High Users Review: Drives Local Health Care System Transformation to Improve Quality and Sustainability. November 19, 2012

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High Users Review: Drives Local Health Care System Transformation to Improve Quality and Sustainability November 19, 2012 Narendra Shah, Chief

1 High Users Review: Drives Local Health Care System Transformation to Improve Quality and Sustainability November 19, 2012 Narendra Shah, Chief Operating Officer Mississauga Halton LHIN Amir Ginzburg, MD FRCPC, Medical Director, Quality & Patient Safety Credit Valley Hospital and Trillium Health Centre

2 MH LHIN Presentation Focus 1 Profile and Origin of Mississauga Halton LHIN s Top 5% High Inpatient Acute Care Users 2 Profile of Top Emergency Department Users 3 Go Forward Implications, Alignment and Applications 4 Practical Application-Rapid Response Nurse Initiative 2

3 Projected Change in MH LHIN Population From 2010 to 2030, the MH LHIN population is projected to increase by over 530,000 (45.8%) The population aged 75 and older will increase by 82,000, an increase of 143% Year Total LHIN Population LHIN Population Age 75+ # Net increase of 26,500/year, or total population of Collingwood every year! % Growth from 2010 # % Growth from 2010 % of Population Age ,160,904-57, % ,278, % 69, % 5.5% ,410, % 86, % 6.1% ,693, % 139, % 8.2% Source: intellihealth, Population Projections LHIN. Accessed July 26,

4 Overview of Evidence-Based Approach Used Acute Inpatient (IP) and Emergency Department (ED) patient services in MH LHIN are included in the High User Analyses: Accounts for 59% of hospital expenditure in MH LHIN (51% and 8%, respectively) Acute IP Based on top 5% highest weighted cases of acute inpatients (CMG+ RIW) CIHI DAD and Medical Services per Claim History Data, intellihealth ED based on 3 or more ED visits per patient CIHI NACRS, intellihealth Data is available, reliable and can be trended and studied longitudinally Review of both 2010/11 and 2011/12 data Presentation based on 2010/11 data unless specified otherwise 4

5 Acute Inpatient 5% Highest Users Weighted Cases 5

occurring include: Circulatory System (CHF, Cardiac) Respiratory System (COPD, Pneumonia) Digestive System

6 Acute IP High Users, 2010/11 3,170 High Users (5%) of MH LHIN Inpatients Accounted for : 35% of all acute inpatient resources 20% of all ALC Days 7,476 ED Visits in 2010/11 6,874 Inpatient Discharges Most frequent MCCs occurring include: Circulatory System (CHF, Cardiac) Respiratory System (COPD, Pneumonia) Digestive System (Gastrointestinal) Nervous System Largest age cohort are those aged (28%) More males than females (1,691 vs. 1,478) 6

7 MH LHIN 5% High User Acute IP Profile, 2010/11 3,170 High Users Account for 35% of Wtd Cases in the MH LHIN Transfer from LTC # ED Visits Discharges ALC Rate Major Clinical Categories Age / Sex FSA 465 Transfers from LTC to ED by 206 Patients* 3.9-5% 7,476 ED Visits Average of 2.4 ED Visits *Includes Nursing Home and Homes for the Aged. **Excludes Newborns. 6,874 Discharges Inpt High User = Top 4 MCCs: 19.9% MH LHIN = 9.7% (10/11)** Avg of 2.2 Discharges, Avg RIW of with Discharge Status = Deceased Target Seniors Circulatory System (38%) Respiratory System (17%) Digestive System (17%) Nervous System (14%) Total 65+ 2,123 Total 75+ 1,415 67% 45% Age # People Sex # People M 1,691 F 1,478 Top 10 FSA # People L5B 176 L5M 166 L5A 163 L5N 154 L6H 134 L9T 116 L5L 111 L6L 104 L5V 103 M9C 98 These 10 FSAs contain 42% of the RIW High Users (1,325 of 3,170) 7

8 Geographic Origin of High Users Top 10 FSAs, 2010/11 & 2011/12 L9T 116 High Users 100 (11/12) L5N 154 High Users 143 (11/12) L5V 103 High Users 124 (11/12) L5M 166 High Users 182 (11/12) L6H 134 High Users 139 (11/12) L5A 163 High Users 172 (11/12) M9C 98 High Users 104 (11/12) L5L 111 High Users 118 (11/12) L4Y 95 High Users 101 (11/12) L5B 176 High Users 181 (11/12) L6L 104 High Users 112 (11/12) Numbers are crude counts, not Age / Sex adjusted. 8

9 Consistency in Profile of 5% Acute IP High Users (2010/11 and 2011/12) Measure 2010/ /12 # High Users (top 5% RIW) 3,170 3,282 Avg # Discharges Annually Avg RIW per Episode Avg Number of ED Visits Annually % High Users % 66% % High Users % 44% % Deceased 22.8% 21.9% 9

10 Socio-Economic Status and Aging in Top 10 FSAs Acute IP High Users (5%), 2006 Census High Users Rate of: Population (2006) Northwest Mississauga Southeast Mississauga Milton Oakville South Etobicoke L5M L5N L5L L5V L5B L5A L9T L6L L6H M9C 80,524 84,180 46,667 47,852 49,800 46,884 48,527 26,283 54,930 35,229 % Seniors (65+) (MH LHIN = 10.9%) 7.5% 5.7% 9.2% 6.4% 10.6% 12.7% 7.9% 20.2% 8.8% 20.8% % High Users % 52.6% 64.0% 61.2% 73.3% 69.3% 60.3% 83.7% 68.7% 81.6% LICO Rate** (Prov. Rate = 11.7%) 9.4% 7.3% 9.7% 10.6% 16.5% 14.7% 2.8% 4.6% 6.1% 9.3% Unemployment Rate (Prov. Rate = 6.4%) 5.9% 5.5% 6.6% 7.0% 7.2% 8.0% 3.5% 4.7% 5.2% 5.4% # of GPs^ *With the exception of GPs, all numbers are based on 2006 Census data and should be used only as a proxy. **The low income cut off (LICO) after tax rate is 9.3% for the MH LHIN, ^Total number of Family Medicine and General Practice physicians in the MH LHIN, provided by the MOHLTC / Corporate Providers Database, January

11 Acute IP High User 5% Discharge Disposition Status, 2010/11 DISCHARGED TO: ANOTHER HOSPITAL SETTING: TOTAL CMG+ RIW NUMBER OF DISCHARGES AVERAGE RIW ACUTE CARE FACILITY 1, CHRONIC CARE FACILITY 2, GENERAL & SPECIAL REHAB FACILITIES 4, DECEASED: 6, LONG-TERM CARE HOME: 2, COMMUNITY/PATIENT S HOME: COMMUNITY CARE ACCESS CENTRE 3, NO FOLLOW UP VISITS WITH PRIMARY CARE PHYSICIANS FOLLOW UP WITH PRIMARY CARE PHYSICIANS WITHIN YEAR 7,704 2, OTHER 1, GRAND TOTAL 30,730 6, % 53% 98% within 30 days; 71% within 7 days 11

12 MH LHIN Presentation Focus 1 Profile and Origin of Mississauga Halton LHIN s Top 5% High Inpatient Acute Care Users 2 3 Profile of Top Emergency Department Users, 2010/11 and 2011/12 Go Forward Implications, Alignment and Applications 4 Practical Application-Rapid Response Nurse Initiative 12

All ED Visits, Frequency by Age 2010/11 Frequency of Visits to the ED in 2010/11 Age Cohort 1 2 3 4 5+ 0 <1 3403 693 192

2,545 871 366 345 4,573 patients 65+ had 3 or more ED visits to an MH LHIN hospital in 2010/11.

13 All ED Visits, Frequency by Age 2010/11 Frequency of Visits to the ED in 2010/11 Age Cohort < ,841 7,717 2, ,221 10,791 3,133 1,143 1, ,908 7,789 2, ,617 2, ,573 patients 65+ had 3 or more ED visits to an MH LHIN hospital in 2010/11. 17,514 patients had 3 or more ED visits to an MH LHIN hospital in 2010/ ,933 3,925 1, Total 144,923 33,460 10,101 3,845 3,568 13

14 MH LHIN Patients with 3+ ED Visits, 2010/11 [Excludes THC West Toronto] 195,897 Patients with at least 1 ED Visit 17,477 Patients with 3+ ED Visits Total of 280,983 ED Visits in MH LHIN Hospitals in 2010/11* # ED Visits Disposition Status Age / Sex Physician Access FSA 68,980 ED Visits CTAS , % CTAS 3 33, % CTAS , % *Valid Health Numbers only. 51,241 Discharges Home (74.3%) 12,223 Admitted as Inpatient (17.7%) All Others: 5,516 (8.0%) Age # People % of Total , % , % , % , % , % 85+ 1, % Sex # People Male 7,917 Female 9, % have a Family Physician Unlike Inpatient High Users, the bulk of patients with 3+ ED Visits were under the age of 65 (73.5%) FSA # Patients L9T 1,756 L5N 1,243 L5M 1,231 L7G 1,134 L6H 921 L5B 818 L5A 716 L6M 730 L5L 658 L5V 611 These 10 FSAs contain 56.2% of the Patients with 3+ ED Visits (9,818 of 17,477) 14

15 ED High Users with 3+ Visits, 2010/11 17,477 Patients (8.9 % of all ED patients) Accounted for 25% of MH LHIN ED Visits (68,980 visits) 29% of ED Visits by the 3+ ED Visit Cohort were CTAS I or II 74% were under the age of % Female and 45.3% Male 19% arrived by ambulance, compared to 15% overall 15

16 Remarkable Consistency in Profile of 3+ ED Visit Cohort Data in 2010/11 and 2011/12 Measure 2010/ /12 # Patients with 3+ ED Visits 17,477 18,898 CTAS I or II 29.4% 29.0% CTAS III 48.6% 48.7% CTAS IV or V 22.0% 22.3% % Admitted 17.7% 17.4% % Age < % 73.7% % Age % 26.3% % Male 45.3% 45.4% % Female 54.7% 54.6% 16

17 Comparison of patients with 3+ ED visits to all patients with an ED visit in 2010/11 FSA # Patients CTAS I-II CTAS III CTAS IV-V TOTAL CTAS I-V ED Visits All Patients with 3+ ED Visits 17,477 20,296 33,520 15,164 68,980 Percentage Breakdown % 48.6% 22.0% 100% All Patients with an ED Visit 195,769 70, ,662 77, ,669 Percentage Breakdown % 47.3% 27.6% 100% Higher Acuity in 3+ ED Visit Patients 17

18 Summary of Most Common FSAs with High Users by Geographic Area Sub-LHIN FSAs Number of High Users by Cost per Ministry (09/10) Top 10 FSAs of Highest Total Inpatient RIW (10/11 & 11/12) Highest FSAs with 3 or more ED Visits (10/11) Southeast Mississauga L4W L5A L5G L4X L5B L5H L4Y L5C L5J 8,410 L5B L5A L4Y (11/12) L5B L5A L4Z L5E L5R Northwest Mississauga L5K L5M L5N L5L L5N L5W 5,205 L5L L5M L5N L5V L5N L5V L5L L5M Oakville L6J L6K L6M L6H L6L South Etobicoke M8W M9C M8Z M9B 4,175 L6H L6L L6H L6M 3,550 M9C Milton L0P L9T 1,515 L9T L9T Georgetown L7G L7J 1,480 L7G 18

19 MH LHIN Presentation Focus 1 Profile and Origin of Mississauga Halton LHIN s Top 5% High Inpatient Acute Care Users 2 Profile of Top Emergency Department Users 3 Go Forward Implications, Alignment and Applications 4 Practical Application-Rapid Response Nurse Initiative 19

9% DEATH AFTER ARRIVAL / LEFT WITHOUT TREATMENT OR BEFORE TREATMENT COMPLETED 2,789 4.0% DISCHARGED HOME 51,241 74.

20 2010/11 Disposition Status 3+ ED Visit Cohort (17,477) Post ED Follow-Up+ DISPOSITION STATUS # ED Visits % CLIENT ADMITTED AS INPATIENT TO CRITICAL CARE UNIT % CLIENT ADMITTED AS INPATIENT TO OTHER UNITS 11, % DEATH AFTER ARRIVAL / LEFT WITHOUT TREATMENT OR BEFORE TREATMENT COMPLETED 2, % DISCHARGED HOME 51, % DISCHARGED TO PLACE OF RESIDENCE/INSTITUTION (I.E NURSING HOME; CHRONIC CARE, PRIVATE DWELLING WITH HOME CARE, VON, JAIL) 2, % OTHER % Grand Total 68, % 20

21 Timing of ED Visits by 3+ ED Visit Cohort, 2010/11 80,000 70,000 60,000 50, % 69,139 Need for Advanced Access 40,000 30,000 38% 28% 34% 20,000 10,000 26,370 19,310 23,459 Source: CIHI, NACRS. - After Hours M-F Weekends Weekdays 9-5 All # Visits 21

Chronic Disease in 3+ ED Visit Cohort, 2010/11 [Excludes THC West Toronto] Prevalence Rates:* MH LHIN Rate = 9.0% Ontario Rate = 9.7% 17,477 Patients with 3+ ED Visits (10/11) Represents 8.

22 Chronic Disease in 3+ ED Visit Cohort, 2010/11 [Excludes THC West Toronto] Prevalence Rates:* MH LHIN Rate = 9.0% Ontario Rate = 9.7% 17,477 Patients with 3+ ED Visits (10/11) Represents 8.9% of Patients with an ED Visit Condition # Patients Coded with Condition (MPDx or Any) % of 3+ Visit Cohort Coded with Condition Asthma % CHF % COPD % Diabetes 2, % Mental Health & Addictions 2, % Focus on key chronic conditions Conditions defined as per Health Analytics intellihealth report Chronic Conditions - Hospitalizations by LHIN where available (Asthma, COPD, Diabetes and Stroke). CHF and Mental Health and Addictions defined by ICD10-CA Codes I50 and F Codes respectively (Main Problem Diagnosis only). *Diabetes Rates based on Ontario's Baseline Diabetes Dataset Initiative, 2011/12. 22

23 3+ ED Visit - Mental Health & Addictions by Hospital Site, 2010/11 [Excludes THC West Toronto] Hospital Site # of PATIENTS with 3+ ED Visits Coded with Condition (MPDx or Any) # of VISITS by 3+ ED Patients Coded with Condition (MPDx or Any) CREDIT VALLEY HOSPITAL (THE) 675 1,158 TRILLIUM HEALTH CENTRE-MISSISSAUGA 836 1,523 HALTON HEALTHCARE SERVICES CORP-OAKVILLE 584 1,015 HALTON HEALTHCARE SERVICES CORP-MILTON HALTON HEALTHCARE SERVICES CORP- GEORGETOWN Grand Total 2,370* 4,045 * Not discrete counts. 23

24 Implications Where do we begin? Aligns with Baker s report - focus on target populations not specific conditions/diseases in isolation. I. Key populations: a) Frail elderly b) Geographic locations of high users c) Those with: i. Multiple co-morbidities ii. Mental health and addictions 24

25 Implications continued II. Use of reliable evidence-based assessment tools to get at most complex patients: a) Inpatient-LACE b) Develop a simple predictive tool to get at high users in ED (entry point for 70% of all high users) Fred Smith 3 rd Visit to ED in 12 Months III. Develop strategies in ED (gateway for entry into heavy use of health care resources) ---beyond treat and release of high users 25

Focus on high users aligns with Ministry and LHIN priorities 1.

Sustainability-reduce avoidable hospitalization through integrated care for

Right care, right place and the right setting and at the right time 6.

26 Focus on high users aligns with Ministry and LHIN priorities 1. Seniors Strategy 2. ALC 3. Improve Primary Care with Advanced Access 4. Sustainability-reduce avoidable hospitalization through integrated care for chronic diseases, mental health and addictions 5. Right care, right place and the right setting and at the right time 6. Improve quality of care more upfront and timely primary and community care intervention 7. Reduce avoidable ED visits 8. Health equity 26

27 Practical Applications to Improve Local Health System Useful in LHIN planning of networks Realign community mental health and addictions programs to respond to avoidable ED visits Implementing effective diabetes and chronic diseases strategy in the community Focus on enhanced palliative care at home Investment of limited additional resources to target high users e.g. Rapid Response Nurse (RRN) initiative 27

28 MH LHIN Presentation Focus 1 Profile and Origin of Mississauga Halton LHIN s Top 5% High Inpatient Acute Care Users 2 Profile of Top Emergency Department Users 3 Go Forward Implications, Alignment and Applications 4 Practical Application - Rapid Response Nurse Initiative 28

29 Rapid Response Nurse (RRN) Program Deployment: Targeting High Users in the MH LHIN Amir Ginzburg, MD FRCPC November 19, 2012

30 30-Day Readmissions MH-LHIN 30

31 BIG DOT AIM DRIVERS Projects Planned Projects In Progress Projects Completed Minimize complications Medication safety Required Organizational Practices ( e.g. dangerous abbreviations, narcotic safety, drug concentration standardization, admission medication reconciliation ) Infection prevention and control Anti-microbial stewardship Collaborative Care by Design (CCbD) Inpatient rehabilitation programs (e.g. Stroke Rehabilitation, Short/Medium/Long term Rehabilitation) Right care in hospital Preserve cognition and function Senior Intervention Team (SIT) in ED Hospital Elder Life Program ( HELP) Confusion Assessment Method (CAM) Pilot Multiple policies and procedures (falls prevention, least restraints, early mobilization, Silver Spoon etc) Pain management Multiple strategies, see No Needless Pain driver diagram Analysis of local data to identify high risk populations QIP Change Idea Engage patients and families to identify root causes for readmissions via use of IHI diagnostic tool Identification of patients at risk of readmission QIP Change Idea Pilot and deploy LACE Index to identify high risk patients in real time Automate LACE Index in EPR with e- whiteboard visual management Collaborative discharge planning with CCAC and other community partners ( e.g. Supports for Daily Living, Restore) Patient Navigator role for dedicated discharge planning No Needless Harm 30- day readmissions For 2011/12 the 30- day readmission rate for selected CMGs will be 11.5% Discharge planning Support of providers including nurse practitioners for patient education and discharge planning (e.g. Medicine, Respirology, Oncology, Cardiac, Neurosurgery, Spine) Lean ALC initiative Develop formal communication strategy to educate families on discharge best practices QIP Change Transition and Re-admission Team (TReaT) Idea Leverage Flo Collaborative discharge processes to develop a care pathway for transition of care Nursing and allied health discharge summaries Baseline performance is 12.5% as per QIP Selected CMG s Effective transitions to the community Communication to community based providers Leverage LHIN MRP Collaborative to improve completion of physician discharge summaries within 48 hrs Increase remote access to EPR for local family physician Leverage Medical Quality of Care plan to improve utilization of discharge medication reconciliation process Cardiac (CAD, Arrhythmias) Ambulatory ( e.g. Cardiac, COPD, Stroke and other outpatient rehabilitation programs) CHF Stroke (Ischemic and Hemorrhagic COPD Pneumonia Expand follow up telephone communication programs (currently in Surgery, Orthopedics Cardiac Tele- ask) Palliative Care Initiative Follow up clinics within 30 days ( e.g. Surgery Medicine) Diabetes Post discharge follow up Nurse Practitioner based follow up within local long term care facilities ( NP-STAT) GI (all med/surg/ onc CMGs) Outreach Programs Mental Health ( ACTT, ReLinC,) QIP Seniors Outreach Teams ( Geriatrics, Change Idea Seniors Mental Health) Transitions outreach team Chronic disease Patient and family education via providers, educators, ( e.g. diabetes) literature, and other Patient self modalities management Consumer portal Multi disciplinary team- based clinics for key populations ( e.g. Heart Function Clinic, Oncology Clinic, Diabetes Management Centre, Stroke Prevention Clinic, Chronic Airway Diseases Clinic) management 31

32 Priority 1 in QIPs Across MH LHIN Quality Dimension Integrated Indicator Reduce unplanned readmissions to hospital Corporate Target 12.5% Target Justification 3% Improvement 32

33 LACE Index L LOS A Acuity C Comorbidities E ED in 6 months 33

34 e-lace Tool THC Site 34

35 Visual Management 30 35

36 RRN - An Integrated Program Response to Effective Management of High Inpatient Users Partners: CCAC Hospital Primary Care MH LHIN MH LHIN CCAC Primary Care Hospital RRN Role: 1 st in home visit within 24 hrs of discharge Teach-back method to reinforce transitions plan Medication reconciliation in home Coordinate with primary care Enhanced skills to self-manage chronic disease 36

37 Identification of High Users MH LHIN RRN program targets high users in 2 ways: LACE 10 or more (readmission risk > 12%) AND Home address in a High User postal code as defined by MH LHIN data e-lace data used to model RRN volumes / workflow Vast majority are seniors 37

38 Geographic Origin of High Users Top 10 FSAs, 2010/11 & 2011/12 L9T 116 High Users 100 (11/12) L5N 154 High Users 143 (11/12) L5V 103 High Users 124 (11/12) L5M 166 High Users 182 (11/12) L6H 134 High Users 139 (11/12) L5A 163 High Users 172 (11/12) M9C 98 High Users 104 (11/12) L5L 111 High Users 118 (11/12) L4Y 95 High Users 101 (11/12) L5B 176 High Users 181 (11/12) L6L 104 High Users 112 (11/12) Numbers are crude counts, not Age / Sex adjusted. 38

In Summary, the RRN Initiative = Alignment Designed to improve care for High Users in MH LHIN by integrating across the continuum of care Focus mostly on frail seniors with multiple comorbidities Use

39 In Summary, the RRN Initiative = Alignment Designed to improve care for High Users in MH LHIN by integrating across the continuum of care Focus mostly on frail seniors with multiple comorbidities Use of Ontario evidence-based tool (LACE) Reducing readmissions is engrained hospitals QIPs Aligns with expected bestpath recommendations Utilizes process improvement to improve quality of care Core infrastructure for lean virtual ward 39

40 Thank you Any Questions?

Hamilton Niagara Haldimand Brant LHIN. Current State Health System Utilization and Performance by PAG

Hamilton Niagara Haldimand Brant LHIN Current State Health System Utilization and Performance by PAG A summary current state data profile has been collected for PAGs where data is available PAG level data