@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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