@NHLC2019 #NHLC2019

Debra Walko, LOFT Community Services

Lori Holloway, Bellwoods Centres for Community Living

Beverley Nickoloff, Project Manager, Short Term Transitional Care Models

System Transformations:

Building a regional system of reintegration programs to support

the transition of patients from hospital into the community

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Background

Momentum behind designing a regional system of short term transitional care models

Launch of the pilot project

Project participants

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Response to ALC pressures prompted interest in the design of new transitional/ reintegration care models to facilitate transition of patients from hospital

Total hospital beds in Toronto

Central LHIN = 6,359

Beds occupied by ALC patients

= 805 (12.7%) equivalent to the

size of three community

hospitals (250 beds each)

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The Impact of the ALC Challenge

Known consequences ….

Patients not in the most appropriate

care setting

Impact on funding and capacity

(beds, services)

Impact on transition and flow -

access to beds/services for other

patients

Other (emerging) consequences …

Barrier to introduction of new programs

(hospital and systems’ level)

Impact on achieving funding refor

targets

Impact on clinical care, teaching and

resourcing (decreased acuity)

HR/Staffing (capacity, team-based care,

right care providers, gaps in expertise)

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Toronto Central LHIINALC Task Group 2015/16-2017/18

Success of pilots undertaken to test short stay reintegration models:

- St. Hilda’s Short-Stay Reintegration Unit [n= 29 beds]

- Non-insured population [n=7 patients]

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St. Hilda’s Short-Stay Reintegration Unit Pilot: Lessons to build on

SUCCESSES

Significant savings based on hospital IP days

saved

Good job on medical clients with a range of

conditions successfully managed

Strengthening of relationships and trust with

hospitals

Good staff morale (nurses, OT, etc.)

Timely transition of clients from acute care

Minimal repatriations

ALOS within < 6 week target

LESSONS LEARNED

Many clients admitted did not have medical needs

◦ Challenges managing non-medical needs (e.g., clients with no home; social-economic /behavioural issues)

◦ Clients with mental health/ addiction issues were a significant challenge *

Accessing housing and dedicated mental healthsupports

HR/Staffing Challenge:

◦ Complexity arising from working with multiple partners

◦ Heavy case management work load

◦ Challenges transitioning more socially complex clients

◦ Physician / on call coverage

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Short-Term Transitional Care Models (STTCM) Pilot Project Launched in November 2017

Toronto Central LHIN’s proposal to the MOHLTC informed by input from

Community Agencies who were providing reintegration programs (a.k.a.

Transitional Care Programs) confirming:

Interest in building and testing a range of reintegration care models (community beds + services)

Importance of aligning RCU models to build a regional system (integrated, coordinated, centralized supports)

Desire to develop system-level supports to advance development of a regional system of reintegration care models (e.g., centralized referral) and triage)

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Testing of STTCMs involve 14 organizations

Short Term Transitional Care

Models

Reintegration Care Units (RCU beds)

Caregiver ReCharge Services (CRS)

In home respite

Away from home respite

Adult Day Programs

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RCUs : A Regional Collaboration Model

RCU Providers

LTC Providers

Hospital Providers

Supportive Housing

Providers

CSS Providers

Home and Community

Care Providers

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RCU Providers

➢Bellwoods

➢Les Centres D’Accueil Heritage

➢LOFT – White Squirrel Way

➢Pine Villa – LOFT

➢Pine Villa – SPRINT Senior Care

➢Reconnect Community Health Services

➢The Neighbourhood Group (TNG)

➢The Rekai Centres

➢UHN – Hillcrest

➢UHN – St. Hilda’s Towers Senior Care

Centre

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Reintegration Care Units (RCUs)

All RCUs support transition of

patients at risk of ALC / ALC from

hospital to the community

Common goals:

• Enable patients to receive

support, regain strength and

independence and/or adapt to

altered functional state outside of

hospital.

• Help patients and their caregivers

make informed decisions about

future care needs and facilitate

access to housing / support

needs

Reintegration Care Units

(RCUs) = 210 beds

Length of stay of programs

ranging from 42 - 180 days

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RCUs: Client Eligibility Criteria

Valid OHIP Number Medically stable and ready for transition to

community

Have a discharge/transition plan that can be met

within the RCUs maximum length of stay

Require nursing and/or personal care while

awaiting for transition (i.e., not just requiring

housing)

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RCU Programs Designed and being Adapted To Meet Needs Of Clients

Models have been created that truly meet the transition needs of ALC patients - Creating successful, solid

and person-centred transitions

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RCUs: Aligned with health/community sector priorities

Decrease ALC days in hospital

Facilitate successful transitions

Strengthen integration among HSPs

Reduce # ED visits, avoidable admissions/

readmissions/

Support

Transition

& Flow

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2018/19 Data & Trends

Highlights

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STTCM 2018/19 Year End Dashboard

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STTCM Referrals (RCU/CRS): Monthly Totals

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2018/19 Monthly Admission & Discharges

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High occupancy levels & persistent client wait lists in some RCUs

Examples of reasons for waitlists…

Infection Control

Waiting for LTC

Mental Health

Hoyers/ Low

Barriers

Full occupancy in some RCUsUnique client needs unable to be met in one of the current RCUs

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Observations & Outcomes

Learnings from the STTCM Pilot Project

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Success of Centralized Referral Management Team Process

◦ Reviews standardized referrals and consider matches based on client’s care needs

◦ Sends referral to RCU that “best fits client needs” (based on vacancies)

◦ Communication with the referral source (hospital) to confirm referral received and next steps (i.e., matched; need for more details; or waitlist).

◦ Maintains waitlists for specific populations as well as for specific sites.

◦ Compiles referral data (referrals, admissions, denials etc.)

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RCU Program Design “Working”

1. RCUs offering a new level of care • High level of awareness of RCUs• Trust in CRM process• Providing support for patients between hospital and home

2. Transition and flow happening• Timely transition of clients from acute care• Length of stay within targets • Few repatriations back to hospital

3. Specialty RCU programs emerging within the pilots

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Specialty RCU Programs

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RCU Program Design “Working”

4. Savings

▪LOS in RCU as a proxy for inpatient days saved(total LOS in RCU = 64,165 days)

▪Evidence of LTC diversions (n=19)

▪ Opportunities to prevent ED visits, admissions

5. High levels of client and staff satisfaction

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Client Satisfaction Survey Results (n=292)

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Staff Satisfaction

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Value of reintegration care models for hospitals

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Streamlining & coordinating

communication with and access to community

supports

Supporting transition & Flow

Improving understanding of breadth and depth of

caseloads that can be successfully transitioned

to the community

Building of relationships

Identifying specific cohorts of patients who are difficult to transition (and the need for program changes within

hospitals )

Validating the complexity of the ALC caseload in hospitals

and the lack of transition options for some cohorts

Value of reintegration care models for community partners

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Demonstrating the ability and expertise of

community partners to manage complexity and

case mix

Fostering ‘integration’ among community partners in setting

standards, confirming care practices, etc.

Increased connection and coordination with hospital

partners

Catalyst for other collaborations and

integrated approaches

Future Expansion Opportunities

Continuation of Service Resolution Tables

Expansion of Centralized Referral Management

Expansion of Referral Base

Additional Client Cohorts

Transitional Care Navigators

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Service Resolution Tables (SRTs) – hospitals and community partners engaging in ongoing discussions

to support successful transitions of ALC patients

Leverage surge funding being provided to hospitals to

optimize transition and flow.

Transition as many appropriate ALC patients as possible by a

specified date

Identify processes/

structures to improve linkages between hospitals and the

community sector to facilitate transitions for specific ALC

client groups.

Identify existing system gaps (and barriers) impacting on

transition from hospital

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Centralized Referral Management Expansion

CareDove

To provide a centralized electronic data repository for LHIN optimizing security

of PHI, data collection, access, etc.

Future expansion of CRM

To provide a centralized point of access for other CSS partners and programs

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Expansion of Referral Base

• Direct admits from community

• Direct admits from primary care

• Direct admits from ED

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Other client cohorts whose needs could be met in an RCU

Other Client

CohortsBariatric

Enhanced In-Home Transitional

Programs

Chronic Vent

Other care needs (e.g., transplant)

Forensic and/or

forensic avoidance

Clients awaiting LTCH

placement

Clients with no discharge destination

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Transitional Care Navigators

• Case management & follow up to connect clients with the right care

services /housing to support safe and smooth transitions

• Book and attend intake meetings /discharge planning conferences

with clients, families, and interprofessional team to review care plans

• Follow-up with care plan progress and goals

• Complete Client Service Reports and Long Term Care applications

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WHY THIS WORK HAS BEEN SO IMPORTANT!

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Questions?

Discussion

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Appendix

Description of RCU Models

Profiles of actual RCU clients

(2017/18- 2018/19)

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RCU Descriptions

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CLINICAL CARE UNITS PERSONAL CARE UNITSCommon Eligibility Criteria

Patient is designated ALC or at risk of ALC and medically stable

Eligibility Criteria

• Patient requires 24/7 nursing support

• Patient is able to use call bell and/or is safe with q4h checks

• Patient has a valid OHIP including version code (for MD billing)

• A maximum 6-week discharge plan with agreement to repatriate if

necessary

• Average Length of stay is 34 days; Maximum of length of stay of 42

days

• Discharge destination is home

Eligibility Criteria

• Patient needs 24/7 PSW/ Case management/Social Work

• Patient needs ADL/ADL supports

• Patient needs urgent/frequent/unscheduled 24 hour access

• Patients designated ALC with mental health, chronic conditions, cognitive

Impairment, Behavioural Supports, Attendant services needs

• Patient does not have informal support network

• Average length of stay is 90 days: A maximum 6 months admission plan with

transition to long stay reintegration/transitional (Assisted Living Services)

program if needed

Common Exclusion Criteria

• Patient cannot self-direct their care

• Patients are not designated ALC or at risk of ALC

Exclusion Criteria

• Patient without OHIP

• Patient has active uncontrolled abusive/aggressive behaviours.

• Patient has wandering issues.

• Patient has bed alarms/restraints (Note: Lap belts and tilt wheelchairs

>30 degrees are considered restraints)

Exclusion Criteria

• Patient needs nursing supports

• Patient are not medically/mentally/cognitively stable

• Patient needs 24 hour 1:1 supervision and support

Client cohorts served in RCU

PHYSICAL CARE NEEDS

Clients with a history of multiple ED visits or re-admits,

post-acute illness

Clients with significant changes in function (stroke,

amputees, spinal cord injury) who would benefit from

supportive environment to learn greater independence

Clients requiring assistance/learning new self-care (e.g.,

Stoma, g-tube and catheter care)

Clients completing active OP treatment (e.g.,

Chemo/radiation/PT) and requires supportive environment

due to side effects (e.g., decreased Mobility, fatigue,

exhaustion, cognition)

Clients with IV and wound care not a candidate for receiving at home or community nursing clinic care

Clients requiring supportive environment for period of recovery or need for reconditioning and reactivation following an admit for decline in mental or physical health .

Post-fracture clients with short-term weight-bearing restrictions that impact their ability to complete ADLs effectively/safely alone.

Client with mobility issues at risk of increased falls who may benefit practice in mobilizing in a supervised environment

Client needing a supportive environment (with Nursing and/or PSW) while waiting for their confirmed destination to be ready (waitlisted new home, modifications to old home, deep clean, decluttering etc).

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Client cohorts served in RCU

SOCIAL/HOUSING NEEDS

Failure to cope by clients who live alone or with a caregiver who can no longer meet all of the individuals needs and are planning for other resources or destinations

Client waiting for time-specific home modifications or waiting for a deep clean

Client requires more time for family to arrange additional services and supports

Client needs period of monitoring & support while ensuring properhand-off & set-up of community support services to return home safely

Client requires alternative housing during a période of recovery as their home is: not adequately supportive; accessible etc.

CAREGIVER NEEDS

Clients whose barrier to discharge is caregiver burnout

Palliative client where caregiver requires short période of respite.

Caregiver unable to care for the patient due to ownacute health event.

BEHAVIOURAL NEEDS

Clients with responsive behaviours related to dementia, mental illness, substance use and other neurologicalconditions who require a safe spot to wait for othersupportive environments (home, LTC, new supportivedestination)

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