Transitions in Care Discharge Planning Pathway & Dashboard Scott Jarrett Executive Vice President and Chief of Clinical Programs Humber River Hospital Carol Hatcher Vice President Clinical Programs Humber River Hospital Mehdi Somji Manager, Clinical Process Optimization Humber River Hospital Julie Sullivan ALC Collaborative Co-Lead Central Local Health Integration Network Patient Care Director Markham Stouffville Hospital Mary Burello Director, Hospitals Home and Community, Central Local Health Integration Network
Live Polling
Live Poll Question 1 Please indicate the type of organization where you work. https://manage.eventmobi.com/en/ars/results/question/17500/340809/e 37efd4c486b0978989005baa9acc083/
Outline Welcome and Opening Remarks ALC Collaborative Discharge Planning Pathway: Approach Discharge Planning Pathway: Walkthrough and Outcomes iplan Demonstration
ALC Collaborative 1 The Central LHIN Hospitals identified Alternative Level of Care (ALC) as one of their major challenges to emergency department pressures, patient flow, hospital capacity and operational efficiencies 2 In 2015, the Central LHIN formed an ALC Collaborative with Central LHIN Hospitals, Central Home and Community Care (formerly CCAC) and Central LHIN to provide focused, collective resources across the continuum for the benefit of Central LHIN patients 3 The ALC Collaborative worked together on identifying gaps in processes related to ALC management/avoidance, and prioritized areas for improvement resulting in the development of the Discharge Planning Pathway & Discharge Planning Dashboard
ALC Collaborative Governance Structure Hospital and Central LHIN Executive Sponsors Hospital Leads Central LHIN Home and Community Senior Staff Hospital Co-lead Central LHIN Project Manager & Decision Support Central LHIN Home and Community Planning Staff Central LHIN Co-lead
ALC Collaborative
Central LHIN 1.9 Million Residents Highest Number of Seniors Largest of the 14 LHINs and 2 nd Fastest Growing 6 Hospital Sites 48% Diverse with 864,000 immigrants
Central LHIN ALC Patient Journey (FY 16/17) 71% ALC Patient Age 75+* ALC Rate: FY16/17-15.7%, FY17/18 Q1 14.03% ALC Days (%): FY16/17 Q3 YTD - 15.3%, Q4 17.32% Long Term Care Home w/ CLHIN Services ALC Rate (Percentage) 17% 16% 15% 14% 13% 12% 11% 10% Admit to Hospital 13.61% 13.38% 14.07% 285 Cases* (Open) 28,202 ALC Days* ALC Designation 14.36% 14.61% 16.13% 16.10% 15.98% 14.03% Provincial Target: 12.70% Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 FY 15/16 FY 16/17 FY 17/18 Referral to Discharge Destination 90 th Percentile ALC LOS* 32 Days (Closed) 256 Days (Open) 77% Discharge from Hospital Data Source: Quarterly Stocktake Report CLHIN 080817; ALC Central LHIN Performance summary and ALC Trending Report 201706, ATC CCO. *Data as of June 30, 2017 or for June 2017, including Acute and Post-Acute. The directions are to compare June results to May 2017 results. Rehabilitation Supervised/ Assisted Living Palliative Care Complex Continuing Care Convalescent Care Home w/ Community Services Home
Live Poll Question 2 At your hospital, what ALC destination has the highest number of patients waiting? https://manage.eventmobi.com/en/ars/results/question/17500/340811/3 c2d375c04bfb47c55eccdf47de51974/
Central LHIN Highlights: Patient Flow at a Glance Throughput Ratio: 1.02 365 279 372 Newly Added ALC Cases; 7% Designated within 2 Days of Admission (May 2017) What are they waiting for? (As of June 30, 2017, Open, Acute Only) % of CLHIN ALC Cases % of ON ALC Cases % of CLHIN ALC Days LTC 50% 34% 75% Rehab 15% 12% 6% Home w/clhin Services 12% 13% 10% CCC 3% 8% 2% Home w/comm. Services 3% 2% 2% Home w/o Support 0% 1% 0% Supervised or Assisted Living 4% 9% 1% Convalescent Care 3% 4% 0% Mental Health 0% 1% 0% Palliative 3% 5% 0% Unknown 6% 11% 3% As of June 30, 2017, the longest wait time at median is for LTC, 86 days; the median wait time for other common discharge destinations is 4 days for rehab, 21 days for home with CLHIN services (Home and Community) and 21 days for unknown. Data Source: ATC ALC Reports and iport Access, June 2017 Snapshot Open ALC Cases (May 2017) 48% Where are they waiting? Long Term Care 17% 16% 12% 4% 2% HRH NYGH MSH SRHC MH SMH Rehab 46% 35% 30% 27% 23% 14% 11% 0% 0% NYGH MSH SRHC MH HRH SMH Home with CLHIN Services 8% 8% 0% SRHC NYGH MH HRH MSH SMH Discharged ALC Cases (May 2017) Barriers to ALC Patient Discharge Social Supports Behavioural/ Mental Health Bariatric Medications/ Lab/Therapy Equipment/ Structure
ALC Collaborative Strategic Initiatives Standardization ALC Avoidance Framework Discharge Planning Pathway Coordination and Communication Hospitals Behavioural Support Transition Resource Discharge Planning Dashboard (iplan) Assess and Restore (A&R) Central LHIN Systems & Technology Outpatient Stroke/ Neurological Rehab RCA Definitions Framework Collaboration
ALC Avoidance Framework ALC Avoidance Framework outlines patient centered leading practices and strategies for ALC Avoidance in Ontario
ALC Avoidance Framework CLHIN ALC Avoidance Leading Practices and Improvement Strategies for Acute Care Leading Practices and Improvement Strategies 1. Leading Practice: Admissions are limited to clients that require inpatient acute care for more than 48 hours. All alternatives are explored to ensure that anyone admitted could not be managed in a community care setting STRATEGIES ACUTE CARE HOSPITALS If the hospital has over 30,000 Emergency Department (ED) visits annually, the ED has conisdered a fixed or virtual Clinical Decisions Unit The ED has considered/or implemented a short stay unit. No Client is admitted without being assessed first by a Geriatric Emergency Medicine (GEM) Nurse, CCAC Care Coordinator or Discharge Planner to determine if the client's presenting condition can be managed in the community. This includes clients being held overnight in the ED being assessed in the morning. It excludes clients that have an acute medical, surgical or psychiatric diagnosis The hospital has a process to identify clients that were designated ALC within 48 hours of admission and reviews each case to identify opportunities for improvement The hospital has a process to review whether patterns of ED visit volumes align with GEM nurse and SW staffing patterns 2. Leading Practice: All clients/substitute Decision Makers (SDMs) are provided with and Estimated Day of Discharge (EDD) shortly following admission STRATEGIES ACUTE CARE HOSPITALS There is an established process for estimating EDD (i.e. QBP's, Case mix index, etc.) The EDD, discharge plan and discharge expectations are communicated to the client/family within the first 2-7 days of admission and documented on the patient chart A process is in place to audit and evaluate how quickly the hospital determines an EDD and how quickly it communicates to client/ SDM 3.Leading Practice: Limiting the generation of ALC clients is a priority for the hospital. The hospital identifies clients at high risk for being designated ALC and focuses on ALC avoidance and on limiting ALC days. North York General Hospital Markham Stouffville Hospital Humber River Hospital Self Assessments MacKenzie Health Southlake Regional Health Stevenson Memorial Hospital MET MET MET MET MET UNMET MET MET UNMET MET MET UNMET MET MET MET MET ALMOST THERE ALMOST THERE MET MET UNMET ALMOST THERE MET MET MET ALMOST THERE MET MET UNMET MET ALMOST THERE MET ALMOST THERE ALMOST THERE MET MET ALMOST THERE ALMOST THERE UNMET ALMOST THERE MET ALMOST THERE ALMOST THERE UNMET ALMOST THERE ALMOST THERE MET UNMET Central LHIN ALC Collaborative identified opportunities for improvement Formed two subgroups to work on standardized SDM and escalation processes Led to the development of the discharge planning pathway STRATEGIES ACUTE CARE HOSPITALS The hospital uses a screening process (based on ALC predictors) for early identification of clients that present a high risk for being designated ALC. The clients' barriers to discharge are aggressively case managed The hospital has implemented strategies outlined in the Senior Friendly Hospitals Framework to ensure optimal outcomes for seniors The hospital minimizes risk of longer than expected lengths of stay by embedding evidencebased practices that actively mitigate the risk of avoidable deconditioning, falls and/or delirium etc. There is a process in place for auditing the identification of clients at high risk for being designated ALC and compliance with the practices implemented to mitigate risk ALMOST THERE ALMOST THERE ALMOST THERE ALMOST THERE ALMOST THERE MET MET ALMOST THERE ALMOST THERE UNMET MET MET MET ALMOST THERE ALMOST THERE ALMOST THERE MET MET MET ALMOST THERE UNMET ALMOST THERE ALMOST THERE ALMOST THERE 4. Leading Practices: Robust admission policies and procedures are in place to support ALC avoidance and management STRATEGIES ACUTE CARE HOSPITALS Admission policies and procedures include: A. A clear time/timeframe for communicating, in writing, the expected EDD to the client or their SDM B. A philosophy that embraces discharge planning conversations with the client/sdm beginning on admission. These initial discussions focus on the "Home first" philosphy and community discharge destinations. C. The responsibility and requirement of the client/sdm to identify LT choices for clients requiring LTC. Including requested number of short LTC choices and the target timeline for submitting a first choice D. The responsibility and requirement of the client/sdm to pay a co-payment, and to accept the first available bed, if the client needs to waitn in an acute care for a LTC bed E. Reference to an Escalation Process that will be initiated if the client/sdm refuses to engage/collaborate in a discharge plan. This includes triggers and timelines for enacting the escalation process F. An admission agreement signed by the client or SDM A process is in place to audit and evaluate compliance and effectiveness of these admission policies and procedures Self Assessment UNMET ALMOST THERE UNMET ALMOST THERE ALMOST THERE ALMOST THERE ALMOST THERE ALMOST THERE ALMOST THERE MET MET UNMET ALMOST THERE UNMET MET MET MET MET MET MET MET ALMOST THERE ALMOST THERE ALMOST THERE MET UNMET UNMET ALMOST THERE UNMET UNMET UNMET MET UNMET UNMET ALMOST THERE
Challenges in Reporting: Data Gaps
Challenges in Reporting: Manual Reporting
Live Poll Question 3 Do you experience similar challenges in reporting? https://manage.eventmobi.com/en/ars/results/question/17500/340810/2 573c23237f0348969c375bf3a185d50/
Discharge Planning Pathway Approach
Discharge Delays: Patient Story
Patient Centered Care The ALC Collaborative was formed to identify challenges and find efficiencies to improving patient flow, hospital capacity and operational efficiencies. Our approach focused on our patients and/or family, promoting early engagement to ensure discharge plans are aligned with care plans, allowing our patients to better prepare for their transitions This resulted in reduced delays and a more efficient process; reducing our ALC numbers
Our Approach Combining standardized clinical workflows with a newly developed application for Central LHIN Hospitals, Central Home and Community Care and Central LHIN The Discharge Planning Pathway allows for the early identification, engagement and management of patients that require discharge planning interventions, and is supported by literature and leading practices iplan is a new technology that integrates with hospital electronic medical records, and brings together information from Central LHIN Hospitals, Home and Community, and Resource Matching and Referral (RM&R).
Live Poll Question 4 Do you have a defined and standardized process for Discharge Planning? https://manage.eventmobi.com/en/ars/results/question/17500/340812/d 4d48d32e514f3f745b3743d7162e670/
Engagement and Collaboration
Iterative Approach to Development Analyze user requirements Evaluate Design & Prototype
Stakeholder Engagement Executive Leadership Administration Discharge Coordinator Hospital Manager Central LHIN Manager Hospital Care Coordinator Nursing Physician Allied Health Patient Flow Project Management Decision Support Information Systems & Tech Patient Experience
Joint Discharge Rounds A Culture of Communication, Planning & Support Long-Term Care Rounds Complex Discharge Rounds
Discharge Planning Pathway Walkthrough
Outcomes: Decrease in ALC Patients Number of ALC Patients 100 90 80 70 60 50 40 30 20 93 92 90 Humber River Hospital, Total ALC Patients (April 2016 - April 2017) 95 99 87 99 103 89 88 75 72 71 Apr 2016 May 2016 Jun 2016 Jul 2016 Aug 2016 Sep 2016 Oct 2016 Nov 2016 Dec 2016 Jan 2017 Feb 2017 Mar 2017 Apr 2017 Month Go Live Humber River Hospital Linear (Humber River Hospital) 22 Beds Increased Capacity for Acute Patients Data Source: WTIS iport Access
Outcomes: Decrease in ALC LTC Patients 80 73 73 73 Go Live 29 % Decrease In ALC for Long Term Care Patients 66 65 58 60 57 Aug 2016 Sept 2016 Oct 2016 Nov 2016 Dec 2016 Jan 2017 Feb 2017 Mar 2017 Apr 2017 Data Source: WTIS iport Access = 10 ALC LTC Patients
Outcomes: Decrease in ALC Rate ALC Rate 19.0% 18.0% 17.0% 16.0% 15.0% 14.0% 13.0% 17.6% 16.7% 16.3% CLHIN HSAA Target 12.2% Humber River Hospital, ALC Rate (April 2016 - April 2017) 17.1% 18.5% 17.4% 15.9% 16.8% 16.5% 15.1% Go Live 14.8% 4.8% Decrease in ALC Rate 13.2% 12.8% 12.0% 11.0% 10.0% Month Data Source: WTIS iport Access
Continuous Quality Improvement Patient Patient & Family Advisory Council (PFAC)* Follow-up Phone Call* Patient Survey* Process & Workflow PDSA Cycles Monitor Staff Workload Staff feedback via iplan, focus groups, surveys Hospital & LHIN Governance committee Monitor outcome metrics System level decision making and support *In Progress
iplan Demonstration
Thank You msomji@hrh.ca