Ministry-LHIN Performance Agreement (MLPA) Patient Flow Report Quality and Safety Committee Hamilton Niagara Haldimand Brant (HNHB) Local Health Integration Network (LHIN) November 21, 2012
Agenda 2012-13 MLPA Targets First quarter (Q1) Summary of Results Alternate Level of Care (ALC) Emergency Room (ER) Wait Times Wait time from community for Community Care Access Centre (CCAC) services Recap on Public Reporting 2
MLPA (Patient Flow) Targets for 2012-13 Four of the five targets unchanged from 2011-12 New target for CCAC wait time indicator, representing a 10% improvement over the 2011-12 year end performance of 29 days New for 2012-13 a 10% corridor on targets MLPA Indicator 2011-12 Target 2012-13 Target (10% corridor) Percent ALC Days 11% 11% (12.1%) ER Wait Time 90 th Percentile Admitted Patients ER Wait Time 90 th Percentile Non -admitted High Acuity ER Wait Time 90 th Percentile Non-admitted Low Acuity Wait time for CCAC services from Community 28.3 hours 28.3 hours (31.13 hours) 7.5 hours 7.5 hours (8.25 hours) 4.5 hours 4.5 hours (4.95 hours) 27 days 26 days (28.6 days) 3
MLPA Summary of 2012-13 Performance MLPA Indicator 2011-12 Year End 2012-13 Target Q1 2012-13 Q2 2012-13 Provincial Average Percent ALC Days 15.7% 11% 16.02% *13.31% *13.1% ER Wait Time 90 th Percentile Admitted Patients (hours) ER Wait Time 90 th Percentile Non -admitted High Acuity (hours) ER Wait Time 90 th Percentile Non-admitted Low Acuity (hours) Wait time for CCAC services from Community (days) *Reports on April 1 June 30 2012 Source: MOHLTC MPLA Reports 35.45 28.3 32.3 33.4 28.4 Q1 & 2 7.75 7.5 7.52 7.8 7.2 Q1 & 2 4.87 4.5 4.78 4.8 4.2 Q1 & 2 29 days 26 days 35 days *26 days *31 days 4
% ALC Days - Patient Flow vs System Efficiency MLPA indicator calculated on number of ALC days patient accumulated during their entire acute care stay at the time of discharge. Scenario 1 Scenario 2 5 patients discharged each collected 400 ALC days = 2000 days. 20 patients discharged each collected 30 ALC days = 600 days 5 beds were not available for other patients over a long period of time Impact on: patient higher risk of decline (functional and cognitive) and hospital acquired complications Patient flow - the overall number of beds available each day for new patients only decreased by 5 Costs to the system - assume a daily cost of acute care bed of $1,034, 2000 days * $1034 = $2,068,000 ALC rate LHIN s ALC rate higher Less beds (20) available for new admissions on a daily basis Impact on: patient lower risk of decline (functional and cognitive) and hospital acquired complications Patient flow - the overall number of beds available each day for new patients decreased by 20 Cost to the system- assume a daily cost of acute care bed of $1,034, 600 days * $1034 = $620,400 ALC rate LHIN s ALC rate lower Source: Acute care daily bed rate HNHB LHIN ALC SC Oct 2012 5
Percent Alternate Level of Care (ALC) Days Note: Preliminary data for April June show the ALC rate ranging from 10.8% in April to 13.8% in June. In Q1 2012-13, 42 individuals with long waits that together accumulated 6,623 days were discharged. The LHIN expects the ALC rate will be lower in Q1 2012-13. Source: HNHB LHIN IDS Source: MOHLTC MLPA, August 2012 6
Percent Alternate Level of Care (ALC) Days cont d The % ALC Days (closed cases) has shown a steady improvement from a starting point of 23.24% in Q1 09/10 to a reported low of 12.94% in the first quarter of 2011-12 (the lowest rate reported since 2007). The rise in the % ALC Days through 2011-12 going from 12.94% in Q1 to 16.02% in Q4, was the result of a focused strategy to transition individuals experiencing long waits to the right level of care. This strategy resulted in the successful discharge of 146 individuals with long waits (>30 days) that accumulated over 27,019 ALC days in Q3 and Q4. Since the implementation of this focused strategy, the number of individuals with super long waits (>100 days) has decreased from 118 to 52 in 1 year (Sept. 2011 to Sept. 2012). The major barrier for those individuals remaining is choice. 7
% of ALC Days (MLPA) (DAD) Control Chart Percent ALC Days 30.0% 25.0% Percent ALC Days (MLPA) (DAD) Use: Successive decreasing points suggest trend. This could suggest impact from bundled strategies and Home First. The blue dots in December could reflect impact of CCAC service cap 20.0% UCL 20.69% % of ALC Days (MLAA) (DAD) UCL CL 16.43% +2 Sigma 15.0% LCL 12.17% +1 Sigma Average -1 Sigma 10.0% -2 Sigma LCL 5.0% Apr-09-12-Jul UCL = Upper Control Limit and the number of standard deviations above the mean LCL = Lower Control Limit and the number of standard deviations above the mean Data Source: HNHB LHIN IDS October 2012 8
17.1% 16.1% 14.8% 15.2% 14.8% 14.1% 14.3% 13.2% 13.3% 13.3% 12.6% 15.4% 15.6% 15.3% 14.8% 16.5% 15.2% 15.2% 14.2% 13.2% 13.0% 13.2% 14.6% 15.4% 14.4% 14.4% 14.1% 14.2% 14.0% 13.3% 12.8% 14.0% 13.5% 13.2% 12.7% 15.7% 18.5% 22.5% 23.1% 21.8% 20.6% Percent Alternate Level of Care (ALC) Days HNHB LHIN Acute ALC Rate (Internally Monitored) Source: Weekly Hospital ALC Trigger Report 25.0% 20.0% 15.0% 10.0% 5.0% 0.0% Influences Year to Date: Additional AR beds at SJV (September 2011) & at Wellington Park (July 2011) Crisis placement status for hospital patients with > 100 days ALC (September 2011) CCAC personal support maximum service cap of 56 hours per week (December 2011) CCAC re-instated service hours >56 hours (January 2012) 9
Percent Alternate Level of Care (ALC) Days The LHINs Internally monitored % ALC Rate has shown a steady improvement since January 2012. The peak of 15.7% noted in January 2012, was a result of a CCAC personal support maximum service cap of 56 hours per week due to financial pressures in December 2011. CCAC re-instated service hours of >56 hours in January 2012. The LHIN has maintained a % ALC rate of 14.0% or less since February 2012. 10
1/3/2010 3/3/2010 5/3/2010 7/3/2010 9/3/2010 11/3/2010 1/3/2011 3/3/2011 5/3/2011 7/3/2011 9/3/2011 11/3/2011 1/3/2012 3/3/2012 5/3/2012 7/3/2012 9/3/2012 11/3/2012 % Alternate Level of Care (ALC) Days 700 600 500 656 Number of Open ALC Cases - ALL Bed Types Source: ALCIS The number of individual waiting in hospital for an ALC steadily decreased from a peak of 656 reported in January 2010 to 401 reported September 23, 2012. The number of individuals waiting in hospital for LTCH decreased from 396 in January 2010 to 138 reported September 2012. 400 300 200 100 0 Home with CCAC Grand Total Total Long Term Care Linear (Grand Total) 391 The measured success can be attributed to a bundle of strategies that have been implemented across the care continuum: Screening for High Risk Seniors Home First Escalation process for individuals designated ALC-LTC Intensive Case Management Review Process and Tool Restorative Transitional Care Programs - Assess & Restore LHIN weekly calls with Hospitals and CCAC 11
Acute ALC Rates by Hospital Corporations: 0.35 0.3 0.25 0.2 0.15 0.1 0.05 0 Acute ALC Rate - Internally Monitored Source: Weekly Hospital ALC Trigger Report 0.35 0.3 0.25 0.2 0.15 0.1 0.05 0 Acute ALC Rate - Internally Monitored Source: Weekly Hospital ALC Trigger Report 10% Corridor Target HHS NHS St. Joseph's 10% Corridor Target BCHS JBMH 0.35 Acute ALC Rate - Internally Monitored Source: Weekly Hospital ALC Trigger Report 0.35 Acute ALC Rate - Internally Monitored Source: Weekly Hospital ALC Trigger Report 0.3 0.3 0.25 0.25 0.2 0.2 0.15 0.15 0.1 0.1 0.05 0.05 0 0 10% Corridor Target NGH WLMH 10% Corridor Target HWMH WHGH
ALC 2012-13 Action Items 2012-13 ALC Action Plan Activities ALC Bundled strategies Continue bundled strategies that demonstrated improvement in 2011-12 Improve Identification of High Risk Seniors through screening. 2011-12 High ALC User population Analysis by Hospital site. Roll out the modified interrai ED Screener across all LHIN hospital ERs Expand Primary Care Screening tool to St. Catharines and Hamilton Family Health Teams In 2011-12, 730 patients identified as the High ALC Users (top 10% of ALC users), accounting for 51% of the total ALC Days in the HNHB LHIN 68% over the age of 75, 83% admitted through the ED and 65 % were not receiving home care services All LHIN hospitals have completed an analysis of their high ALC population to develop action strategies Improve Transitions in Care: Introduction and rollout of the Rapid Response Transition Team (R2T2). Team consists of nurses and nurse practitioner who will: provide a face-to-face visit with high risk clients within 24 hours of a hospital discharge and visit with clients currently in the community at risk of an avoidable ED/hospital visit Implement HQO BestPATH Discharge Transition Bundle at two hospital sites Pilot and evaluate processes and tools to improve and facilitate transition from hospital to the community. Develop a toolkit for easy adoption by other LHIN hospitals 13
90th Percentile Wait Time Hours ER Admitted Patients 90 th Percentile Wait Time HNHB ER Admitted Patient 90th Percentile Wait Time 50.0 45.0 40.0 35.0 30.0 25.0 20.0 15.0 10.0 5.0 0.0 Baselin e Q 1 08/09 Q 2 08/09 Q3 08/09 Q4 08/09 Q1 09/10 Q2 09/10 Q 3 09/10 Q4 09/10 HNHB LHIN 45.1 42.6 40.7 43.7 46.8 39.6 31.6 33.3 37.7 35.4 39.9 36.8 42.1 34.6 31.1 34.7 42.0 32.3 33.4 LHIN Target 28.3 28.3 28.3 28.3 28.3 28.3 28.3 28.3 28.3 28.3 Provincial 36.4 33.4 31.5 33.6 37.5 30.9 29.8 30.4 33.3 30.3 30.8 32.2 35.8 30.4 28.9 30.2 33.1 28.4 30.3 Q1 10/11 Q2 10/11 Q3 10/11 Q4 10/11 Q1 11/12 Q2 11/12 Q3 11/12 Q4 11/12 Q1 12/13 Q2 12/13 Source: ATC-CCO ER Public Reporting and Pay for Results Hospital Comparison Report Sept 2012 14
ER Admitted Patients 90 th Percentile Wait Time cont d The 90 th percentile wait time for the Admitted population became an MLPA indicator in 2010-11. Prior to 2010-11 the indicator was the % of visits completed within recommended wait time. The LHIN demonstrated improvement for the 90 th percentile wait time in 2009-10 from the base line year of 2008-09. Since then, the LHIN has been challenged to made sustainable improvements in this indicator. 15
Control Chart ER Admitted Patients 90 th Percentile Wait Time Source: ATC-CCO ER Public Reporting and Pay for Results Hospital Comparison Report March and Sept 2012 16
90th Percentile LOS Hours 90th Percentile LOS Hours 90th Percentile LOS Hours 90th Percentile LOS Hours 100.0 90.0 80.0 70.0 60.0 50.0 40.0 30.0 20.0 10.0 0.0 ED Admitted Patient ED LOS Hamilton Hospitals 28.3 21.5 15.9 100.0 90.0 80.0 70.0 60.0 50.0 40.0 30.0 20.0 10.0 0.0 ED Admitted Patient ED LOS - Niagara Health System 51.1 45.4 44.0 HHSC General HHSC McMaster HHSC Juravinski SJHH Target NHS GNG NHS St.Catharines NHS Welland Target 100.0 90.0 80.0 70.0 60.0 50.0 40.0 30.0 20.0 10.0 0.0 ED Admitted Patient ED LOS Large Community Hospitals 47.7 26.2 20.3 100.0 90.0 80.0 70.0 60.0 50.0 40.0 30.0 20.0 10.0 ED Admitted Patient LOS Small Hospitals 37.3 0.0 BCHS NGH JBMH Target HWMH WLMH Target Source: ATC-CCO ER Public Reporting and Pay for Results Hospital Comparison Report Sept 2012
ER Admitted Patient Wait Time Drivers and Actions Drivers Number of patients admitted through the ER requiring isolation protocols Actions Select hospitals are reviewing their isolation processes, including consultation with provincial experts. Request to LHIN Hospital Vice President of Clinical Practice to review isolation protocols/practices across the LHIN. Percent of ER visits that are admitted to hospital LHIN hospitals with higher percent of ER visits admitted to hospital requested to review their admission practices. Roll out of ED screener for high risk seniors to all LHIN hospitals. Availability of inpatient beds Maintain high emphasis on LHIN patient flow strategies, including increased funding for Home First and Service Maximums. Select LHIN hospital ER sites that report higher wait times especially in the last quarter Timely access to primary and specialist care LHIN meetings with hospitals and the CCAC to identify opportunities to improve patient flow and reduce number of admit to no beds in the ER. Implementation and expansion of General Internal Medicine Rapid Assessment Clinics. Hospitals implementing strategies to reduce time for internal medicine consult. 18
90th Percentile Wait Time Hours 90th Percentile Wait Time Hours 90 th Percentile Wait Times for Non-Admitted ER Patients ER Non-Admitted Wait Time High Acuity 8 7.8 7.6 7.4 7.2 7 6.8 Q1 10/11 Q2 10/11 Q3 10/11 Q4 10/11 Q1 11/12 Q2 11/12 Q3 11/12 Q4 11/12 Q1 12/13 Q2 12/13 HNHB LHIN 7.83 7.92 7.93 7.77 7.78 7.73 7.67 7.87 7.52 7.8 Target 7.5 7.5 7.5 7.5 7.5 7.5 7.5 7.5 7.5 7.5 Province 7.62 7.55 7.52 7.62 7.47 7.37 7.2 7.47 7.23 7.2 ER LOS Non-Admitted High Acuity Increasing number of ER volumes Non admitted high acuity volumes have increased 27.5% since 2008-09 (50,773 in 2008-09 to 69,950 in 2011-12). This population often requires diagnostic procedures that result in longer wait times. Hospitals that report longer wait times are Niagara Health System (NHS) Welland and St. Catharines sites and St. Joseph's Healthcare Hamilton. 5.2 5 4.8 4.6 4.4 4.2 4 3.8 3.6 ER Non-Admitted Wait Time Low Acuity Q1 10/11 Q2 10/11 Q3 10/11 Q4 10/11 Q1 11/12 Q2 11/12 Q3 11/12 Q4 11/12 Q1 12/13 Source: ATC-CCO ER Public & Pay for Result Hospital Comparison Report Sept 2012 Q2 12/13 HNHB LHIN 4.8 4.78 4.72 4.95 4.98 4.83 4.78 4.85 4.8 4.8 Target 4.5 4.5 4.5 4.5 4.5 4.5 4.5 4.5 4.5 4.5 Province 4.4 4.38 4.27 4.5 4.35 4.32 4.18 4.43 4.17 4.2 ER LOS Non-Admitted Low Acuity Low acuity volumes increased by 2,118 in Q2 over Q1 2012-13. Wait times for this ER population are impacted by a high number of patients waiting in the ER for an inpatient bed and a high volume of non admitted high acuity patients. Hospitals that report longer wait times are NHS-Welland and St. Catharines sites and Brant Community Healthcare System 19
90th Percentile Wait Time Days 90 th Percentile Wait Time For CCAC Services 90th Percentile Wait Time for CCAC Services from Community Setting 60 50 40 30 20 10 0 Q 3 09/1 0 Q4 09/1 0 Q1 10/1 1 Q2 10/1 1 Q3 10/1 1 Q4 10/1 1 Q1 11/1 2 Q2 11/1 2 Q3 11/1 2 Q4 11/1 2 HNHB LHIN 35 53 28 26 25 54 25 25 25 35 Target 29 29 29 29 CCAC, in order to support clients with higher care needs (Home First), traditionally placed clients determined to have lower care needs on a wait list. As funds become available, clients are removed from the wait list and the wait time in that particular quarter is impacted and increases. Over the past year, CCAC has worked with Community Support Services to transition low acuity clients from the wait list. CCAC has also implemented a strategy- Occupational Therapy Independence Pathway (OTIP) whereby clients would be assessed by an occupational therapist to determine if any equipment needs/assistive devices are required before placing low acuity clients on a wait list. Many clients, once assessed and equipment installed, may no longer require to be wait listed for Personal Support Worker support. Source: MOHLTC Stocktake Report May 2011 and 2012 20
Control Charts Baseline Comparison HNHB LHIN staff have been working with statistical experts at the Ministry of Health and Long-Term Care (ministry) and Health Quality Ontario (HQO) on data reporting. The Quality and Safety Committee data has been presented with upper and lower control limits to assess statistically significant variation. HNHB LHIN staff are now utilizing control charts with comparison against a historical baseline. The limits (calculated on 2009-10 data) have been extended forward so we can compare if a process is in control/out of control compared to 2009-10. This technique is designed to better assess special and common cause variation to assist in making intervention decisions.
Cancer Surgery at the HNHB LHIN Source: Adult Surgery and DI Hospital Comparison Report, WTIS, Access to Care, Cancer Care Ontario
Cardiac By-Pass Surgery at the HNHB LHIN Source: Adult Surgery and DI Hospital Comparison Report, WTIS, Access to Care, Cancer Care Ontario
Cataract Surgery at the HNHB LHIN Source: Adult Surgery and DI Hospital Comparison Report, WTIS, Access to Care, Cancer Care Ontario
Hip Replacement Surgery at the HNHB LHIN Source: Adult Surgery and DI Hospital Comparison Report, WTIS, Access to Care, Cancer Care Ontario
Knee Replacement Surgery at the HNHB LHIN Source: Adult Surgery and DI Hospital Comparison Report, WTIS, Access to Care, Cancer Care Ontario
MRI Scans at the HNHB LHIN Source: Adult Surgery and DI Hospital Comparison Report, WTIS, Access to Care, Cancer Care Ontario
CT Scans at the HNHB LHIN Source: Adult Surgery and DI Hospital Comparison Report, WTIS, Access to Care, Cancer Care Ontario
Recap of Public Indicators Coming in November 2012 Emergency Department (ED) and Alternate Levels of Care (ALC) February 2013 Remaining MLPA indicators 29
Questions? 30