Recent Trends Among Ontario Long Stay Home Care Patients and Long Term Care Residents Jeff Poss, PhD Associate Adjunct Professor, School of Public Health and Health Systems and Health Services Research Consultant, Vancouver 1
Acknowledgements Ontario provincial data from the OACCAC (HC) and CIHI (LTC), held by interrai at U. Waterloo Some of this is an extension of analysis originating with Jeff s PhD dissertation, the committee: John Hirdes Brant Fries Ian McKillop Support and helpful comments from HNHB CCAC: Tom Peirce Jane Blums 2
Overview Time 2006 to 2013 1. Long stay Home Care: RAI HC Informal care analysis/model 2. Long Term Care Homes: MDS 2.0 3. RAI HC among those in placement process to LTC 1) Long stay Home Care (informal care) 3) In Placement to LTC Homes 2) Long term Care Homes 3
A few policy/practice considerations CCAC Personal Support Historically, capped at 60 hours/month (80 in first month) removed/raised in 2008 Aging at Home investments/focus Home First Behaviour Supports Ontario (BSO) Physiotherapy initiatives, notably in retirement homes LTC beds About 77,000 beds, few changes since ~25,000 added from Harris Government initiatives More recently: renovation, repurposing of some beds (convalescent, transitional care) 4
Population Growth: Ontario age 65+ 3.1% growth /year Growth/year 3.4% 7.5% 4.4% 1.7% 1.1% 2.5% 4.8% 5
Population Projections: Ontario age 65+ 3.4% growth /year Growth/year 7.0% 2.7% 1.6% 2.1% 4.3% 4.8% 2.8% 6
LONG STAY HOME CARE 7
Methods 1. RAI HC assessments (exclude those done in hospital) 2. Personal support hours (from HCD) 3. Link to create a time series dataset patient represented in each year in which they received any service and have a RAI HC on record done within 18 months of the last service received in that year Last admitted service referral if more than one in the year 2006 to 2013 (8 calendar years) Approximately 1.3 million patient episodes across this time 8
Long stay Home Care Patient Numbers 2.6% growth /year pop 65+ 3.1% growth /year 9
Age (1 of 3) 10
Age (2 of 3) 11
Age (3 of 3) 12
Demographics 13
Demographics 14
Diagnoses 21,100 37,800 (~11,000 more than expected) 15
RAI Scales 16
MAPLe (1) 17
MAPLe (2) 37,000 more Population growth/aging explains ~10,300 Where did 26,700 come from? Population growth/aging suggests ~19,000 more LTC beds in this time, but no growth there CCACs now serve the equivalent of 150 210 LTC homes, each ~125 beds, that has been added above expected growth, in last 7 years 18
Other 19
Psychotropic Medications 20
Variation by CCAC (1) (dotted line: average of 14 CCAC rates) 21
Variation by CCAC (2) (dotted line: average of 14 CCAC rates) 22
Variation by CCAC (3) (dotted line: average of 14 CCAC rates) 23
Variation by CCAC (4) (dotted line: average of 14 CCAC rates) 24
Formal (CCAC), informal support (any) 25
Formal (CCAC), informal support intensity 26
RUG III/HC CMI Since 2009: Up 2.8%/year, 12.0% overall Up 3.5%/year, 15.6% overall 27
Note: next slides Omit cases with high daily personal support amounts: average >5 hours per day Why? In models, behave like outlier cases, clinical characteristics tend to not explain PS amounts well Fiscal year Total cases With > 5 hrs/day Personal Support 2006 145,630 308 2007 152,851 344 2008 159,063 380 2009 162,849 603 2010 162,047 928 2011 168,708 1,525 2012 172,993 1,938 2013 174,528 2,213 Total 1,298,669 8,239 (0.6%) 28
Recap: Formal care / Informal care hours per day plus ADL hier 1+ (unadjusted, among all, PS>5 hrs/day removed) Up 0.4%/year Up 6.2%/year Up 5.6%/year
Adjusting Use 2006 as reference year, look at relative change Model CCAC formal care, adjusting for informal care and other patient and caregiver characteristics and vice versa: informal care adjusting for formal care, etc. Using directly observed measurements will yield biased results (lack of independence) Use Instrumental Variables (IV) approach, 2 stage regression: Model expected care time, and then use expected time in the models as explanatory variables, instead of the direct measurement this helps yield more valid results 30
Hypothesized Relationship of Formal, Informal Care Exogenous variables Endogenous variables Provider (CCAC) characteristics Care recipient characteristics Formal personal care hours year Informal caregiver characteristics Informal care hours year 31
Relative change (adjusting for patient/caregiver characteristics, and other care received) CCAC personal support hours per day Informal care hours per day *excludes patients averaging >5 hours personal support/day 32
Adjusting for: CCAC personal support: Modeled informal care Age, gender ADL, IADL, CPS Wheelchair use Incontinence Type of residence R sq = 24.6% Informal care: Modeled formal care Age, gender ADL, IADL, CPS Wheelchair use Incontinence Behaviour Primary informal caregiver co resides, and if is spouse R sq = 36.1% 33
Thinking about what this could mean Average ~0.05 HS hrs/day additional, $35 $47M/year in personal support expense CCAC personal support hours per day Informal care hours per day *excludes patients averaging >5 hours personal support/day 34
But some context.. 35
What is informal care time worth? About 80 million hours/year among these long stay home care patients Could be $0 (cost to the health care system) Could be $30/hour (replace with PSW) Could split difference, say $15/hour $0 $1.2 billion $2.4 billion (per year) Models suggest, all else being equal A patient with one hour less informal support gets ~3 minutes more PSW A 5% drop in informal support (4 million hours/year) would require an additional $5.5 million 36
Informal caregiver co residing When patient does not live with an informal caregiver, adjusting for other factors, informal care is about 1.5 hours/day lower About 53% of patients have a caregiver who lives with them, largely stable in recent years 37
Congregate care Living in congregate care (at referral) independently associated with receiving fewer personal support hours (0.24 hours/day lower, adjusting for other factors) Trend: more served in congregate care 38
Home Care Summary See shift of RAI HC assessed patients, starting around 2009 More high needs, fewer low needs, more total patients Adjusting for factors that influence amount of care: Informal support declining CCAC personal support keeping up with increased needs of patients served, and even exceeding 39
Possible Implications CCAC share of the care envelope increasing as more needy patients supported at home Informal caregivers may have reached a limit and cannot increase care in the same way the formal system is able to Or is something else influencing informal care? Could mean supporting higher needs individuals in the community longer may be less efficient than in the past Increased formal care role may have longer term benefit? Informal caregivers get a break which reduces their care burden and may support them to provide care better and longer However caregiver distress levels are not encouraging 40
Caregiver distress (caregiver unable to continue, feelings of distress, anger, or depression) 41
LONG TERM CARE HOMES (MDS 2.0) 42
Methods RAI/MDS 2.0 assessments to March 31, 2013 Done on admission and then repeated every 3 months History in Ontario LTC homes: Early adopters volunteered beginning in 2005 Implementation considered complete by beginning of 2010 Here I use a subset of 84 homes all reporting January 2007 to March 2013 (25 quarterly periods) May not be entirely representative of all homes, but is a consistent cohort to reflect any trends Can compare to all homes since 2010 43
LTC homes: age, sex 44
LTC homes: Dementia diagnosis 45
LTC homes: Stroke diagnosis 46
LTC homes: Psychiatric diagnosis (anxiety or depression, bipolar or schizophrenia) 47
LTC homes: Renal failure 48
LTC homes: 6 or more diagnoses (from pick list of 47) 49
LTC homes: ADL hier 4+, CPS 4+ 50
LTC homes: CHESS 2+ 51
LTC homes: Aggressive Behaviour Scale 5+ 52
LTC homes: Mental Health Treatments (early adopters only) 53
LTC homes: medications (early adopter homes only) 54
LTC homes: 10+ different meds last 7 days 55
Long Term Care Homes Summary Many measures of need, complexity show modest increases Smaller degree of change compared to home care Mood/psychiatric conditions more common but severe behaviour problems trend down 56
TRANSITION: RAI HC AMONG THOSE WAITING FOR PLACEMENT 57
Methods Here, take referrals for long term placement that are discharged Take last RAI HC prior to discharge Note, cannot see for all cases if actually placed to LTC, or when, so somewhat imprecise Assign to year in which discharge from CCAC referral occurred 22,000 to 28,000 discharges of this type per year Represents period in which they were: Placed in LTC Died or gave up waiting for first choice on wait list Died or gave up waiting for LTC placement 58
LTC placement: age, sex 59
LTC placement: diagnoses 60
LTC placement: scales 61
LTC placement: other characteristics 62
LTC placement: Informal caregiver 63
LTC placement summary Similar trends to those seen among long stay home care served population As would be expected most waiting for placement also receiving services 64