IMPROVING TRANSITIONS FROM ACUTE CARE TO REHAB:

SPREADING CHANGE ACROSS GTA HOSPITAL SITES FOR PATIENTS POST-HIP FRACTURE GTA Rehab Network

Charissa Levy, Sharon Ocampo-Chan, Donna Renzetti October 2016

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PROBLEM How can we access rehabilitation programs as early as possible to facilitate the

recovery of patients following hip fracture across the system?

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PROJECT AIM To standardize and enhance access to

rehabilitation post-surgery for patients post-hip fracture across participating

hospitals, with the goal of reducing the acute care length of stay from surgery to discharge (to inpatient rehab program) to an average of 6 days by December 2016.

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OUR CHANGE STORY…. We decided to spread an

Early Patient Referral Model and other learnings of the

original IDEAS project team* on patient flow for hip fracture

* Acknowledgement: − Jane Harwood, Michael Garron Hospital − Mandy Lau, Providence Healthcare − Jackie Eli, Bridgepoint – Sinai Health System

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BARRIERS “Why is the rehab application declined?”

“What can rehab programs manage medically?”

“What information is needed in the rehab application?”

Tools were developed to facilitate referral process improvement.

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NEEDS ASSESSMENT We asked the Project Leads of acute care and rehab sites to identify their team strengths, current referral practices, needs & mitigation strategies to facilitate implementation of the Early Patient Referral Model.

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CHANGE IDEAS Acute care: • Complete & send rehab

application by day 3 after surgery

Rehab: • Respond within 1 day • Consider patient’s premorbid

functional status

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Average LOS from admission to surgery

• Date of admission

• Date of surgery

Average LOS from surgery to sending rehab application

• Date of surgery

• Date rehab application sent by acute care

Average LOS from sending rehab application to receiving rehab response

• Date rehab application sent by acute care

• Date of first response by rehab

Average LOS from receiving rehab response to discharge

• Date of first rehab response

• Date of acute care discharge

OUTCOME MEASURE Average Length of Stay (LOS) from Surgery to Acute Care Discharge

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PROCESS MEASURES • Referrals sent by day 3

following surgery • Referrals with 1 day rehab

first response time • Referrals with Requests for

Information. What info requested?

• Referrals Declined. Why declined?

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BALANCE MEASURES • % patients returning back to acute

care from rehab • Functional outcome & discharge

destinations of patients after rehabilitation

• Length of stay in rehab programs • Patient Experience Questionnaire

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82%

72%

63%

51% 48%

42%

34%

0%

20%

40%

60%

80%

100%

G (3 months) B (8 months) D (16 months) C (11 months) E (8 months) F (3 months) A (10 months)

Rehab

HOSPITAL

HIGHLIGHT: PROCESS MEASURE Proportion of patients that met the Project AIM of

surgery to acute care discharge ≤ 6 days (from April 2015 to July 2016)

7 acute care hospitals: Credit Valley Hospital – Trillium Health Partners (THP), Etobicoke General Hospital – William Osler Health System, Humber River Hospital, Mississauga Hospital - THP, North York General Hospital, St. Joseph’s Health Centre, The Scarborough Hospital – General site

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Average

8.8 days

UCL

LCL

2

4

6

8

10

12

14

Oct '15(n=8)

Nov '15(n=5)

Dec '15(n=7)

Jan '16(n=6)

Feb '16(n=*)

Mar '16(n=6)

Apr '16(n=10)

May '16(n=6)

Jun '16(n=9)

Jul '16(n=15)

Project Aim ≤ 6 Days

Hospital A

Average

5.2 days

UCL

LCL 0

2

4

6

8

10

12

14

Oct '15 (n=*) Nov '15 (n=*) Dec '15 (n=*) Jan '16 (n=7) Feb '16 (n=*) Mar '16 (n=*) Apr '16 (n=*) Jun '16 (n=*)

Day

s

Project Aim ≤6 Days

Hospital B

Average

7.2 days

UCL

LCL

0

2

4

6

8

10

12

14

16

Sept '15(n=5)

Oct '15(n=6)

Nov '15(n=7)

Dec '15(n=7)

Jan '16(n=8)

Feb '16(n=9)

Mar '16(n=*)

Apr '16(n=*)

May '16(n=*)

Jun '16(n=9)

Jul '16(n=5)

Day

s

Project Aim ≤6 Days

Hospital C

Average

6.7 days

UCL

LCL

-4

-2

0

2

4

6

8

10

12

14

16

Apr '15(n=*)

May'15

(n=*)

Jun '15(n=5)

Jul '15(n=*)

Aug '15(n=*)

Sep '15(n=14)

Oct '15(n=*)

Nov '15(n=*)

Dec '15(n=5)

Jan '16(n=5)

Feb '16(n=6)

Mar'16

(n=*)

Apr '16(n=*)

May'16

(n=*)

Jun '16(n=*)

Jul '16(n=6)

Day

s

Project Aim ≤6 Days

Hospital D

Day

s

HIGHLIGHT: PROJECT OUTCOME • Across 7 acute care hospitals* (and rehab partnerships),

319 patients discharged to rehab programs achieved an average of 7.6 days LOS from surgery to discharge since implementation from April 2015 to July 2016.

• The average first response time across 5 rehab hospitals** was 0.4 days.

*7 acute care hospitals: Credit Valley Hospital – Trillium Health Partners (THP), Etobicoke General Hospital – William Osler Health System, Humber River Hospital, Mississauga Hospital - THP, North York General Hospital, St. Joseph’s Health Centre, The Scarborough Hospital – General site **5 rehab hospitals: Baycrest, Providence Healthcare Centre, Runnymede Healthcare Centre, St. John’s Rehab – SHSC, West Park Healthcare Centre

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MOST POSITIVE OUTCOME Enhanced communication and

collaboration across acute care and rehab partnerships.

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SUSTAINING IMPROVEMENT • Reporting back to project sponsor • Continue regular partnership meetings • Monitor performance

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SPREAD • To internal rehab programs • Lessons learned shared through provincial

webinar with IDEAS Alumni • Exploring application to other patient

groups

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LESSONS LEARNED • ↑ celebration of small successes with project teams • ↑ focus on qualitative benefits observed • Engaging project lead/sponsor earlier to obtain a longer

baseline performance

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WHAT’S NEXT • Continue to support partnerships

through quarterly meetings • Analyze audit referral process data

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COST SAVINGS Six of seven hospital sites have achieved or are close to achieving the Project

AIM of six days as the average length of stay from surgery to discharge

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USE OF AWARD FUND Hired an Analyst to help with monthly referral process data analysis across partnerships.

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Participating Acute Care: Credit Valley Hospital – Trillium Health Partners (THP), Etobicoke General Hospital – William Osler Health System, Humber River Hospital, Mississauga Hospital - THP, North York General Hospital, St. Joseph’s Health Centre, St. Michael’s, Sunnybrook Health Sciences Centre, The Scarborough Hospital Participating Rehab: Baycrest, Bridgepoint – Sinai Health System, Credit Valley Hospital - THP, Humber River Hospital, Mississauga Hospital - THP, Providence Healthcare, Runnymede Healthcare Centre, St. John’s Rehab – Sunnybrook, William Osler Health System, West Park Healthcare Centre Other organizations supporting participating sites: Michael Garron Hospital, Mount Sinai – Sinai Health System, Toronto Western Hospital – UHN, Toronto Rehab - UHN

St. Joseph’s Health Centre

Baycrest

Mississauga Hospital

North York General Hospital

Credit Valley Hospital

West Park Healthcare Centre GTA Rehab Network Etobicoke General Hospital Runnymede Healthcare Centre