mix) inappropriate for accommodating patients. Patient destabilization: referring unit will not accept return. Policies that preclude extensive rehab in long-term care facilities. Inappropriate diagnoses. Limited access to specialty services once patients have been transferred to rehab. Lack of knowledge about other available services. Solutions to achieve more timely access Support and linkages to deal with sub-acute cases. Re-examination of staffing mixes and levels. Re-examination of processes and policies (e.g., bed use). Access to geriatricians. Care maps and clinical pathways. Report: Ontario Hip Fracture Care Forum 22 January 2010 19
Regional solution: triage to facilities that have capacity (Note: not a solution in geographically-challenged districts). More time and more recent data used to resize and rebalance the care continuum. Hospital advocacy for increased community resources. Revision and updating of Canada Health Act regarding coverage, insurance, investment. Additional comments from the floor Many centres (e.g., Windsor) do not have rehab services. What do you do then? How many people need to go to rehab? Many people in those areas are going to complex continuing care. Importance of mining outcomes data. Importance of understanding resource allocation variations among regions. Rehab availability varies greatly across Ontario. Intensive rehab programs require more resources but make a huge difference. On average 80% of fractured hips require rehab: We need to be clear about this. Being clear will help to move people to rehab. Some facilities have converted acute care beds into rehab beds. This is a solution in a less-than-ideal world. Where does rehab take place? Some should occur in long-term care and in the home (e.g., CCAC initiatives. Immediate Priorities At the conclusion of the breakout presentations and discussions, the facilitator posed a question to all the participants: What are the immediate priorities and who must take the lead to move the Hip Fracture Model of Care forward? Participants offered these suggestions: We must treat hip fracture patients as people and not as numbers on a page. That means we must improve the approach to a top-down model and everyone must be on same page. Hip fracture patients must be made a priority and not deferred. The same approach must be taken with their post-surgery care. We must dovetail better with what s happening in ALC in order to resolve these issues (the fastest growing ALC is in complex continuing care and rehab). Identify the organizations that are responsible for fracture patients and ensure accountability as it relates to LHINs, hospitals, and physicians. Report: Ontario Hip Fracture Care Forum 22 January 2010 20
Conclusion Dr. James Waddell drew the Forum to a close by summarizing the main observations and recommendations made during the breakout sessions: Addressing the problems that afflict hip fracture care requires strong central planning. This is a natural leadership role for LHINs to assume. Regionalization on the LHIN model can answer many of the problems. Doing so requires LHIN leadership around access to acute care and rehab. We must re-examine the nature and function of rehab care and how it is delivered in hospitals, long-term care facilities, patients homes, and other environments. Everyone who cares for hip fracture patients requires up-to-date medical education. In this regard, however, we are not keeping up, because there is a tendency to see hip fracture patients as a bit of an annoyance. An expert panel would be able to improve the education of physicians and other care givers, in turn positively affecting our ability to deliver care. Processes and procedures remain a concern, and more so at the hospital level than at the LHIN level. For example, we require surgical wait-list management and priority-setting for hip fracture patients in order to ensure surgeries are completed in a timely fashion. We are not asking for more funding; rather, we are looking at ways to increase efficiency and effectiveness. Report: Ontario Hip Fracture Care Forum 22 January 2010 21