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Unpacking Home Health Care Delivery in a Canadian ProvinceWorkshop

October 30, 2019Dr. Tazim Virani, RN, PhDManaging Director, SE Global

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Discuss key insights and lessons learned from a Canadian context to support the application of home health care design and operations in your country

Workshop Overview

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Workshop StructureI. Presentation| 10-12 minsII. Discussion| 30 minsIII. Closing Thoughts| 3 mins

Source: https://www.moma.org/collection/works/79018

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HOME HEALTH CARE IN CANADA

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Home health care in the Canadian context is defined as:

“An array of services for people of all ages, provided in the home and community setting, that encompasses health promotion and teaching, rehabilitation, support and maintenance, social

adaptation and integration, end-of-life care, and support for family caregivers.” – Accreditation Canada and the Canadian Home Care Association, 2015

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The Province of Ontario structure for publicly-funded home health care:

Adapted from: http://health.gov.on.ca/en/public/programs/lhin/docs/hcc_report.pdf

Ministry of Health (MOH)

Local Health Integration Networks(LHINS) (14)

Service Provider Organizations

Community Support Services

Agencies

HOME HEALTH CARE:Nursing, personal support services,

homemaking and therapies

COMMUNITY SUPPORT SERVICES:Meals, transportation, supported

living, home help and other assistance

MOH Definition of Home and Community Care

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Conceptual framework for home and community careUnpaid Activities

Adapted from: Home and Community Care in Canada – May 2012, www.e-library.ca

Paid Activities

Professional & Non-Professional

Home Health Services

VoluntaryDonations &

Services

CaregivingCommunity

CareServices

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General pathway for home health care operations

Eligibility Validation &

Referral

Intake, Assignment &

Scheduling

Assessment & Care Planning Care Delivery

DocumentationDischarge

Supports to clinical staff include: Client Service Representative Scheduler Supervisor Clinical Practice Coaches Advance Practice Leaders Clinical Practice Resource Team

SYSTEM COORDINATION CARE COORDINATION

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Four core eligibility requirements for patients to receive home health care or Personal Support Worker (PSW) services

Requires Ontario Health Insurance Plan(OHIP) coverage

At least ONE professional or personal care service needed

Location where care is to be delivered is appropriate

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03 Services are available in the geographical region that the individual resides

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Service maximums outlined through LHIN service policy for nursing and PSW services

Nursing• 150 visits from a registered nurse or registered practical nurse in a 30-day period• Hours of service in a 30-day period:

• Services provided by registered nurses: 230 hours of service• Services provided by registered practical nurses: 284 hours of service or,• Services provided by both registered nurses and registered practical nurses: 258 hours of services

Personal Support Worker (PSW)• 120 hours, in any 30-day period

Other professional health services• No regulated service maximums (service provision determined by provider)

Source: https://www.ontario.ca/laws/regulation/990386

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Includes: Front-line and leadership for nursing, personal support services, HCA/UCP/HSW

Includes: Front-line and leadership rehabilitation services

Back-off supports including finance, human resources, IT, and business intelligence

General structure for service delivery at SE Health

Service Delivery Centre (14 across Ontario)

Regional Director

Nursing & Personal Support Services

Administrative Support

RehabilitationServices

Includes: Administrative coordinator, Service Coordinators, Customer Service Reps

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CLIENT NEEDS ASSESSMENTS AND ORGANIZATION OF CARE

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What do InterRAI Assessments offer?

Outcome Measurement (Scales)How well is the person doing?

Quality(Quality Indicators)

What is our care quality?How do we compare to others?

Resource Allocation (Case-Mix Systems)

What resources are needed?

Clinical Applications Management Applications

Care Planning Support (CAPs)What does the person need?

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The Inter-Resident Assessment Instrument for Home Care (InterRAI-HC) creates several outputs with different objectives

RAI-HC Assessment

MAPLeRUG-III

GrouperCAPs

Outcome Scales

Quality Indicators

(Prioritize)

(Case mix)

IMPROVE QUALITY

PLANCARE

UNDERSTANDPOPULATIONS

Source: https://www2.gov.bc.ca/assets/gov/health-safety/home-community-care/accountability/pdf/final_rai-hc_guidelines_-_2016.pdf

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Initial contact assessment(for service eligibility)

InterRAI Home Care Assessment

Discipline-specific assessment (if required)

InterRAI re-assessment after 60 days

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Client needs are assessed at differentpoints along the care pathway

Outcome of InterRAIare CAPS which guides care plan

Client care plan developed

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CAP examples by specific section

Functional PerformanceIADL CAP, ADL Cap, Home Environment Optimization CAP, Institutional Risk CAP

Cognition & Mental HealthCognitive Loss CAP, Mood CAP, Delirium CAP, Behaviour CAP, Communication CAP

Social LifeInformal Support CAP, Social Relationships CAP

Clinical IssuesFalls CAP, Pain CAP, Dehydration CAP, Prevention CAP, Pressure Ulcer CAP, Feeding Tube CAP

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Examples of InterRAI outcome scales

Self-Reliance Index

Instrumental Activities of Daily Living Involvement Scale

Pain Scale

Depression Rating Scale

Cognitive Performance Scale

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Nurses work with clients to develop a care plan

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SPECIAL MODELS OF CARE

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Hospital in the Home

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Post-acute model of care: Special populations

PPATH

24/7 Phone Line

Virtual Rounds

Integrated Care Coordinators

(ICCs)

Virtual Care & Tele-monitoring

Integrated Patient Record

Follow-Up Clinic

Putting Patients at the Heart Cardiac Surgery Bundled Care Success 2 Days

Length of Stay

38%Readmission Rate

13%Overall Costs

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Nurse-Led Self-Directed Accountable Teams

24/7, Client/Family Centered Care

Informal & Formal Networks

H.O.P.E. Model ™️Home Opportunity People Empowerment

People & Family’s Needs and Aspirations

Simplifying Processes & Technology | Knowledge Net | Partners

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Reactivation model of care

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Transitional CareReactivation Centre

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Group Seated Exercise

Individual Occupational

Therapy ProgramPhysiotherapy Assistant

Walking Program

Fine Motor Skills Activity

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Hospice/Palliative Care

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We research and develop best-in-class frameworks, digital tools and resources to support family and other informal caregivers

Caregiver AI Chatbot

“How are you feeling today?”

Web-based tool

First of its kind, online B2B platform

Monthly connections with caregivers

Rich, interactive caregiver content

250,000

.com

Elizz Caregiver Solutions

Coming SoonElizz Caregiver

Journal

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QUALITY AND PERFORMANCE INDICATORS IN HOME HEALTH CARE

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SE Health Home Health Care Indicators

Accessibility Effectiveness

Continuity

Work-lifePatient &

Family Centered

Safety

Efficiency

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Here’s to the future!Thank you

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Dr. Tazim Virani, RN, PhD Managing Director, SE Global

+647.654.0147TazimVirani@sehc.com

Amanda Gibson, MHSc, MSW, RSW, CHEProject Specialist, SE Global

+647.444.6718AmandaGibson@sehc.com

@SEHealth_SEHC

https://sehc.com/