Mississauga Halton LHIN: Seniors Care Strategy Presentation to Dr. - - PowerPoint PPT Presentation

Mississauga Halton LHIN: Seniors’ Care Strategy

Presentation to

• Dr. Samir K. Sinha MD, Dphil, FRCPC

Provincial Lead, Ontario’s Senior Care Strategy

Narendra Shah, COO Mississauga Halton LHIN August 2, 2012

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MH LHIN Context

1

Strategic approach to enhance care for seniors

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Performance Results with Aging at Home Investments

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Leading Programs Pioneered in MH LHIN and Impact

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MH LHIN Presentation Focus

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Go Forward Strategy

MH LHIN Context

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Context Strategic Approach Performance Leading Programs Go Forward

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Our Health Service Providers

Public Hospitals 2 with 6 sites Long-Term Care Homes 28 with 4,100 LTC beds Community Support Service Providers 34 Mental Health and Addiction Service Provider 11 Community Care Access Centre (CCAC) 1

Context Strategic Approach Performance Leading Programs Go Forward

Mississauga Halton LHIN Population Trends

• More than 1.2 million residents: fifth

largest LHIN by population and one

• f the fastest growing
• By 2025, our population over the

age 65 will increase by 107,000 – bringing the total number of seniors to 250,000

• Culturally diverse: 43% of our

residents identified as immigrants in the 2006 Census. 36% of our residents are visible minorities.

Central West LHIN Central LHIN Waterloo Wellington LHIN HNHB LHIN

Halton Hills Milton Northwest Mississauga Southeast Mississauga South Etobicoke Oakville

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Projected Change in MH LHIN Population

• From 2010 to 2030, the MH LHIN population is projected to

increase by over 530,000 (45.8%)—Net increase of 26,500/year

• r total pop. of Collingwood every year!
• The population aged 75 and older will increase by 82,000, an

increase of 143%

Year Total LHIN Population LHIN Population Age 75+

# % Growth from 2010 # % Growth from 2010

% of Population Age 75+

2010 1,160,904

• 57,303
• 4.9%

2015 1,278,466 10.1% 69,989 22.1% 5.5% 2020 1,410,955 21.5% 86,319 50.6% 6.1% 2030 1,693,170 45.8% 139,498 143.4% 8.2%

Source: intelliHealth, Population Projections LHIN. Accessed July 26, 2012.

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Context Strategic Approach Performance Leading Programs Go Forward

MH LHIN Population 65+ by DA, 2006

Halton Hills South Etobicoke Southeast Mississauga Northwest Mississauga Oakville Milton

Brampton Burlington

MH LHIN Population 65+ by DA, 2006

Context Strategic Approach Performance Leading Programs Go Forward

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Halton Hills South Etobicoke Southeast Mississauga Northwest Mississauga Oakville Milton

Brampton Burlington

Long-Term Care Locations Total of 28 long- term care homes and 4,100 beds

Context Strategic Approach Performance Leading Programs Go Forward

Long-Term Care Home Beds per 100 People Aged 75+ Years Ontario

Source : MOHLTC LTCH System Report – Dec 2010 and Feb 2012

MH LHIN LOWEST RATIO

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LHIN Dec 2010 LTC Beds per 100 people aged > 75 Feb 2012 LTC Beds per 100 people aged >75 Central 7.25 6.71 Central East 9.05 8.62 Central West 9.90 9.02 Champlain 9.59 9.19 Erie St. Clair 8.75 9.02 Hamilton Niagara Haldimand Brant 9.35 9.09 Mississauga Halton 7.22 6.68 North East 10.93 10.80 North Simcoe Muskoka 9.11 8.61 North West 10.59 10.63 South East 10.08 9.76 South West 10.13 9.87 Toronto Central 7.47 7.46 Waterloo Wellington 8.62 8.24 Ontario 8.92 8.59

We would need an additional 1,184 beds to get to the provincial average. (4,153 beds to 5,337 beds)

• 2.00

4.00 6.00 8.00 10.00 12.00 Dec '2010 Feb'2012

Context Strategic Approach Performance Leading Programs Go Forward

Strategic Approach to Enhance Care for Seniors

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Context Strategic Approach Performance Leading Programs Go Forward

Evidence-Based Approach Seniors to Strategy Development

1. Seniors made up 60% of all acute hospital days while they represented 13% of Ontario’s population 2. 55,000 ALC patients occupied an equivalent of 2,500 acute beds in 2011/12 3. Over 85% of all ALC patients are seniors 65+ years and

• ver 70% are 75+ years.

Focus on age75+ high need seniors MAPLe 3-5

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Context Strategic Approach Performance Leading Programs Go Forward

Strategy to Enhance Care for Seniors at Home/Community Capacity

Most appropriate, least intensive level of care

ER

Reduce

Timely Transfer Home

Reduce

Reduce Post Acute Direct Admissions LTCH

CCAC, CSS & MH&A - $231M and Family Health Care

Home and Community Capacity Enhancement & Transformation

 Support high need-MAPLe 3-5  Expand hours of operation  Follow-up in hospitals to get them back home

All investments must meet key performance outcomes

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Context Strategic Approach Performance Leading Programs Go Forward

• Transformation of community sector to respond to high

need seniors to reduce hospitalization

• Building Right community capacity to manage MAPLe 3-

5 (with extended hours and resources) in the community

• Enhance LTC Homes Capacity to care of its residents

Focus on:

Right Care, Right Time, Right Place –Using Home First Philosophy

Use of evidence-based assessment tools in the community sector and robust performance measurements

Context Strategic Approach Performance Leading Programs Go Forward

Home First is About Patient First

• All hospital patients want to return home (community) after their

hospital stay . No patient plans to go to a LTC home.

• HOME FIRST is about best way for transition from hospital to home as

soon as possible after the decision is made that the patient “no longer requires inpatient care”

• It is about :
• How best to take care of high need seniors post hospitalization in

the community/home with appropriate supports

• Keeping high need seniors at home with right supports to avoid or

reduce hospitalization and admission to LTC homes

• Changing the “provider driven/knows best” discharge approaches

that at times are not reflective of right care, right time, right place at the right cost AND is not inclusive of patient/family engagement

Context Strategic Approach Performance Leading Programs Go Forward

• Requires significant transformation – fundamental change in processes

and culture across the health care continuum:

• The default to LTC must change - there are other alternatives
• It is about culture shift for hospital (physicians, nurses), and

change in discharge and workflow processes for the BOTH CCACs and hospitals

• Hospital is a “transition” place not for long-stay and not a

destination

• It is about appropriate and consistent patient/family education
• Both hospitals and CCAC need to operate as one team with one vision

and the same sense of “time clock”.

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Home First is About Patients First

Context Strategic Approach Performance Leading Programs Go Forward

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Objectives  Demand  Right Persons 28 Homes 4,100 Beds

LT LTCH

Transformation of Community HSPs

MH LHIN Strategic Approach to Reduce ALC

Right Care, Right Place, Right Time, Right Cost

Community Capacity Enhancement

Most Investments Use Evidence-Based Provincial Assessment Tools

Objectives LOS ALC

Objectives ER Use  Treatment Time

ER ER

CCAC Enhanced (RAI-HC) Transitional Beds in Hospitals Assess & Restore (RAI-HC) SDL and SDL 24/7 Mobile (RAI-CHA) Behavioural Unit Sheridan Villa (RAI – HC) Chronic Diseases CHF/ COPD (RAI-HC) Home Care by CCAC (RAI-HC) Adult Day Programs (RAI-HC)

Specialized Geriatric Outreach (Internal Screener)

NP’s In LTC

24/7 Crisis Response to Mental Health & Addiction (OCAN)

Home Supports (RAI-CHA) Enhanced Palliative (RAI-HC) Enhanced Respite (CSI) & RAI-CHA Psycho- geriatric Outreach

Dementia & Alzheimer’s Outreach & Day Programs (RAI-HC) Continence Mgmt 75+

Falls Program

RAI Suite of Instruments Other Assessment Tool Extended Hours

Behavioural Supports Ontario Program

Pre-LHIN 2007/08

Transformation of MH LHIN CSS Sector: Focusing on High Need Seniors to Stay at Home Safely

Supportive Housing

Most clients MAPLe 1,2s No 24/7 support Limited integration with hospitals

Adult Day Services

Most clients MAPLe 1-3

ABI

Residential with Community Outreach

Enhanced Respite Care

Day-To-Day Caregiver Relief Home Making/Maintenance Other CSS Stand-alone Transportation Services

Supportive Housing

24/7; Integrated Approach LHIN-wide Mobile Capacity Extensive interaction with hospitals and CCAC - MAPLe 4,5

Adult Day Services

Support more “at risk” Seniors - MAPLe 3+

ABI

Significant outreach to Hospitals and LTCHs

Enhanced Respite Care

High needs

Integrated Home Making/Maintenance

Other CSS Integrated Transportation LHIN wide

$13.5M $5.5M $3.6M $2.9M $1.5M $1M

$6.3M

TOTAL $34.3M

2011/2012

Objective: Increase Community Capacity to Reduce Dependence on Institutions (LTC and Hospitals)

$29.8M $4.7M $5.9M $8.1M $2.3M $2.8M $7.7M TOTAL $61.3M

MAPle 3 to 5 MAPle 1 to 2 Increased funding $27M To support higher need “At Risk” Seniors

Low Acuity High Acuity

Context Strategic Approach Performance Leading Programs Go Forward

Halton Hills South Etobicoke Southeast Mississauga Northwest Mississauga Oakville Milton

Brampton Burlington

Adult Day Program Locations

18 Total of 11 sites with 23 programs Over 793 clients served 2009/10 – 2011/12 88% 65+ with Avg. MAPLe 3.7 69% 75+ with Avg. MAPLe 3.8

• Avg. MAPLe overall 3.7

CCAC Community Sector Transformation (2009/10-2011/12)

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32.0% 68.0% 37.4% 23.6% 76.4% 43.2% 19.8% 80.2% 44.4%

0.0% 10.0% 20.0% 30.0% 40.0% 50.0% 60.0% 70.0% 80.0% 90.0% % MAPLe (1,2) % MAPLe (3,4,5) % MAPLe(4,5)

MAPLe Scores Clients 75+

2011-12 2010-11 2009-10

Moved to appropriate CSS sector Context Strategic Approach Performance Leading Programs Go Forward

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2,501 2,037 1,877 $5,473 $4,180 $2,214

• 1,000

2,000 3,000 4,000 5,000 6,000

• 500

1,000 1,500 2,000 2,500 3,000 09/10 10/11 11/12 $ Total Expense ($000) 75+ Number of Clients 75+

MAPLe 1 & 2 Clients 75+

Clients $ 2,916 3,730 4,208 $14,685 $19,659 $18,890

• 5,000

10,000 15,000 20,000 25,000

• 500

1,000 1,500 2,000 2,500 3,000 3,500 4,000 4,500 09/10 10/11 11/12 $ Total Expense ($000)75+ Number of Clients 75+

MAPLe 4 & 5 Clients 75+

Clients $

CCAC Transformation to 75+ years

(New investments and reallocation of priorties within CCAC)

Transferred to CSS with additional LHIN funding

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Key Success Factors

• Focus on right care in the community and shift to lower cost

settings

• Key performance indicators with measurable targets
• All sectors embrace the agenda and have dedicated focus at ALL

levels (LHIN; CCAC; Hospitals; CSS; LTC)

• Continuous performance monitoring by LHIN and make course

corrections to ensure sustainability

• Education of patients, physicians and all provider staff

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Context Strategic Approach Performance Leading Programs Go Forward

Performance Results with Aging at Home Investments

Context Strategic Approach Performance Leading Programs Go Forward

Context Strategic Approach Performance Leading Programs Go Forward

Impact on ALC to LTC (75+) in MH LHIN

(Acute Only)

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13739 7752 11103 9034 41.6% 27.7% 36.3% 32.6% 0% 5% 10% 15% 20% 25% 30% 35% 40% 45% 2000 4000 6000 8000 10000 12000 14000 16000 2008 2009 2010 2011 % of ALC discharges to LTC Number of ALC to LTC Discharges

MHLHIN ALC to LTC 75+ (2008/09 – 2011/12)

ALC-LTC Discharges % of ALC-LTC Discharges

Context Strategic Approach Performance Leading Programs Go Forward

Volume of MHLHIN LTCH Admissions from Community vs. Hospitals (2009/10 – 2010/11)

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89 101 77 97 364 76 37 75 73 261 38 42 60 55 195 136 123 150 196 605 195 234 233 261 923 217 208 211 256 892

200 400 600 800 1000 1200 1400 Hospital Community

62% 78% 82%

• We have seen a 45.9% decrease in the number of referrals to LTC homes that are admitted

from hospital since fiscal year 2009/10

Context Strategic Approach Performance Leading Programs Go Forward

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Ontario CCAC Model of Care Needs

High ghly C y Com

• mplex
• Inter-professional care
• Align with house-calls;

geographic clustering

Chron

• nic

ic H High igh R Ris isk

• Increasingly complex care needs i.e.

CCAC support/services Thr hreshol hold T d Trans nsition

• n (e.g.

.g. pa patient nt requi quired i d inc ncreased d int ntens nsity Chr hron

• nic
• Early identification and provision of low intensity

CSS services e.g. PSW home making and personal support; Adult Day Programs etc. Wel ell-Stable le

• Self managed care to enhance awareness of healthy living/ageing

(Elderly Persons Centres, website/”hotline”

Seamless ss Transf sfer Bet etwee een CSS a SS and CCA CCAC

Context Strategic Approach Performance Leading Programs Go Forward

Impact of High Risk and Community Capacity (2011/12)

Sector # of clients served % of clients served 75+ % of clients served with MAPLe Scores (3,4, or 5) CSS 3,158 75% 92% CCAC All Enhanced Home Care 770 66% 98% Enhanced Palliative 276 39% Na Total 4,204 60% 96%

Context Strategic Approach Performance Leading Programs Go Forward

MH LHIN Strategic Approach to Strengthening Community-Based Care

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Highly Complex Inter-professional care Align with house-calls; geographic clustering

Chronic High Risk Increasingly complex care needs i.e. support/services

Chronic

Early identification and provision of low intensity CSS services e.g. PSW home making and personal support; Adult Day Programs etc.

Well-Stable

Self managed care to enhance awareness of healthy living/ageing (Elderly Persons Centres, website/”hotline”)

Context Strategic Approach Performance Leading Programs Go Forward

Threshold Transition (e.g. patient required increased intensity

Leading Programs Pioneered in MH LHIN and Impact

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Context Strategic Approach Performance Leading Programs Go Forward

http://www.mississaugahaltonlhin.on.ca/uploadedFiles/Home_Page/Provincial%20Home%20First%20Implementation%20Guide%20and%20Toolkit%20April%202011.pdf

Co-Chair and significant membership from MH LHIN

Context Strategic Approach Performance Leading Programs Go Forward

MH LHIN Pioneered “Home First” Philosophy

 MH LHIN recognized in H Cof C’s “Seniors in need, caregivers in distress: What are the home care priorities for seniors in Canada”, April 2012  Recognized by Canadian Home Care Association as best practice  Recognized by Ontario Home Care Association Advocating for programs and recognizing our pioneering efforts  Recognized in Dr. Walker’s report (June 2011) as the most important best practice component of ALC reduction  Many Canadian jurisdictions have requested information about this highly successful program

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Context Strategic Approach Performance Leading Programs Go Forward

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 Received National 3M Quality Award, June 2011  Significantly informed the development of the MOHLTC’s “Assisted Living for High Risk Seniors Policy” 2011  Many Canadian jurisdictions have requested information about this successful program  Independent evaluation completed in 2010 indicates success with high level of client satisfaction and outcomes  One of key areas of investment recommended by Dr. Walker

MH LHIN’s Highly Successful Supports for Daily Living - An Innovative Program to Support Seniors 24/7 in their Homes

Context Strategic Approach Performance Leading Programs Go Forward

Halton Hills South Etobicoke Southeast Mississauga Northwest Mississauga Oakville Milton

Brampton Burlington 33 Sub-LHI LHIN # S SDL DL Loc

• cation

ions Halton Hills 3 Milton 3 Northwest Mississauga 4 Southeast Mississauga 12 Oakville 13 South Etobicoke 1

• Tot
• tal of
• f 743 s

743 spot

• ts
• Ove

ver 2,973 c 2,973 clients s serve ved

• Avg. A
• vg. Age

ge 77 ( 77 (80% 80% are 75+ 75+)

• Avg. M
• vg. MAPLe 3.9

3.9

• 71%

71% are M e MAPLe 4 e 4-5

Supports for Daily Living

Context Strategic Approach Performance Leading Programs Go Forward

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Context Strategic Approach Performance Leading Programs Go Forward

Independent Evaluation of Supportive Housing vs Supports for Daily Living (SDL) by MAPLe

MAPLe Score Pre SDL 2008 * Post SDL 2010 ** 1,2 42% 6% 3 53% 41% 4,5 5% 53%

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* Independent study performed by Dr. Hirdes ** Independent study performed by Shercon Associates Inc.

Context Strategic Approach Performance Leading Programs Go Forward

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0.00% 10.00% 20.00% 30.00% 40.00% 50.00% 60.00% 70.00% 80.00% 90.00% RUG III PA1 PA2 Least impaired CCS 2+ MAPLe 4- 5 CHESS 3+ Hospital Admits 1+ ER Visits 1+ SRI Impaired 1+ IADL 7+ DRS 3+ CPS 3+ 2010 2008

Third Party Validation on “S.D.L” Program

Source: Shercon Associates Inc., November 2010

Context Strategic Approach Performance Leading Programs Go Forward

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• 26 bed unit in a LTCH that provides rehabilitation and restorative

care for people no longer requiring acute care but cannot safely return home due to de-conditioning and loss of ability to complete ADLs

• Supports flow from hospital and prevents premature admission to

long-term care

• First LHIN to create transitional capacity (assess and restore) in LTC

setting in 2008

• External evaluation show successful performance and high level of

client satisfaction and outcomes

• One of key areas of investment recommended by Dr. Walker

MH LHIN Assess & Restore Program

Context Strategic Approach Performance Leading Programs Go Forward

Indicators 2008/09 2009/10 2010/11 2011/12

Admissions Total Admissions 169 125 134 155 Average Length of stay 44 days 56 days 56 days 58 days Discharges Discharge Home Discharge to LTC Other 78% 11% 10% 72% 15% 13% 55% 33% 11% 58% 27% 15% Admission MAPLe Scores 3,4,5 97% 100% 89% 95% Client Satisfaction Good to Excellent Satisfactory Somewhat Satisfied 74% 10% 16% 81% 14% 5% 85% 13% 2% 83% 14% 3%

Restore program (26 beds) performance

Over the four years a total of 583 people have received service. This represents a total system savings of 23 acute care beds as calculated using an avg. occupancy rate of 86.6% of 26 available Restore beds.

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Context Strategic Approach Performance Leading Programs Go Forward

Return on Investment of Key Community Programs to Support High Need Seniors (Client Profile 2009/10-2011/12)

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Program # of clients served % of clients served 75+ % of clients served with MAPLe Scores (3,4, or 5) Approximate number of hospital referrals Approximate number of days reduced from hospital LOS * Supports for Daily Living (SDL) 2,973 80% 93% 934 27,086 Lifecare (RESTORE) 583 74% 95% 583 16,907 Enhanced Palliative 1,212 na na na na Wait@Home LTC 924 74% 98% 924 26,854 Wait@Home Enhanced 1,113 71% 99% 1,113 32,277 Stay@Home 774 68% 99% na na Total 6,177 3,554 103,124

Number of seniors being served in the community with high needs that would have otherwise been admitted in the hospital or LTCH. *The number of days reduced from hospital is an approximation based on reduced ALOS..

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Smarter Healthcare Spending: Bending The Cost Curve

RESTORE, SDL, Enhanced Home Care - 2009/10 - 2011/12

Savings Sector Net Annual Savings Emergency Room $ 126,578 Hospital Days $11,941,581 Long Term Care Days $ 2,106,174 Total Savings Per Year $14,174,333

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The following should be noted:

• Cost per patient within each program is becoming more efficient.
• The long-term care days savings is based on data from 2010/11

Context Strategic Approach Performance Leading Programs Go Forward

Savings/Benefits Not Quantified

• Reduced Ambulance Trips
• Decreased ED wait times
• Reduced medical complications as a result of delayed care

(e.g. infections etc.)

• Reduce ED Visits & Hospitalization

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The cost of improved patient experience and quality of care – PRICELESS

Context Strategic Approach Performance Leading Programs Go Forward

Go Forward Strategy 2012 - 2015

Context Strategic Approach Performance Leading Programs Go Forward

3,170 High Users Transfer from LTC # ED Visits Admissions MCC Age / Sex FSA

MH LHIN – 5% High User Inpatient Profile

6, 6,874 A 874 Admission

• ns

Top 4 M MCCs CCs: Circulatory System (38%) Respiratory System (17%) Digestive System (17%) Nervous System (14%) Ag Age # P Peop

• ple

0-19 146 20-44 153 45-64 747 65-74 708 75-84 900 85+ 515 Sex ex # P Peop

• ple

M 1,691 F 1,478 Top 10 10 FSA SA # P Peop

• ple

L5B 176 L5M 166 L5A 163 L5N 154 L6H 134 L9T 116 L5L 111 L6L 104 L5V 103 M9C 98 7, 7,476 E 476 ED Visits

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465 T 465 Transfers from LTC to E ED b by 206 y 206 Patients*

*Includes Nursing Home and Homes for the Aged. Tot

• tal 65+

65+ 2,123 2,123 Tot

• tal 75+

75+ 1,415 1,415

These 10 FSAs contain 42%

• f the RIW

High Users (1,325 of 3,170)

67% 67% 44% 44%

3.9-5%

Context Strategic Approach Performance Leading Programs Go Forward

Client Centric- What does it mean?

“Is it a novel idea to think of caregiver as a “provider” too—engage the caregiver in a meaningful way-how can you the health service provider augment my role to enable my loved one to stay home safely and live in dignity?”

* Loud and Clear, Change Foundation Report, 2012

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Context Strategic Approach Performance Leading Programs Go Forward

Seniors Strategy

• Address sustainability challenges- continue to develop

strategies to keep high need seniors at home

• Family health care (primary care) to be more

responsive to same day and after hours care

• Increase care at home for frail and high need seniors
• Engage the client and family and include them in the

discussion of care plan

• Leverage government desire to expand house calls
• Focus on high need seniors in community

Purpose:

With the focus on supporting seniors to stay healthy and at home longer:

Context Strategic Approach Performance Leading Programs Go Forward

Enhance Community Capacity to Avoid Unnecessary Hospitalization

 Faster access to Family Health Care  Better chronic disease prevention and management  Shift from “Home Care” “Care at Home”  Engage community providers to develop strategies to optimize care at home to increase safety and reduce hospital use (impact

• n ALC reduction rate; re-admits to ED; highest users)

 Increase use of PSW and integrate them with teams of NPs; RNs to optimize care in the community

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Context Strategic Approach Performance Leading Programs Go Forward

Example: Home-care workers were to ask their clients three simple questions: 1.At the beginning of their visit: What is the most important thing I can help you with today? 2.Ten minutes from the end: Is there anything I can help you with before I go? I have the time. 3.When they left: Is there anything you’d like me to tell the agency? For VHA Home Health Care, it meant a 25 per cent jump in its client satisfaction rating. ** Pioneered in TC CCAC, Toronto

Transforming How Frontline Care is Approached “Task First” to “Talk First” **

Context Strategic Approach Performance Leading Programs Go Forward

The bridge between acute care and home/community

“The Essential 16” Needs For Seniors

Family physician engagement, caregiver support/adult day programs, activities of daily living, falls prevention, transportation, mobility, wound care, safe swallowing, continence, cognition, mental health, nutrition, pain management, home safety, medication management, spiritual support.

Source: Adopted from Dr. Nord, Providence Healthcare. Toronto

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24/7 24/7 Challenge and Opportunity

MH LHIN Strategy-Create Comprehensive Community Care Hubs in the LHIN

Context Strategic Approach Performance Leading Programs Go Forward

Right Client in LTC Homes Best Practices

Demark Model

Dementia Support Improved Access Caregiver Support

In Summary

LTC Capacity for BSO Primary Care

NP in LTC Care

User-friendly Single Point of Access to Information

24 hour RN Visit Post Acute

(Rapid Response Nurses)

Telemedicine

Better Integration between PCPs, CCAC, CSS

High Users

Thank you for your attention! Any Questions?

www.mississaugahaltonlhin.on.ca N.Shah, COO

Coffe

• ffee Br

Break

10:40 – 10:50am