A Transform ed 2 4 hr Com m unity Health Service Offering for the MH - - PowerPoint PPT Presentation

“A Transform ed 2 4 hr Com m unity Health Service Offering for the MH LHI N” MH LHIN EXPO Presentation: September 29, 2010

Lisa Gammage, SDL Lead Kristina Hall, ED Nucleus Independent Living

8 Approved SDL Providers

MICBA Forum Italia Community Services Nucleus Independent Living Oakville Senior Citizens Residence (OSCR) Ontario March of Dimes (OMOD) Peel Senior Link (PSL) Regional Municipality of Halton Victorian Order of Nursing (VON) Peel Yee Hong Centre for Geriatric Care

“This collaborative effort among our eight approved SDL Providers provided an excellent opportunity to maximize our ability to improve support for our seniors,” Bill MacLeod, CEO Mississauga Halton LHIN.

SDL Service Transform ation

Service Features:

• Personal care and associated light homemaking

to assist with essential activities of daily living

• Also safety checks, reminders and urgent response
• Multiple daily visits by trained PSWs anytime

throughout 24hr period

• Scheduled and on-call availability 365 days per year

Targeted Population:

• Frail seniors over the age of 65 (minimum assessment score)
• Reside at home within Oakville, Mississauga and Southwest Etobicoke

within MH LHIN boundaries

Transformation:

• Previous Supportive Housing framework was redesigned to expand

geographical access to service and eliminate low income housing requirement as means to access service

• Result is 3 models of service operation (“in building”, “hub/ spoke”,

“mobile”)

• Standardized service offerings and hours of care among all providers

Goals & Outcom es

2 0 0 9 – Jun 2 0 1 0

Reduce acute care and

ALC pressures

Reduce unnecessary ED

visits of target seniors

Avert unnecessary ED

admissions

Divert premature LTC

placement

Admit/ Discharge SDL

clients at the right time

Outcom es on Hospitals

• 55 ALC clients taken out of hospital
• 161 patients accepted to SDL directly
• 1,189 ER visits diverted
• 379 clients returned back from hospital

sooner

• Over 1365 patient days reduced

Outcom es on LTC Hom es

• 13 left LTC homes to SDL
• 191 clients diverted from going to LTC
• 296 LTC Spots no longer needed

Outcom es for the HC System

• 1,701 clients being served
• Cost to the system reduced
• $5.3Million Net savings
• Client Satisfaction-aging at home

Factors of Success



Designed and implemented with high-level systems view



Designed to improve outcomes for seniors based on identified needs and interests (i.e. preference to age at home, need for frequency etc.)



Designed and coordinated collectively by providers with MHLHIN support



Strategic investments (i.e. population density, geographical proximity etc.)



Systems level cost savings (alternatives to existing solutions – ALC, LTC etc.)



Use of Common Assessment Tool (InterRAI-CHA) to ensure appropriateness (right care, right place, right time)



Centralized information and referral pathway (easy navigation for referrals sources)



Responsive to system demands (hospital pressures etc.)



Strong ‘customer service’ focus – (referral sources as “customers”)



Changed from housing focus to service needs



Standardized delivery of services (approved SDL providers)



Innovative service offerings within model (Hub/ Spoke, SDL Mobile)



Clear performance measures and deliverables (system level)

Greatest Learnings

 Focus support on early

adopters – they are the drivers for change

 Being agile is a key to

success in today’s rapidly changing landscape

 Know your “customer”, their

pressures and needs and deliver accordingly

 Innovation is born through

the acknowledgement of what’s not working

SDL GAPS

Opportunities:

• Enhancement of services
• ffered
• Linking to more prevention
• r wellness strategies
• Linking to volunteer

supports

• Targeting increased

support for “hard to serve/ hard to place” clients

• Potential for greater

interconnectiveness between different segments

• f the healthcare continuum

Gaps:

• Demand vs. Capacity
• Isolated in planning

from larger healthcare partners (i.e. Hospitals and CCAC)

• Untapped potential

(i.e. Other mobile healthcare solutions etc.)

Breaking New s: SDL Mobile becom ing Transitional Service

• Purpose is to leverage SDL Mobile’s flexibility and responsiveness to
• ptimize hospital discharge of SDL appropriate patients
• Discharging clients to more appropriate services following period of

stabilization on SDL Mobile’s transitional program (includes to other SDL Providers) Changes include:

• No waitlist for hospital SDL appropriate referrals
• Upstream involvement in hospital SDL referral process
• Planning for hospital surges etc.
• Greater interconnectedness between SDL, CCAC’s and CSS providers:
• Pull strategy development
• Priority referral placements
• Service enhancements
• Shared Services – hard to place, hard to serve
• Developed SDL Mobile Client discharge pathways
• Manage flowthrough with pathway LOS targets
• Implement Admission, Discharge and Transfer (ADT) strategies

Opinions

“The Mississauga Halton LHIN’s Supports for Daily Living program is exactly the type of innovative thinking that is needed across the province . It will allow Ontario’s seniors to live in the comfort of their

• wn home for as long as possible resulting in saved health care

dollars,” Kevin Flynn, MPP Oakville. “The success of the MH LHI N’s Supports for Daily Living( SDL) program , launched in 2008-09, continued and enhanced throughout 2009 and 2010, provides help and support to our frail seniors, enabling them to continue living safely in their own homes” Bill MacLeod, CEO, MH-LHI N