Alberta Continuing Care What the RAI data can tell us

Transcription

1 Alberta Continuing Care What the RAI data can tell us Jeff Poss, PhD Associate Adjunct Professor School of Public Health and Health Systems University of Waterloo and Health Services Research Consultant Vancouver

2 Outline Perhaps, some of the things the data can tell us: 1. Alberta Continuing Care Descriptive, drawn from RAI 2. Quality Indicators Home care and residential care indicators 3. Hospitalization rates RAI measures to adjust for risk 2

3 Acknowledgements Alberta Health Services, for making the data available, and for supporting my work with them 3

4 Applications of interrai Instruments Care Plan Resource Allocation Assessment Outcome Measures Quality Indicators

5 1) Alberta Continuing Care 5

6 Home Living Non-Designated Supportive Living Designated Supportive Living 3 Designated Supportive Living 4 Designated Supportive Living 4 Dementia Long-Term Care Who are the clients being served in Continuing Care? Home Care Program AHS Case Management RAI-HC LTC Site Case Management RAI Barb Proudfoot, AHS 6

7 How many and where? And with a recent RAI? Cross-section of active/served individuals Index date: April 1, 2014 AHS annual report (beds) ADT count (persons) With RAI assessment % with RAI assessment Home Living 44% Home Living 22,884 18,330 80% DSL4D Non-Designated SL 4% 7,533 6,134 81% Designated SL3 1,565 1,342 1,278 95% DSL4 9% Long-term care 27% Designated SL4 4,889 4,573 4,292 94% NDSL Designated SL4D 2,043 1,906 14% 1,789 94% DSL3 2% Long-term care 14,370 13,857 13,655 99% 52,095 7

8 Served/Active Individuals, by setting, by zone: April 1, % 90% 80% 15% 31% 29% 27% 24% 27% 70% 60% 50% 51% 14% 29% LTC SL4D SL4 40% SL3 30% 34% 55% 47% 37% 36% 44% NDSL HL 10% 0% South Calgary Central Edmonton North All per

9 Average Age % female Age & Sex % % 78 64% 67% 65% 57% 72 HL NDSL SL3 SL4 SL4D LTC Average age % female 90% 80% 70% 60% 50% 40% 30% 10% 0% 9

10 Average Age % female Age & Sex: DSL3 only, by zone % 60 42% 84 67% 38% 80 65% 72 57% 90% 80% 70% 60% 50% 40% 30% % 50 South Calgary Central Edmonton North All Average age % female 0% 10

11 Some diagnoses 100% 95% 90% 80% 70% 60% 59% 50% 46% 40% 30% 10% 21% 28% 30% 13% 14% 16% 11% 0% dementia stroke HL NDSL SL3 SL4 SL4D LTC 11

12 Some diagnoses 30% 25% 15% 15% 13% 17% 13% 23% 16% 14% 27% 25% 23% 22% 21% 18% 10% 11% 6% 5% 0% heart failure COPD/asthma/emph diabetes HL NDSL SL3 SL4 SL4D LTC 12

13 Physical, cognitive impairment 100% 90% 80% 70% 60% 50% 40% 30% 10% 0% 86% 72% 68% 70% 34% 28% 28% 13% 11% 12% 8% 12% 14% 19% 15% 14% 8% 8% ADLh 3+ CPS 3+ wheelchair HL NDSL SL3 SL4 SL4D LTC 13

14 Proportion ADL hierarchy scale, distribution among settings 80% 70% 60% 50% 40% 30% 10% 0% ADL hierarchy score HL NDSL SL3 SL4 SL4D LTC 14

15 Proportion CPS scale, distribution among settings 80% 70% 60% 50% 40% 30% 10% 0% CPS score HL NDSL SL3 SL4 SL4D LTC 15

16 Some scale measures 45% 40% 41% 35% 30% 25% 15% 10% 16% 11% 29% 24% 21% 19% 16% 17% 18% 16% 29% 5% 0% DRS 3+ CHESS 2+ HL NDSL SL3 SL4 SL4D LTC 16

17 Other 90% 80% 70% 60% 50% 40% 30% 10% 0% 85% 61% 50% 51% 42% 42% 38% 39% 39% 34% 34% 27% 29% 26% 27% 24% 12% daily pain bladder incontinence recent fall* HL NDSL SL3 SL4 SL4D LTC *HC: last 90 days MDS 2.0: last 180 days 17

18 Behaviours, social 60% 50% 51% 52% 40% 30% 10% 0% 9% 8% 22% 17% 3% 2% 4% 5% 37% 21% 6% 15% 11% 10% 6% 22% any aggressive wandering not at ease interacting with others HL NDSL SL3 SL4 SL4D LTC 18

19 Medications 80% 70% 60% 50% 40% 30% 10% 0% 61% 58% 55% 73% 57% 67% 11% 10% 40% 29% 46% 9+ meds antipsychotic /neuroleptic 28% 28% 29% HL NDSL SL3 SL4 SL4D LTC 53% 53% 50% 48% antidepressant 19

20 % CPS 3+ The National Picture 100% 90% 80% AB SL4D 70% 60% YT LTC BC LTC NS LTC Wpg LTC AB LTC ON LTC NFLD LTC SK LTC 50% 40% 30% BC HC ON HC AB SL3 NS HC AB SL4 10% AB HL Wpg HC AB NDSL YT HC 0% 0% 40% 60% 80% 100% % ADL Hierarchy 3+ 20

21 2) Quality Indicators 21

22 Quality Indicators Wish to understand quality of care in health services delivery Very difficult to assess it directly Look for events or measures that we believe are related to quality of care Desired (good outcomes), or undesired (bad) 22

23 At the heart of a Quality Indicator 23

24 Why risk adjust? Underlying factors associated with higher rates of the QI outcome beyond the control of the care providers unevenly distributed Wish to put all on the same scale so comparisons can be made more fairly With others, or over time 24

25 Uses of Quality Indicators System monitoring/review Quality improvement initiative monitoring Requires timely data Public Reporting US: CMS nursing homes Health Quality Ontario: home care & LTC CIHI Health System Performance initiative 10 MDS 2.0 indicators, facility level, May 2015(?) 25

26 Quality Indicators: RAI-HC and MDS 2.0 and risk adjustment RAI-HC MDS 2.0 Original interrai HCQIs (2004) covariate adjustment New interrai HCQIs (2014) direct adjustment: stratified, weighted with covariate adjustment 1 st generation stratification/exclusion 2 nd generation covariate adjustment 3 rd generation direct adjustment: stratified, weighted with covariate adjustment 26

27 Original HCQI: Falls (province, April 2013) 35% 30% 25% 15% 10% 5% 0% HL NDSL SL3 SL4 SL4D raw adjusted Risk adjustment: age 55+, stamina (<2 hrs activity last 3 days), unsteady gait, arthritis, CPS 3+ 27

28 New HCQI: Falls (province, fiscal 13/14) 35% 30% 25% 15% 10% 5% 0% HL NDSL SL3 SL4 SL4D raw adjusted Risk adjustment: age 65, age85, time between assessments, locomotion, unsteady gait, walking device, institutional risk CAP, CPS 4+, ADLh 2+, DRS3+ Stratification: clinical risk (similar to CHESS) 28

29 Original HCQI: Falls (by zone) adjusted rates only 40% 35% 30% 25% 15% 10% HL NDSL SL3 SL4 SL4D 5% 0% South Calgary Central Edmonton North 29

30 New HCQI: Falls (by zone) adjusted rates only 40% 35% 30% 25% 15% 10% HL NDSL SL3 SL4 SL4D 5% 0% South Calgary Central Edmonton North 30

31 Long-term Care: Fall in the last 30 days 166 AB facilities with 20 or more in 4 rolling quarters 45% 40% Adjusted for locomotion, transfer, unsteady gait & CPS 2+, wandering, severity index, age 65 Stratified by RUG-III CMI 35% 30% 25% 15% 10% 5% 0% South Calgary Central Edmonton North Within zone, sorted low to high by adjusted rate raw adjusted 31

32 3) Hospitalization rates 32

33 Hospitalization Rates study Compared samples of residents of Designated Assistive Living (now DSL) to long-term care Reported, after adjusting for risk, hospitalization rates much lower in LTC (14%, compared to 39%) Q1: Is this finding still evident in more recent data? Q2: What about other continuing care populations? 33

34 Methods Active continuing care clients/residents as of April 1, 2013 (not currently in hospital) HL, NDSL, SL3, SL4, SL4D, LTC With a RAI-HC/MDS 2.0 in last 12 months or the next month Linked to DAD Time to first hospitalization, while in this setting, up to March 31, 2014 Cumulative Incidence Competing Risk (CICR) Proportional hazards regression 34

35 Cumulative Incidence Hospitalization Incidence (CICR) April 1, 2013 cohort 0.80 Cumulative Incidence Competing Risk (CICR), Hospitalization HL NDSL SL3 SL4 SL4D LTC Time to admission, days 35

36 CICR, Hogan et al, April 1, 2013 cohort 6 months 12 months Hogan et al, DAL 25.2 ( ) 38.9 ( ) Hogan et al, LTC 8.0 ( ) 13.7 ( ) HL 22.3 ( ) 41.6 ( ) NDSL 23.3 ( ) 42.6 ( ) SL ( ) 36.5 ( ) SL ( ) 37.8 ( ) SL4D 16.7 ( ) 29.9 ( ) LTC 11.1 ( ) 19.6 ( ) CICR (95% confidence interval) 36

37 Proportional Hazard Model Time to first hospitalization, April 1, 2013 cohort Time to first hospitalization hazard ratio 95% confidence limits female age (ref=18 to 64) CHESS score(ref=0) level of care on Apr 1, 2013 (ref=long term care) Zone (ref=edmonton) HL NDSL SL SL SL4D South Calgary Central North

38 Adjusting for risk and other factors Long-term care residents least likely to be hospitalized SL4D about 60% more likely HL, NDSL, SL3, SL4 settings similar to each other, over twice as likely as LTC 38

39 Thank you! 39