An ideal and sustainable rehab system possible? Best Practices Day 2012, Panel Discussion

Transcription

1 An ideal and sustainable rehab system possible? Best Practices Day 2012, Panel Discussion

2 Panel Participants Michel D Landry, PT, PhD» Chief, Doctor of Physical Therapy Division, Duke University; Associate Prof., Dept of Physical Therapy, Univ. of Toronto Colin Preyra, PhD» CEO and Scientific Director of Preyra Solutions Group and Affiliate Scientist at the Institute for Clinical Evaluative Sciences Donna Cripps, BSc(PT), MBA» CEO, Hamilton Niagara Haldimand Brant LHIN Karima Velji, PhD» VP, Clinical and Residential Programs & Chief Nursing Executive, Baycrest 2

3 Introduction Michel D Landry, PT, PhD Chief, Doctor of Physical Therapy Division, Duke University; Associate Prof., Dept of Physical Therapy, Univ. of Toronto 3

4 Introduction The large question we are asking ourselves: An Ideal and Sustainable Rehab System - Is It Possible? Other related questions include:» What is the current provincial rehab system?» What would an ideal rehab system look like?» What does it mean to be sustainable?» Do we have a common definition of rehab?» What are the social, political and economic unknowns? 4

5 A question of Supply and Demand (or Need) 5

6 A question of Supply and Demand (or Need) Supply (financial and workforce) Increases in absolute numbers of health professionals (i.e. Bill 171) Decreases (or at least changes) in funding allocations Changes in settings to access rehab Increase reliance on private sources Demand Demand (utilization) Need for rehab A series of modifiable and uncontrollable factors The aging population (controversial issue) Success in decreasing mortality = increased disability (= greater need?) 6

7 Where are we now? Note: not real data 7

8 Reality Check? time "0" time "1" time "2" time "3" do nothing implement positive change implement negative change Note: not real data 8

9 Do comparisons of rehabilitation system help? United States Finland Cuba Haiti 9

10 Policy Options Use (and measure) the language of decision and policy makers What are our options:» Status quo:» Radical Changes» Incremental changes Can we use the scope of conflict theory to provide direction. 10

11 Colin Preyra, PhD CEO and Scientific Director of Preyra Solutions Group and Affiliate Scientist at the Institute for Clinical Evaluative Sciences 11

12 Ontario Health Care Context 1. Health system reform is a priority for the Ontario government, demonstrated for example by: The Excellent Care for All Act, and associated funding reforms Action Plan for Health Care Drummond Report 2. A consistent theme in health system reform has been the importance of keeping people healthy and avoiding hospital inpatient modalities 3. New funding methods will bundle care across the continuum and promote substitution of ambulatory for inpatient care 12

13 Health System Funding Reform Source: Ontario MoHLTC Presentation February

14 Clinical Quality Groupings Source: Ontario MoHLTC Presentation February

15 Framework for Discussion 1. Adequate access: Is the system providing enough rehab services based on what is needed? 2. Consistent access: Is the variation in service based on need or based on historical supply? 3. Evidence based care: Are rehabilitation interventions and treatments based on best evidence? Are they standardized? 4. Timeliness: Does timeliness in accessing rehabilitation services increase effectiveness? Are rehabilitation services accessed in a timely way? 15

16 Framework for Discussion 5. Efficiency: Are rehabilitation services provided efficiently? 6. Effectiveness: What is the role of rehabilitation care in restoring patient functional status and independence 7. Specialization: Could some rehabilitation services be designed target specific patient types 8. What is the role for rehabilitation in substituting for acute care? 16

17 1. Rehabilitation in Ontario: What Settings is Rehabilitation Provided in? Rehabilitation care is provided in many settings: -Inpatient hospital care -Hospital based clinics -Allied health -Home care Rehabilitation care makes up 5% of hospital expenditures and 5% of home care expenditures 17

18 1. Rehabilitation in Ontario: Has cost grown in the past 10 years? 180% 160% 140% 120% 100% 80% 60% 40% 20% 0% 10 Year Trend in Rehabilitation and Acute Expenses 2000/01 to 2010/11 Rehabilitation Inpatient Acute Inpatient & Day Surgery Provincially, rehabilitation expenses increased at a slightly lower rate than acute expenses over the last 10 years (74% compared to 83%) The 10 year increase in rehabilitation expenses varies substantially across LHINs 18

19 1. Rehabilitation in Ontario: Did cost increase because of activity or cost per service? 60% 50% 40% 30% 20% 10% 0% -10% 10 Year Trend in Rehabilitation and Acute Patient Days 2000/01 to 2010/11 Rehabilitation Inpatient Acute Inpatient & Day Surgery Over the last 10 years, acute patient days and rehabilitation patient days increased at a similar rate The 10-year increase in acute and rehabilitation expenses varies substantially across LHINs 19

20 1. Rehabilitation in Ontario: Per Diem Cost Increases 140% 120% 100% 80% 60% 40% 20% 10 Year Trend in Rehabilitation and Acute Per Diem Costs 2000/01 to 2010/11 Rehabilitation Inpatient Acute Inpatient & Day Surgery Consistent with expenses, acute per diem costs increased at a slightly higher rate than rehabilitation per diem costs for most LHINs 0% 20

21 Rehabilitation in Ontario: What is the Mix of Acute and Rehabilitation Inpatient Care? Ratio of Rehabilitation Inpatient to Acute & Day Surgery Expenses 2010/ The ratio of rehabilitation expenses to acute expenses varies substantially across LHINs (2.1% to 6.1%)

22 1. Rehabilitation in Ontario: What is the Mix of Inpatient and Ambulatory Rehabilitation? Ratio of Rehabilitation Clinics to Rehabilitation Patient Days Mix of Inpatient and Ambulatory Rehabilitation Care 2007/08 to 2010/11 OTTAWA The Ottawa LONDON St Joseph's Hospital MISSISSAUGA Trillium Health Centre HAMILTON Health Sciences Corp WINDSOR Regional TORONTO Bridgepoint TORONTO Rehabilitation Institute This graph shows the ratio of rehabilitation clinic visits to patient days among the hospitals with the largest rehabilitation clinics The mix of ambulatory to inpatient rehabilitation varies substantially across hospitals and has not increased over years for most hospitals / / / /11

23 1. Rehabilitation in Ontario: Is there Variation in Allied Health Services and Mix Among Hospitals? $1,400 Allied Health Spending per Acute Case - Hip Fracture Physiotherapy Occupational Therapy - General Social Work Clinical Nutrition Audiology/Speech Language Psychology $1,200 $1,000 $800 $600 $400 $200 $- A B C D E F G H I The amount and mix of therapeutic service provided to Hip Fracture patients vary considerably across hospitals Therapeutic services cost per case range from $500 to $1,200 23

24 1. Rehabilitation in Ontario: Is there Variation in Allied Health Services and Mix Among Hospitals? $1,600 $1,400 $1,200 $1,000 $800 $600 $400 $200 Allied Health Spending per Acute Episode- Stroke Physiotherapy Occupational Therapy - General Social Work Clinical Nutrition Audiology/Speech Language Psychology $- A B C D E F G H I The amount and mix of therapeutic service provided to Stroke patients vary considerably across hospitals Therapeutic services cost per case range from $500 to $1,500 24

25 1. Rehabilitation Services: What Acute Populations are Most Commonly Sent to Rehabilitation? 25

26 1. Rehabilitation Services: What Acute Populations Have the Highest Discharge to Rehabilitation? Proportion of Acute Cases Discharged to Rehabilitation Inpatient, Home Care and Long Term Care 2008/ /10 Rehab Home Care Long Term Care Rehab Home Care Long Term Care Arthritis and Muskuloskeletal 13% 24% 3% 14% 24% 3% Nervous System 9% 14% 6% 10% 14% 5% Burns 5% 29% 1% 6% 34% 0% Factors Influencing Health Status and Other Health Service Contacts 3% 14% 4% 3% 14% 3% Infectious and Parasitic Diseases 2% 15% 4% 2% 14% 4% Skin and Subcutaneous Tissue 2% 28% 4% 2% 29% 4% Endocrine, Nutritional And Metabolic System 2% 16% 4% 2% 17% 4% Injuries, Poisoning And Toxic Effect of Drugs 2% 18% 1% 2% 18% 1% Respiratory System 2% 16% 5% 2% 15% 5% Circulatory System 2% 12% 2% 2% 12% 2% Kidney And Urinary System 1% 15% 6% 1% 16% 6% Alcohol/Drugs or Alcohol/Drug Induced Mental Disorders 1% 7% 1% 1% 8% 1% Myeloproliferative DDs (Poorly Differentiated Neoplasms) 1% 20% 1% 1% 22% 1% Hepatobiliary System And Pancreas 1% 10% 2% 1% 11% 1% Mental Diseases and Disorders 1% 9% 3% 1% 9% 2% Digestive System 1% 13% 2% 1% 13% 2% Blood and Blood Forming Organs and Immunological Disorders 1% 15% 3% 1% 15% 2% Other 0% 2% 0% 0% 2% 0% Total 3% 11% 2% 3% 11% 2% Overall, 3% of all acute cases are discharged to rehabilitation care Arthritis & Muskuloskeletal, Nervous System and Burns have the highest proportion of acute cases discharged to rehabilitation, consistently over 2008/09 and 2009/10 A much higher proportion of acute cases are discharged to home care across all clinical groups 26

27 2. Equitable Access Across LHINs: Is Access to Rehabilitation Services Similar Across LHINs? There are substantial differences in access to rehabilitation services across LHINs 27

28 2. Equitable Access Across LHINs: Is the Ratio of Beds per Capita Similar Across LHINs? The supply of rehabilitation beds varies substantially across LHINs Part of this reflects patients leaving their LHIN to access Rehab care and part reflects differences in access to service 28

29 3. Growth of Rehabilitation Services: How Much Growth is Forecasted Over the Next 20 years? Due to demographic change and population growth alone, rehabilitation inpatient services are forecasted to grow by 72% provincially The growth forecast varies considerably by LHIN (42% to 118%) 29

30 3. Growth of Rehabilitation Services: How Different are Growth Estimates from Actual Growth? The four year rehabilitation growth forecast (2005/06 to 2008/09) is over-predicted for most LHINs Provincially, rehabilitation growth over the four year period is over-predicted by 10% 30

31 Opportunities to Improve Quality and Contain Costs: The High Use Population Hospital use is concentrated among few people: 1 percent of the population uses 50 percent of hospital resources. Improvement strategies aimed at this population can have a large effect on quality and costs. 31

32 People in the High Use Group Have Rehabilitation Sensitive Conditions People in the high use group have conditions for which rehabilitation care and home care are part of a complete care path 32

33 4. The Future: Best Practice in Rehabilitation Care Seniors Early mobilization protocols prevent functional decline in the elderly population 1, 2 Hip Fractures Dedicated and specialized orthopedic surgery units ensure earlier time to ambulation and subsequently shorter length of stay and lower risk of complications 3 Organized multi-disciplinary rehabilitation reduces the chance of poor outcomes 4 Earlier admission to rehabilitation post-surgery increases improvement in functional status 5 Stroke Coordinated, interprofessional evaluation and intervention on a stroke rehabilitation unit reduce death and disability among post-acute stroke patients 6 Early, and frequent mobilization within 24 hours of stroke symptom onset 7 individualized, frequent and direct task-specific therapy by inter-professional stroke team 7 Joint replacement Pre-surgical education, exercise and training improve functional status 8 Home-based physiotherapy 1 Brown CJ, DT Redden, KL Flood, and RM Allman (2009). The Under recognized Epidemic of Low Mobility During Hospitalization of Older Adults. Journal of the American Geriatrics Society 57: Gillis A, and B MacDonald (2005). Deconditioning in the Hospitalized Elderly. The Canadian Nurse 101(6): Kamel, H.K., Iqbal, M.A., Mogallapu, R., Maas, D., and Hoffman, R.G. (2003). Time to ambulation after hip fracture surgery: Relation to hospitalization outcomes. Journal of Gerontology: Medical Sciences, 58A(11), Halbert, J., Crotty, M., Whitehead, C., Cameron, I., Kurrle, S., Graham, S., Handoll, H., Finnegan, T., Jones, T., Foley, A., and Shanahan, M. (2007). Multi-disciplinary rehabilitation after hip fracture is associated with improved outcome: A systematic review. Journal of Rehabilitation Medicine, 39, McGilton, K.S., Mahomed, N., Davis, A.M., Flannery, J., Calabrese, S. (2009). Outcomes for older adults in an inpatient rehabilitation facility following hip fracture (HF) surgery. Archives of Gerontology and Geriatrics, 49, e23-e31. 6 Foley N, Meyer M, Salter S, Bayley M, Hall R, Liu Y, Willems D, McClure A, Teasell R. Inpatient stroke rehabilitation in Ontario: Are dedicated units better? Int J Stroke (accepted for publication) 7 Canadian Best Practice Guidelines for Stroke Care 2010 Section & Siggeirsdottir, K., Olafsson, O., Jonsson Jr., H., Iwarsson, S., Gudnason, V. and Jonsson, B. Y. (2005). Short hospital stay augmented with education and home- based rehabilitation improves function and quality of life after hip replacement. Acta Orthopaedica,76(4),

34 Planning for Rehab Services in HNHB LHIN Best Practices Day Panel Discussion: An ideal and sustainable rehab system is it possible? Donna Cripps, Chief Executive Officer Hamilton Niagara Haldimand Brant Local Health Integration Network Monday, February 27, 2012

35 HNHB LHIN Includes Burlington and Norfolk 1.4 million people 200+ HSPs $2.5 billion

36 Vision A health care system that helps keep people healthy, gets them good care when they are sick, and will be there for our children and grandchildren."

37 Decision-Making Framework Key Principles Fair process Value for Money Framework helps LHINs: Aligns resources with system goals & community needs Facilitate stakeholder engagement Reach decisions based on evidence & values Fulfill accountability for health system resources

38 Decision-Making Framework Four Domains System Alignment Population Health System Values System Performance Alignment with Integrated Health Service Plan (IHSP) and/or Annual Service Plan (ASP); provider system role Contributions to improvements for health status, prevalence, health promotion/prevention Contributions to client focus, partnerships, community engagement, innovation, equity, efficiency Contribution toward improvements in access, quality, sustainability, integration

39 Clinical Program Integration Integrated service delivery for selected clinical areas LHIN-wide coordinated programs to improve access, quality and efficiency Service delivery model Common definitions, assessment, referral, admission, discharge, care pathways, intake processes, etc. Configuration model Population-based assessment of needs and sizing and siting of services Transition Framework Implementation steps Year One Complex Care, Vascular, Thoracic, Lab, Oncology, Rehabilitation, Maternal/Newborn

40 HNHB LHIN Rehabilitation Task Group Goals Members selected for system thinking and rehab expertise Standardized definitions, admission and discharge criteria Identify patient streams, service locations and service delivery model based on best practice Project future demand and inpatient capacity requirements Recommend siting of ambulatory rehabilitation services Identify mechanism for waitlist management and intake/referral process Develop transition framework, identify key enablers and barriers to implementation of future state

41 Rehabilitation Planning Process Planning Methodology for General & Specialized Inpatient Rehabilitation Beds: Phase 1: Sizing Phase 2: Siting

42 Phase One: Sizing Methodology Identify baseline utilization rates for inpatient rehabilitation beds by future patient stream Adjust rates for projected changes in prevalence, e.g., chronic disease Adjust rates for unmet needs and to improve equity of access

43 Phase One: Sizing cont d 4 5 Adjust rates for advances in health care technology Adjust rates for projected changes in practice/delivery of health services 6 Apply changes to population growth and aging to determine future cases

44 Phase One: Sizing cont d 7 8 Apply target length of stay and target ALC rate Adjust for future inflow/outflow 9 Apply occupancy rate and calculate bed equivalents

45 Phase Two: Siting Based on criteria that reflect: Population Health Experience of Care Sustainability

46 Participants were asked to identify what was more important when considering the siting of rehab beds/services: these are the weighting results: Domains and Weights Criteria Criteria Weights Improve Health of Population Siting of beds/services must be in close.130/1.0 (Accessibility).445/1.0 proximity to the patient/client population Siting of beds/services must optimize equitable and timely access to care.315/1.0 Enhance Individual s Experience of Care (Quality).425/1.0 Siting of beds/services must support a critical mass of patients, clinical expertise and health human resources Siting of beds/services must optimize clinical coherence and adjacencies.337/ /1.0 Maintain or Reduce Cost (Sustainability).129/1.0 Siting of beds/services must leverage existing and proposed capital infrastructure Siting of beds/services must optimize operational efficiencies.072/ /1.0 Results of HNHB LHIN Rehab Siting Criteria Weighting Exercise

47 Summary of patient stream results: Most important (red) to less important (blue) Proximity to rehab services Leverages existing and proposed capital infrastructure Results of HNHB LHIN Rehab Siting Criteria Weighting Exercise Optimize operational efficiencies Optimizes clinical coherence Supports a critical mass Equitable and timely access to rehabilitation care Stroke Pulmonary Other (disabling impairments, arthritis, pain syndrome, burns, congenital deformaties) Debility/Medically Complex/Cardiac Brain Dysfunction Neurological Conditions Spinal Cord Dysfunction Amputation of Limb Orthopedic Conditions

48 What does this mean for the person? Improved accessibility Population Health Improved quality Experience of Care Maintaining costs Sustainability

49 We want to hear from you! Hamilton Niagara Haldimand Brant Local Health Integration Network 264 Main Street East Grimsby, ON L3M 1P8 (905) (866) HNHB_LHINgage

50 Enhancing rehabilitation focus can alter the consequences of aging demographic shift - thus creating a more sustainable health care system Karima Velji, RN, PhD, CHE Baycrest 50

51 Objectives Demographic considerations Consequences of aging Myth busters of aging Benefits of rehabilitation in aging conditions 51

52 Challenges Inconsistent definition of aging Inconsistent definition/delineation of rehabilitation protocols Inconsistent outcome measures Benefits of rehabilitation in aging conditions focused on short term functional gains; few studies measure cost effectiveness impact; difficult to consider sustainability question. 52

53 The proportion of older adults 65+ is expected to double by % of the total population 53

54 Per-Capita Health Spending by Age Group,

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56 Aging consequence Aging is a significant cost driver, though its importance has been overestimated. Population aging in and of itself is not the driver of costs. The cost of health care is driven by inflation, population growth, aging, new technology and the increasing use of procedures like hip and knee replacements. Per capita costs for those over 65 has actually declined since 2001 (from $10, 834 (Health Canada) to $10,742 in 2009 (CIHI). 56

57 Aging consequence 1% on Ontario s population accounts for 49% of hospital and home care costs; 10% accounts for 95% of costs. Complex care inpatients accounted for 40% of all inpatient days; 80% of all ALC bed days. Half of these patients over 75 years. Approximately 50% over 65 years have two or more chronic conditions. Crisis of frailty and complexity is a crisis of function. CHSRG, 2010; CIHI

58 Aging consequence There has been a dramatic increases in the number of seniors living in long-term care institutions. 38 percent of women and 24 percent of men 85 years and older live in an institution. For many seniors, home care is the preferred method of receiving care. One in four people (OHA survey indicates up to 40%) placed in LTC could potentially be cared for in alternative settings. 58

59 Aging consequence Dementia is a common trigger for institutionalization. If we do nothing, number of Canadians with dementia in 2038 will be 2.5 times Cumulative cost in 30 year period will be $872 billion. 59

60 Rehabilitation Rehabilitation helps individuals to improve their function, mobility, independence and quality of life. It helps individuals live fully regardless of impairment. It helps people who are aging or living with various health conditions to maintain the functioning they have. GTA Rehab Network,

61 Rehabilitation and Frailty Physical activity has positive impact on frailty syndrome including sarcopenia, functional impairment, cognitive performance. Exercise as a single intervention can improve balance confidence and prevent falls in older adults. Stand alone exercise programs are effective in reducing falls rates and falls risks in community dwelling older adults, and in long term setting. Increasing physical activity can reduce risk of cognitive decline in older adults. Coleman et al., 2011; Davies et al., 2010; Keyser & Brembs, 2011; Gu & conn, 2008; Landi et a., 2010; Liu & Fielding, 2011; Grancher et al., 2011; Motle & McAuley, 2010; Rand et al., 2011; Rose & Hewrnandez, 2010; Sherrington et al., 2011; Snowden et a., 2011; Yeom,

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63 Rehabilitation and Chronic Disease Management Persons with COPD performing physical activity have lower risk of COPD related hospital admission and mortality Exercise training reduces heart failure related hospitalizations and QOL. Exercise shows short term positive outcomes for depression and depressive symptoms. Improved physical functioning and reduction in disability for osteoarthritis. Exercise can avert bone loss and osteoporosis in post menopausal women Exercise based cardiac rehab reduces total CV mortality, hospital admissions Balraj et al., 2010; Blake et al., 2009; Bosomworth, 2009; Davies et al. 2010; Howe et al., 2010; Vorrink et al.,

64 Rehabilitation and Dementia Aerobic exercise attenuates cognitive impairment and dementia risk. Exercise has neuroprotective properties. Exercise in older adults with Alzheimer's disease has a beneficial effect on physical fitness, ADL, symptoms. Exercise and cognition focused interventions can elicit functional improvements Cognitive rehab protocols produced long lasting improvement in memory performance, goal management and psychosocial status. Abrisqueta-Gomez et al., 2003; Allskog et al., 2011; Archer, 2011; Fang You, 2011; Thom&Clare, 2011; Van Praag, 2009; Windle et al., 2010; Winocur et al.,

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66 Rehabilitation and Hospitalization Hospitalized older adults who were ambulatory during the two weeks prior to admission, spent a median 43 minutes per day standing or ambulating. Without mobilization, elderly patients lose two to five percent of muscle strength every day. Mobility protocol implemented for hospitalized older adults reduced functional decline and lowered length of stay from 8.72 days to 4.96 days. Brown et al., 2009; Covinsky et al., 2011; Gillis & MacDonald, 2005; Oldmeadow et al., 2006; Padula et al.,

67 Rehabilitation and Hip Fractures People with hip fracture are less likely to have a poor outcome (death/admission to nursing homes) after multi-disciplinary rehabilitation. Rehabilitation efficiency is greater for those patients entering rehabilitation facilities in less than 15 days after surgery. Link between delayed ambulation and increased post operative complications and increased length of stay. Kamel et al., 2003; Halbert et al., 2007; McGilton et al., 2009; Sherrington et al.,

68 Rehabilitation and Long Term Care Exercise prescriptions have positive impact on physical fitness, functional performance, ADL, QOL in institutionalized older adults. Among older people with Alzheimer s disease in residential care facilities, exercise improves walking performance and declines in ADL. Restorative care interventions in long term care show significant improvement in overall mobility and balance. Patients in CCC who receive PT made significant gains in function within first 12 months post admission; 21% discharged to another level of care; 10.5 % to home. Foster et al., 2011; Wong et al, 200; 21%;Weening-Dijksterhuis et al.,

69 Goal Attainment Results Phase I: 61.1% of clients attained or exceeded their goals Phase II: 70.2% of clients attained or exceeded their goals 69

70 BAYCREST - Current Assets 70

71 Myth Busters Myth: People should expect to deteriorate mentally and physically. Fact: There is a steady trend towards better functional health for the elderly, challenging the myth of inevitable major decline into total dependency. Physical activity and improving diet can tackle most issues associated with old age. CHSRF, 2010; Thornton, 2002; WHO,

72 Myth Busters Myth: Old people are dependent; dependency ratios are used to create panic. Fact: Only 7% of those over 65 live in institutions and only 7% of those living in private homes need assistance with daily living. One in ten grandparents live in homes without a middle generation, where they are the primary caretakers of their grandchildren. In 2007, there were 1 million Canadian caregivers over

73 Myth: Myth Busters Creativity and making a contribution is the province of young people. The experience of older people has little relevance in modern society. Fact: In 2000, seniors in Canada contributed 179 million hours to volunteer agencies. Older people (particularly women) provide a whole invisible labor force. Creative contribution of experience and intergenerational programs are associated with healthy aging. 73

74 Myth: Myth Busters Hospital beds and nurses are the main issue. Fact: It is healthy seniors who have driven the most significant increases. Informal care giving is the bedrock of LTC system. In the US, informal care giving accounted for 30 million hours or 300 billion dollars. Family caregivers are primarily female,,, women represent 70% of all caregivers and 77% of children giving care. 74

75 Reframing Aging Aging is mainstream - it begins the day we are born. We need a comprehensive life span strategy. Move to a coordinated and comprehensive continuum of care Less resources to acute, episodes of care. More attention to prevention and wellness. More effort in chronic disease management. 75

76 Reframing Aging Substituting community care management for institutional care. Low cost social support services are a cost effective alternative to institutional care. The role of informal care is important in its own right. Focus on autonomy vs. risk in institutional care 76

77 5. Case for Change So what are the problems?» Sustainability» Need and Equitable Access» Changing population expectations» We know we could do better How can we help?» Identify, adapt and invent rehab interventions that materially reduce cost and institutionalization, and improve outcomes» Align with MoHLTC and organizational strategy» Propose human and financial resources required» Use LHINs to help it happen» Make a directional change and check that its working» Repeat 77