MH LHIN Community Investments Foundation For Change Dale Clement, - - PowerPoint PPT Presentation

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MH LHIN Community Investments Foundation For Change Dale Clement, - - PowerPoint PPT Presentation

Feb 17, 2023 399 likes •600 views

MH LHIN Community Investments Foundation For Change Dale Clement, ALC Strategy Lead, MH LHIN Community Investments CCAC Programs Wait At Home Stay At Home Geriatric System Navigators Adult Day Programs Supports for Daily

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MH LHIN Community Investments

Foundation For Change

Dale Clement, ALC Strategy Lead, MH LHIN

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Community Investments

  • CCAC Programs
  • Wait At Home
  • Stay At Home
  • Geriatric System Navigators
  • Adult Day Programs
  • Supports for Daily Living
  • Mobile
  • Hub & Spoke
  • Transitional Services
  • Restore Program
  • Outreach Programs
  • Regional Geriatric Mental Health Outreach
  • Peel Halton ABI Services
  • Nurse Practitioners in LTC
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Wait At Home – Targeted Base Funding CCAC

  • Enhanced service package – up to 56 hours / week

PSW

  • Available for a 60 day period
  • Designed to facilitate hospital discharge with

appropriate supports while planning and waiting for transition to LTC / SDL / ADS etc

  • All applications completed at home
  • Stronger operational linkages with CCAC Community

Case Managers and CSA agencies to facilitate smooth transitions

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Stay At Home – Targeted Base Funding CCAC

  • 106 spots created for seniors with high MAPLe scores,

currently on 60 hrs PSW services waiting for LTC in the community

  • Clients receive the new service maximum of 90 hours

PSW services / month

  • Program helps to keep clients out of hospital, enabling

them to wait safely for LTC at home

  • Many clients have found this level of service sufficient

to delay / defer need for LTC

  • Clients are waitlisted for program – 106 spots are fully

utilized at all times

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Geriatric System Navigation (GSN) – AAH Funds

  • Any person 75+ treated and released from an ED in

MH LHIN is automatically referred to MH CCAC GSN team for contact, assessment and linkage to appropriate community resources

  • Decreases risk and inappropriate utilization of ED
  • Process for referral is a scheduled report every 24

hours from each hospital information system which is faxed to CCAC

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Geriatric System Navigation (GSN): (Nov 1, 2008 to June27, 2009)

Referrals to GSN Team Information & Referral by GSN Total Referrals 2728 Laboratory services 50% Total from LTC 195 Meals on Wheels 80% Known to CCAC 654 Lifeline / Connect care 15% Total Contacted by GSNs 1879 Housekeeping 90% Admitted to CCAC (All left ED before seen) 11 Home Maintenance (outside) –

snow shoveling largely

98% 100% had family doctor Adult Day Program Info 70% Transportation (for family doctor

& clinic appointments, groceries)

90%

GSN reviewed alternatives to ED use with all contacts

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Adult Day Program Expansion – AAH Funding

  • Programs expanded to offer greater community

services

  • Performance measures include requirement to offer

services for a higher needs client and take patients with higher RAI – HC MAPLe score

  • Specialized programs identified to meet a greater need

i.e.: Alzheimer’s and Bathing Programs

  • New programs required to locate in areas within LHIN

where seniors live

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Supports for Daily Living (SDL) – AAH Funding

  • Service model which separates Supportive Housing and

Care Delivery

  • Model supports an average 1.5 hours PSW services /

day delivered throughout the 24 hour period to meet clients more frequent needs

  • Services are available to clients at scheduled times or

as needed, anytime of the day within a 24 hour period, 365 days a year

  • Services are designed for clients with overnight needs
  • r more frequent visitation than those services offered

through the CCAC.

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Supports for Daily Living (SDL) – AAH Funding

  • Supports for Daily Living provides non-medical

services that include:

  • personal support /attendant care (prescheduled

tasks)

  • homemaking services
  • safety and reassurance checks (via phone or in

person) & 24 hour urgent response

  • The delivery model is through two methods – mobile

services (in client’s own home in community clusters) & hub and spoke (Extends in 2km radius from existing supportive housing site to community)

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Restore Program: A “Sub-Acute” Transitional Service

  • Specialized LTC unit for acute patients who require

additional time (~4-8 weeks) and reactivation to enable them to go home

  • Higher acuity than typical LTC resident
  • Reduces ALC days in acute care and avoids

premature institutionalization in LTC

  • Similar to Convalescent Care model
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Restore Program: Performance Results Over First Year 4935 acute-care days made available = 13.5 acute care beds

Target length of stay = 35-42 days

  • Average length of stay = 44 days

Restore Program Admissions from # of Clients Trillium 100 Credit Valley 29 Halton Healthcare 8 Others 10 MH LHIN 147 Restore Program Discharges to % of Clients Home 80% LTC 6% Hospital 10% Deceased 4%

Source: Mississauga Lifecare, March 2008 - March 2009

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Outreach Services – AAH Funding

  • Psychogeriatric outreach teams and PHABIS work with

hospitals, CCAC and LTC to support transitions to LTC for hard to serve patients

  • Work directly with LTC staff to ensure successful

transition plans developed and implemented

  • PHABIS is funded to provide on-site care in LTC (up to

8 hrs / day) and offers Adult Day Services to LTC residents with ABI

  • Both providers help with behaviour escalation

management to support LTC staff and avoid unnecessary transitions to acute care

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Outreach Services – ED & MOHLTC Funding

  • LTC Nurse Practioners now provide coverage to all

27 LTC homes in MH LHIN

  • Nurse Practitioners focus on:
  • Building clinical capacity within LTC homes
  • Supporting on-site care to avoid inappropriate

transfers to acute care

  • Assisting with timely repatriation of residents from

Acute Care

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Impact

  • LTC Waitlists
  • Hard to Serve Patients
  • Number of ALC Individuals in Acute Care
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LTC Waitlist Impact

50 100 150 200 250 300 350 400 450 Jan. 08 Feb. 08 Mar. 08 Apr. 08 May. 08 Jun. 08 Jul. 08 Aug. 08 Sep. 08 Oct. 08 Nov. 08 Dec. 08 Jan. 09 Feb. 09 Mar. 09 Apr. 09 May 09

3 Clients 3 w/ Transfer

Avg. 215 Avg. 176

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Hard to Serve Patients who require post-hospital care: A new approach

  • Addresses the needs of people with complex medical issues,

behavioral problems and/or mental health challenges who are in hospitals

  • Extensive engagement with providers on “Day 1” LTC-eligible
  • Acute care, CCAC, ABI services, Psychogeriatric outreach,

Nurse Practitioners and LTC

  • Process requires referral to each provider organization and data

sharing requirements

  • Currently manual: eReferral will streamline
  • Ongoing monitoring of patient group
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Hospital # Hard to Serve Patients @ Jan 26/09 # Hard to Serve Patients @ March 27/09 % Impact

THC 43 14

  • 67%

HHS 19 2

  • 89%

CVH 6

  • 100%

MH LHIN 68 16

  • 76%

Hard to Serve performance results: Number of patients > 60 acute-care ALC days reduced by 76% over a 2-month period

Aug 3, 2009 – 15 Hard to Serve Patients - not all the same patients as in March / 09

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MH LHIN Reduction in Alternate Level of Care (ALC) – Individuals Waiting in Acute Care

MH LHIN ALC Data 220 225 206 202 227 187 133 122 112 93 152 155 141 136 121 73 55 77 73 64 50 100 150 200 250 Sept-08 Oct-08 Nov-08 Dec-08 Jan-09 Feb-09 Mar-09 Apr-09 May-09 Jun-09 Total ALC Total ALC - LTC

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Thank You

Presentations will be posted at the link below following the video conference An area for questions is also available in the link http://www.mississaugahaltonlhin.on.ca/Form.aspx?ekfrm=4658