Emergency Room (ER) & Alternate Level of Care (ALC)

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1 Emergency Room (ER) & Alternate Level of Care (ALC) Appendix March 6, 2009

2 Note to Reader This document is a working paper. It is intended to be a starting point to further analysis. There may be instances where more updated and/or detailed information is required to support decision making. A separate and concurrent project is currently being conducted by the MH LHIN that examines ER capacity in the MH LHIN hospitals. This document will be updated as more information becomes available.

3 Introduction The Mississauga Halton LHIN is updating the Integrated Health Service Plan (IHSP) for As part of the IHSP update, the LHIN is completing an environmental scan to provide a profile of the local population, health programs and services, and performance. This document presents the quantitative component of the IHSP environmental scan specifically related to Emergency Room (ER) Services and Alternate Level of Care (ALC). ER wait times are a top priority for the Mississauga Halton LHIN. It is considered a priority of the MOHLTC, and has been identified as a Ministry-LHIN Accountability Agreement (MLAA) indicator. This document is a working paper. Additional data and information is currently being collected and the document will be updated as the data is received and analyzed (e.g. MH LHIN ER Capacity Review).

4 Demand and Supply for ER Services Demand is often an expressed need for a service. Patients may have many needs and for a number of reasons, may not express them. However, when a patient goes to the ER for health services, that is a demand for those services. The demand for, or utilization of ER services, is the expressed need of a patient for services offered in the ER. Historical utilization of ER services the number of patients the ER receives and attends t, can be seen as a proxy for the historical demand for ER services. However, it is important to note that demand for ER services can be heavily influenced by a number of supply challenges. For this reason we are including information in this part of the environmental scan about the impact of Alternate Levels of Care (ALC) on services. ER utilization rates can be used as a reflection of healthcare needs, but not necessarily the health needs of a population. Where possible social determinants of health should be considered along with the ER rates to get a broader picture of current and potential future ER service demands. This is beyond the scope of this environmental scan and future work is required to complete a demographic analysis and review of population trends and impacts on ER services.

5 Ontario s Emergency Room (ER) Wait Time Strategy The Ministry of Health and Long Term Care (MOHLTC) has developed an ER Wait Time Strategy to help reduce the time people spend in the emergency room waiting for service and ensure prompt emergency care to people when they need it. The overarching strategy includes: Expanding alternatives to ER services (e.g. creating more urgent care centers and increasing awareness of alternative health care services available to the public) Increasing capacity and improving processes within ERs (e.g. providing dedicated funding to hospitals who perform within the benchmarks of performance) Discharging Alternative Levels of Care (ALC) patients faster (e.g. increasing home and community supports and community day/outreach programs) Measuring and reporting on patient time spent in ERs (e.g. reporting time spent in ER on a public web site)

6 ER Wait Times: The Facts

7 Ontario ER Cases per 1000 Population (FY 2006/07) The Mississauga Halton LHIN generally experiences lower ER rates in comparison to the rest of the province. This may be attributed to: Erie St. Clair 2. South West 3. Waterloo Wellington 4. Hamilton Niagara Haldimand Brant 5. Central West 6. Mississauga Halton 7. Toronto Central 8. Central 9. Central East 10. South East 11. Champlain 12. North Simcoe Muskoka 13. North East 14. North West Province visits/1000 pop LHIN Good access to Primary Care Healthier population Younger population Wealthier population Source: PHPDB NACRS FY 2006/07 / Environic Analytics - Population & Projections (2008), Infonaut (Information courtesy of Mississauga Halton LHIN Health Service Needs Assessment and Gap Analysis Report October/November 2008)

8 Ontario ER Cases/1000 Population by Age Group (FY 2006/07) ER visits/1000 pop The largest number of users of ER services across Ontario by age group were, in descending order, seniors (ages 65 and above), infants and toddlers (ages 0-4), followed by adults (15-44) all age group Source: PHPDB NACRS FY 2006/07 (Information courtesy of Mississauga Halton LHIN Health Service Needs Assessment and Gap Analysis Report October/November 2008) 8

9 Overview of ER Cases MH LHIN MH LHIN ER Visits # of ER Visits Credit Valley Trillium Halton Health Care 20003/ / / / /08 Fiscal Year Source: Health Data Branch, MOHLCT, 9

10 Unscheduled ED Visits by Seniors Annual % Change in the Number of Unscheduled ED Visits by Seniors, Age % 2005/ /07 12% 1 8% 6% 4% 2% -2% ERIE ST. CLAIR SOUTH WEST WATERLOO WELLINGTON HAM.NIAG.HALD.BRANT (HNHB) CENTRAL WEST MISSISSAUGA HALTON TORONTO CENTRAL CENTRAL CENTRAL EAST SOUTH EAST CHAMPLAIN NORTH SIMCOE MUSKOKA NORTH-EAST NORTH-WEST Total LHIN Source: Provincial Health Planning Database (PHPDB) Ambulatory Visits

11 ER Services by Triage Level All Ontario hospitals are required to track their emergency department visits and to categorize each visit according to the Canadian Triage Acuity Scale (CTAS) The objective is to improve patient care through more appropriate triaging of patients, but it also allows hospitals to better understand the types of services they are providing to patients. Triage is also a MLAA Indicator, with a focus on improving the diversion of patients with a lower urgency to non-acute care settings. ED CTAS Levels Level I: Resuscitative (e.g. cardiac arrest) Level II: Emergent (e.g. chest pain) Level III: Urgent (e.g. gastroenteritis, colitis) Level IV: Less-Urgent (open wound to hand) Level V: Non-Urgent (e.g. surgical dressing change) 11

12 ER Performance The Ministry of Health and Long Term Care (MOHLTC) will fund 50 Emergency Departments across the province in 2009/10 as part of the Year II ED/ALC Strategy. In the Mississauga Halton LHIN, the following sites have been identified: Trillium Health Centre Mississauga site, Credit Valley Hospital, and Halton Health Care Services Oakville and Georgetown sites. Ontario has set two provincial targets for the optimal length of time within which a patient should spend in ER: < 8 hours for all admitted patients, and non-admitted high acuity patients (CTAS 1-3) < 4 hours for all non-admitted low acuity patients (CTAS 4 & 5) Total Time Spent in the ER: Time spent in the emergency room begins when a patient registers until the patient is discharged or is admitted to a hospital bed. During that time emergency room doctors and nurses may be diagnosing or treating a patient s condition, ordering tests and waiting for results in order to determine the best course of treatment. Sometimes treatment for a condition requires admission to a hospital bed, which may result in a patient spending time being cared for in the ER before a bed becomes available. Source: Ontario Ministry of Health and Long Term Care: February 28, 2009

Provincial Total Time Spent in the ER by Canadian Triage and Acuity Scale (CTAS) October 2008 Canadian Triage and Acuity Scale is a five point scale used by ERs to evaluate a patients acuity level to

13 Provincial Total Time Spent in the ER by Canadian Triage and Acuity Scale (CTAS) October 2008 Canadian Triage and Acuity Scale is a five point scale used by ERs to evaluate a patients acuity level to more accurately define their needs and allow for timely care. The following table shows Total Time Spent in the ER by CTAS for all patients, admitted patients and non-admitted patients. Source: Ontario Ministry of Health and Long Term Care: February 28, 2009

14 Total Time Spent in ER Mississauga Halton LHIN Source: Ontario Ministry of Health and Long Term Care: February 28, 2009

15 Rate of ER Visits That Could Be Managed Elsewhere Source: Performance Indicators Report Ministry of Health and Long Term Care, February 15, 2009

16 MH LHIN % ER Admits For Halton Health Care, %Admissions from ER September 2008 was 1 and YTD September 2008/09 are the same as compared to 2007/08 YTD September at 9%. For Credit Valley Hospital, %Admissions from ER for Sep 08 was 12% and unchanged compared to Aug 08. For Trillium Health Centre, %Admissions from ER SEP/08 YTD are 11% and are the same as last YTD Halton Health - Oakville/ Milton/ Georgetow n Credit Valley Trillium Health Centre - Miss/ West Toronto MH LHIN 1 13% 12% 11% 1 12% 11% 11% 9% 12% 11% 11% 9% 13% 11% 11% 9% 12% 11% % 11% 11% Apr-08 May-08 Jun-08 Jul-08 Aug-08 Sep-08 Oct-08 Nov-08 Dec-08 Jan-09 Feb-09 Mar-09

17 MH LHIN % ED Patients CTAS Level 1,2,3 Meeting 6 Hour Target For Halton Health Care, September 2008 the percentage of unplanned ER visits with CTAS level 1, 2 and 3 within 6 hours increased to 88% from 86% in August 2008 with a YTD September 2008 of 85%. At Oakville, the percentage decreased at 83% in September from 84% in August; Milton increased to 87% in September 2008 from 83% in August 2008; and Georgetown increased to 94% in September from 93% in August For Credit Valley Hospital, Sep 08 shows a slight decrease (2%) in rate (73%) of unplanned ER visits with CTAS level 1, 2 and 3 leaving ER within 6 hours compared to Aug 08 (75%). For Trillium Health Centre, As of Apr/07 time spent in ER after Decision to Admit is included where as last year it was not. SEP/08 is 2% down from AUG/08. Halton Health - Oakville/ Milton/ Georgetow n Credit Valley Trillium Health Centre - Miss/ West Toronto MH LHIN Variance from 9 Target 82% 68% 6 71% 85% 71% 61% 73% 85% 7 61% 72% 88% 74% 64% 76% 86% 75% 64% 75% 88% 73% 62% 74% -19% -17% -18% -14% -15% -16% Apr-08 May-08 Jun-08 Jul-08 Aug-08 Sep-08 Oct-08 Nov-08 Dec-08 Jan-09 Feb-09 Mar-09

18 MH LHIN % ED Patients CTAS Level 4,5 Meeting 4 Hour Target For Halton Health Care, the percentage of unplanned ER visits with CTAS level 4 and 5 within 4 hours has increased to 87% in September 2008 from 83% in August 2008 with a YTD September 2008 of 83%. At Oakville the percentage has increased to 88% in September from 84% in August 2008; Milton increased to 82% in September from 78% in August 2008; Georgetown has increased to 91% in September from 88% in August For Credit Valley Hospital, Sep 08 percent of unplanned ER visits with CTAS level 4 and 5 meeting the 4 hours target has stayed the same as Aug 08 at 92%. CVH's has met and passed its target of 9. For Trillium Health Centre, YTD Sept/08 9 of CTAS 4 and 5 for unplanned visits are discharged from ER within 4 hours, thus meeting the target (9). It should be noted also that Sept/08 has shown a 2% increase over last month. Halton Health - Oakville/ Milton/ Georgetow n Credit Valley Trillium Health Centre - Miss/ West Toronto MH LHIN Variance from 9 Target 78% 89% 87% 85% 81% 89% 86% 85% 82% 86% 83% 83% 87% 91% 91% 9 83% 92% 88% 88% 87% 92% 9 89% -1% -5% -5% -7% -2% Apr-08 May-08 Jun-08 Jul-08 Aug-08 Sep-08 Oct-08 Nov-08 Dec-08 Jan-09 Feb-09 Mar-09

19 MH LHIN ER Time To Admission Average The ER Length of Stay (LOS) after decision to admit has increased to 15.3 in September 2008 from 9.0 in August At Oakville, the average LOS increased to 20.4 in September 2008 from 9.9 in August 2008; at Milton the average LOS increased to 6.4 in September 2008 from 5.3 in August 2008; at Georgetown the average LOS decreased to 6.4 in September 2008 from 8.8 in August There has been a decrease of 2.8 hrs in the average ERA LOS for an inpatient bed at Credit Valley Hospital in Sep 08 (21.6 hrs) compared to Aug 08 (18.8 hrs). For Trillium Health Centre, ER LOS after Decision to Admit is on average 1 hour lower YTD Sep/08 compared to last year to date. However September shows an increase over August Halton Health - Oakville/ Milton/ Georgetow n Credit Valley Trillium Health Centre - Mississauga MH LHIN Apr-08 May-08 Jun-08 Jul-08 Aug-08 Sep-08 Oct-08 Nov-08 Dec-08 Jan-09 Feb-09 Mar-09

20 Alternate Level of Care: The Facts

21 Alternate Level of Care (ALC) Alternate level of care or ALC is a phrase used to describe a level of care provided to patients occupying hospital beds who no longer need acute services while they wait to be discharged to a more appropriate setting (1). These non-acute hospital days are captured in hospitalization data as patients awaiting an alternate level of care (or ALC patients). Uncovering how ALC is being used in acute settings may inform discussions on whether the health care system has sufficient capacity to provide necessary care in the most appropriate setting. 1. Source: Alternate Level of Care in Canada, January 14, 2009, Canadian Institute for Health Information Analysis in Brief

22 Who Are ALC Patients? A National Perspective ALC patients are distinct from other patients: ALC patients are older than non-alc patients and more likely to begin their hospital experience in an emergency department (than non-alc patients). ALC patients are more than twice as likely to have a co-morbid condition. Acute lengths of stay are longer in ALC hospitalizations than non-alc hospitalizations (11 versus 4 acute days). The most common reasons for ALC admissions are palliative care, followed by waiting for admission to another adequate facility and physical therapy. ALC patients have a median age of 80 compared to 63 for non-alc patients. Some clinical diagnoses are associated with ALC status, such as dementia, stroke and trauma. Interventions such as feeding tubes, long-term ventilation and dialysis appear to be associated with high ALC use. Most ALC patients are waiting for placement and end up in a long term care (LTC) or rehabilitation facility. When ALC patients are discharged home, they have a higher likelihood of visiting an emergency department and being readmitted to hospital within 30 days of discharge than non-alc patients. Source: Alternate Level of Care in Canada, January 14, 2009, Canadian Institute for Health Information Analysis in Brief

23 Percentage of all ALC LOS % 73.7%

25 Alternate Level of Care A Provincial Perspective To get an up to date provincial picture, OHA had hospitals complete a survey in: 2007: Jan, Mar, Jun, Aug, Sept, Oct, Nov & Dec 2008: Feb, Mar, Apr, May, Jun, Jul, Sept, Oct, Nov & Dec 2009: Jan, Feb Survey represents self-reporting by 10* of acute care beds in the province All results that follow are based only on the most recent data of those responding to the survey * Excludes Hospital for Sick Children and Children s Hospital of Eastern Ontario Source: OHA February 2008 ALC Survey Results

26 February 2009 OHA Survey Results Acute Care Beds Baseline of 15,858 acute care beds used to calculate survey results Currently, about 2,935 patients are waiting in an acute bed for an alternate level of care on a daily basis This represents 19% of acute beds* that are staffed and in operation The majority (55% in acute beds) are waiting for long term care On average, 776 patients were waiting in the emergency department to be admitted to an inpatient bed, representing 4.9%** of the 15,681 acute beds * Paediatrics and Obstetrics beds are excluded ** Assuming all patients in the ER are waiting for an acute in-patient bed Source: OHA February 2008 ALC Survey Results

27 Percent of Acute Care Beds Occupied by ALC Patients By LHIN North East Hamilton Niagara Haldimand Brant North Simcoe Muskoka Waterloo Wellington Central Champlain North West Mississauga Halton Erie St. Clair South East Central East Toronto Central South West Central West Ontario 22% 21% 2 19% 17% 17% 17% 14% 13% % 27% 26% 28% Percent of Acute Care Beds Occupied by ALC Patients = Number of patients in an acute care bed waiting for an ALC Total acute care beds Source: OHA February 2008 ALC Survey Results

28 Number of Acute Care Beds Occupied by ALC Patients By LHIN North East Hamilton Niagara Haldimand Brant North Simcoe Muskoka Waterloo Wellington Central Champlain North West Mississauga Halton Erie St. Clair South East Central East Toronto Central South West Central West Ontario = 2, Source: OHA February 2008 ALC Survey Results

29 ALC Patients in Acute Care, Ontario November 2007 to February 2009 # of ALC patients in acute care beds % of acute care beds occupied by ALC ,811 2,791 2,909 2,927 2,852 2,829 2,787 2,785 2,814 2,958 3,074 2,969 3,017 2, % % Nov-07 Dec-07 Jan-08 Feb-08 Mar-08 Apr-08 May-08 Jun-08 Jul-08 Sep-08 Oct-08 Nov-08 Dec-08 Jan-09 Feb-09 November 2007 to February 2009 OHA ALC Survey Results

30 Percent of ALC Patients in Acute Care Waiting for Long-Term Care By LHIN South East Champlain Central East South West North East Waterloo Wellington North Simcoe Muskoka Central Mississauga Halton Hamilton Niagara Haldimand Brant Erie St. Clair North West Toronto Central Central West Ontario 28% 55% 55% 51% 48% 48% 43% 42% 39% 55% 65% 64% 63% 76% 79% Percent of ALC Patients in Acute Care Waiting for Long-Term Care = Number of patients in acute care waiting for long-term care Total ALC patients in acute care Source: OHA February 2008 ALC Survey Results

31 Number of ALC Patients in Acute Care Waiting for Long-Term Care By LHIN South East Champlain Central East South West North East Waterloo Wellington North Simcoe Muskoka Central Mississauga Halton Hamilton Niagara Haldimand Brant Erie St. Clair North West Toronto Central Central West Ontario = 1, Source: OHA February 2008 ALC Survey Results

32 Other ALC Reasons Patients in Acute Care Beds Rehabilitation 376 Complex Continuing Care 292 Palliative Care 178 Convalescent Care 124 Home 54 Home Care 33 Assisted Living / Supportive Housing 31 Mental Health 14 Other 217 Source: OHA February 2008 ALC Survey Results

33 Number of Patients in Emergency Waiting for an In-patient Bed By LHIN (at any given point in time) Hamilton Niagara Haldimand Brant Central Central East Mississauga Halton Toronto Central Champlain South West North Simcoe Muskoka Waterloo Wellington North East Central West Erie St. Clair South East North West Source: OHA February 2008 ALC Survey Results Ontario =

34 Number of Admitted Patients Waiting in Hallways or Other Public Space *Results based on responses by 122 of 148 hospitals (82%) to question 127 admitted patients (not in ED) are waiting in hallways or other public space (ALC or otherwise) * Results exclude Hospital for Sick Children, Children s Hospital of Eastern Ontario and Bloorview Kids Rehab Source: OHA February 2008 ALC Survey Results

35 Number of Patients in Emergency Waiting for an In-patient Bed Nov Feb (at any given point in time) % increase in one year (Nov Nov. 2008) Nov-07 Dec-07 Jan-08 Feb-08 Mar-08 Apr-08 May- 08 Jun-08 Jul-08 Aug- 08 Sep- 08 Oct-08 Nov-08 Dec-08 Jan-09 Feb-09 27% increase from Nov. 07 to Apr. 08 6% increase from May 08 to Nov. 08 November 2007 to February 2009 OHA ALC Survey Results 0.1% increase from Nov. 08 to Feb. 09

36 Percentage of General Medical Beds Occupied by ALC Patients Results based on responses by 120 of 123 hospitals (98%) with general medical beds* On average, 26% of general medical beds are occupied by ALC patients Percentage of general medical beds occupied by ALC patients ranges from to 86% * Calculation of general medical beds includes combined medical and surgical beds. Excludes Hospital for Sick Children and Children s Hospital of Eastern Ontario. Source: OHA February 2008 ALC Survey Results

37 February 2009 OHA Survey Results Other In-patient Care Beds Baseline of 12,922 other in-patient beds used to calculate survey results Currently, about 1,838 patients are waiting in an other in-patient bed for an alternate level of care on a daily basis This represents 14% of other in-patient beds* that are staffed and in operation The majority (81% in other in-patient care beds) are waiting for long-term care * Paediatrics and Obstetrics beds are excluded; Bloorview Kids Rehab excluded from results Source: OHA February 2008 ALC Survey Results

38 Percent of Other In-patient Care Beds Occupied by ALC Patients By LHIN North East Erie St. Clair North West Hamilton Niagara Haldimand Brant South East Central East South West Champlain Waterloo Wellington North Simcoe Muskoka Mississauga Halton Toronto Central Central Central West Ontario 4% 7% 16% 13% 12% 11% 11% 1 9% 14% 19% 23% 22% 23% 29% Percent of Other In-patient Care Beds Occupied by ALC Patients = Number of patients in an other in-patient care bed waiting for an ALC Total other in-patient care beds Source: OHA February 2008 ALC Survey Results

39 Short-Term Strategies to Relieve ALC Pressures Expand Capacity for Transitional LTC Beds 60 Increase CCAC Service Provision Hours 57 Subsidize LTC Preferred Beds 39 Subsidize Retirement Homes 35 Funding & Development of Supportive Housing Units 34 Expand Capacity Funding for CCC & Rehab Programs 33 Expand Resources for Specialized Geriatric Behaviours 31 MOHLTC Support Hospital First Available Bed Policy 29 Implementation of Nurse Practitioners in LTC Homes 15 Expand Capacity for Palliative Care Programs 8 Note: Hospitals were asked to select, from the above list, three short-term strategies that would be most effective in reducing ALC pressures for their hospital or to provide their own suggestions. Results based on responses from 116 of 152 hospitals (73%) to question. February 2008 ALC Survey Results

40 Alternate Level of Care A LHIN Perspective Source: Performance Indicators Report Ministry of Health and Long Term Care, February 15, 2009

41 Alternate Level of Care MH LHIN Hospitals Perspective The number of patients designated as ALC in hospitals (across all the LHIN hospitals) has fluctuated slightly over the past 5 months with a significant increase seen in January However, the number of ALC designated patients who are waiting for long-term care bed placement has declined. This suggests we are doing well in placing patients into long-term care facilities, but remain challenged with ALC patients in acute settings that are typically waiting for other types of services such as complex continuing care or rehabilitation. Total Number ALC Patients in Mississauga Halton LHIN Hospitals by Month, September 2008 January 2009 Sept 08 Oct 08 Nov 08 Dec 08 Jan 09 Total ALC in Hospitals Total ALC LTC

42 ER = ALC: Solutions

43 MH LHIN Approach to ED/ALC Challenges 2009 and 2010 Investments to directly impact on improving ER Wait times and reduce ALC Decisions made based on evidence where possible Changes and transformation of all sectors with respect to care for the seniors Show value for money in our investments move to performance based investments Deliver health care that respects MH LHIN s diversity Improve overall care and service for our seniors

44 Comprehensive Strategy to Address Alternate Level of Care/ER The LHIN is focused on Appropriate Level of Care. APPROPRIATE MEANS: RIGHT CARE, RIGHT TIME, RIGHT SETTING Evidence that programs from home care, hospitals, LTC Homes and Supports in Daily Living -SDL- (supportive housing), do have some clients/residents/patients in inappropriate settings To meet the post-acute care needs of ALC patients in hospitals, community providers need to increase capacity (intensity and volume) to care for them Major cultural transformation in current processes and practices in hospitals, CCAC and community agencies and need to re-orient their approach Education of providers and the public

45 Evidence Based Approach LTC Beds Supports for Daily Living Adult Day Services CCAC Understand Seniors Needs 4,031 Beds 99.5% utilization 29.2% turnover/yr 12% inappropriate Avg CMI (07): Range: excluding 5 RAI early adopters Total LTC bed supply/1000 population 75+ MH LHIN 7.9% Province 9.3% Biggest capacity challenge: Alternatives to more LTC beds Increase community capacity 1,018 clients on the program in 07/08 17% /367 inappropriate (research) Introduction of evidence based tool (CHA) Common program framework & reorientation to focus on alternative to LTC Beds Those needing 24/7 care supervision Central referral to SDL coordinators from CCACs, D/C planners Acute ALC Days & Patients 1084 clients on the program in 07/08 Increase capacity to move towards Diversion from LTC and caregiver relief to remain at home Referral from CCAC only ED Growth 4 yrs (to 2007/08) Increased services for 75+ target age group Intensity 37%/205 inappropriate CCAC Wt list (research) 1/1419 inappropriate CCAC Community (research) ED Use 2007/08 Environics Poll 2008 Focus groups with Elderly Summer 2008 % MH LHIN 06/ / % Province LHIN 22.4% CTAS 1,2,3 % for MH LHIN CTAS 1,2,3 % Province 06/ /08 * * 3 rd Best of all LHINs

46 Summary of the 75+ Age Group Emergency Room visits in the Mississauga Halton LHIN for FY 2006/7 Number of 75+ Residents in the Mississauga Halton LHIN 51, Cohort in Supportive Housing Supports for Daily Living 9,245 1,138 (07/08) Retirement Homes 3,392 Long Term Care Facilities 4, ER Visits 40.5% 75+ Admitted through ER 75+ Admitted with ALC Days 27,696 (76 pts/day) 44.4% 11,208 (31 pts/day) 1,292 (64% of ALC Days) Patient Days for inpatients admitted through ER (Total) 261,420 Beds Req. 716 Patient Days for inpatients admitted through ER (75+) 115,964 Beds Req. 318 ALC Patients Admitted through ER Total: 2, : 1,774 (88%) Source: Discharge Abstract Database, accessed through the PHPDB, Ver 17.09, adjusted for Mental Health

47 Case Finding Seniors 75+ Treated and Released from ED Phase 1 Roll Out (Credit Valley Hospital site only) 2 months (Nov. & Dec. 2008) 722 Seniors 75+ referred 233 were from a LTCH or currently active with CCAC 489 Seniors contacted by CCAC Geriatric System Navigator (CM) for follow up RAI HC assessment and linking to community resources 94 declined CCAC follow up, 5 transferred into CCAC for CCAC nursing services (all 5 had left ED prior to being seen) 390 remain active with Geriatric System Navigator (annual follow up) Most Common Community Linkages for Seniors: Snow Removal Mobile Laboratories Transportation Connecting to primary care Lifeline/Connect Care type services Seniors Centres Identification of nearby walk in clinics for use instead of ED when appropriate

48 Currently in place Being Implemented To be Implemented Process Improvements For Geriatric Population in Hospitals, LTC, CCAC, & Community LHIN wide Standardized U.M. Program [MEDworxx] Improved Discharge Planning in Hospitals Evidence Based Assessment & Admission to SDL Programs Elder Friendly Care CCAC Improve quality & consistency in identification of ALC; early discharge planning Monthly reports by LHIN by Hospital Home First Cultural shift Train CCAC Staff on Geriatric Assessment Capacity One HSP for Discharge Planning (Phase 2) Review of Appropriate Care (Dr. Hirdes) SDL Assessment Tool (CHA) Use of MAPLe to admit right person to right care Increase Geriatric Care capacity for all front line staff in Hospitals Educate Providers, Patients & Families Nimble RAI Assessments; 9 done in 3 days in acute care Transformation of case management practices Comprehensive Review of Placement Processes Case finding 75+ Investments: UPF Yr 1 One Time; New Tool paid by Hospitals A@H Regional Geriatric Program CHA Algorithm A@H Regional Geriatric Program CCAC Operations 3/16/

49 Where are we headed in the next two years? LHIN Priorities With Respect to System Expectations Reduce ALC (Alternate Level of Care) in hospitals 1 each year Reduce wait times in ED 1 each year Reduce ED visits for CTAS 4, 5 (less of a concern for MH LHIN) How? All HSPs in LHIN have ALC/ER as their top priority too community providers must step up to care for the frail and elderly with complex needs Divert the culture from default to LTC placement by actively increasing community options including wait at home Integrated-LHIN-wide approach Performance based system-all new investments must meet performance requirements

Enablers to Reduce ALC and Unnecessary ER Use A@H 08/09/10 Pilot; LHIN

08/09/10 Central point of access and intake LHIN wide coordinated

50 Enablers to Reduce ALC and Unnecessary ER Use 08/09/10 Pilot; LHIN wide care delivery model for Seniors 09/10 OMA Agreement 08/09/10 Central point of access and intake LHIN wide coordinated scheduling & resource management 09/10 LHIN wide system navigator of 75+ from ED

51 MH LHIN s Strategic Approach to Investments ($ 33 M in base over three years < 3% of total current allocation) Implement Transitional Capacity Increase community capacity as alternatives to LTC Homes to directly impact on referrals from ERs and post acute care Increase CCAC, LTC homes and Community sectors capacity to manage more frail and high need seniors and reduce reliance on ER-major transformation Focus on diversion and prevention initiatives for 75+ seniors-largest driver of intensity of care in ERs and constitute the majority of ALCs in hospitals

52 Goal: Reduce ALC in Hospitals by 1 each year Hospitals CSS/MH&A Sectors Increase Supports for Daily Living (SDL) Targeted additional investments in Home with clear performance deliverables Evidence-based approach to client admissions right client for right level of resources- SDL CHA (RAI) assessments Adult Day Programs with high needs focus CCAC LHIN - Wide Discharge to more appropriate programs such as RESTORE, SDL, Home Maximize transitional care programs Have a robust Utilization Management Program Implement standardized approach to determine and use common tool Focus on Home and Home Increase amount of service time for seniors most in need Increase proportion of elderly in home care Change case management culture to meet ALC agenda LTC placement process more rigorous ALC Committee (with ALC Lead) to look at system issues to develop actions that are evidence based Invest to address key areas where impact is seen and felt Measurable outcomes Community engagement of seniors & caregivers Address key enablers to ER/ALC Strategy e.g. Transportation

53 Faster Discharge for ALC Patients and Reduce ALC Days Transitional Capacity Supports for Daily Living Home from Hospital for LTC Beds Increase Home Care for Seniors ( Stay at Home ) Behaviourally Challenged Seniors LHIN Wide Regional Geriatric Program Regional Geriatric Mental Health Outreach A@H 08/09 Sub Acute/Restore 26 LTC Beds MLC Most admissions from hospitals via CCAC 40 Transitional beds at 2 hospitals A@H 08/09/10 07/08: 1,018 increase to 1,862 clients Increased Funding to Care for those needing 24/7 care ER Pay / Perf. CCAC Funds 08/09/10 Target s: 2008/09: 180 clients 2009/10: 360 clients ER Pay / Perf CCAC 08/09/ /09: 108 clients up to 90 hrs/mth at any point in time A@H Yr 2/3 ABI expertise to discharge seniors from hospitals; accept in LTCHs with outreach support Alzheimer's/ Behavioural day programs in secured units Bed Capacity in existing LTC homes A@H 08/09/10 Increasing capacity of existing geriatric services in hospitals Geriatric Urgent Assessment Clinics Geriatric Home Visits A@H Yr. 1 & 3 In place in Halton Expand to cover Mississauga Currently in place Being Implemented To be Implemented Adult Day Services A@H 08/09/10 Capacity: 07/08: 1,084 increase to 1,329 clients Targeted to deal with diverse populations & geographic needs Increase LTC Homes Capacity A@H (NP, SGS) 08/09 CCAC/Hospital Op. Budget High Intensity Fund (MOHLTC) Increase Capacity for Palliative Care & Hospice A@H Yr 1 Yr 3 Planning to focus on reduction of palliative care admissions & deaths in hospitals Better Use of CCC & Rehab Resources Ongoing planning to develop best practice programs & admission criteria Direct Diversion NP in LTC Homes

54 Goal: Reduce Unnecessary ED Visits and Meet Wait Time Targets as Set Hospitals Pay-for- Performance Funding Trillium Health Centre (08/09) Develop hospital specific strategies to address the wait times targets for Credit Valley and Halton Heathcare in 09/10 CSS/MH&A Targeted investments to community-based services to enable seniors to stay in their own homes CCAC Follow-up on all 75+ discharged from ERs Address issue of seniors (and others) who do not have a family care practitioner CCAC Care Connectors LTC Homes Strategies to ensure unnecessary ER visits are managed Maximize use of LTC Nurse Outreach teams Use of Psycho Geriatric Outreach team resources Regional Geriatric Outreach

55 Effective Use of ERs to Reduce Demand & Decrease Wait Times Direct and Diversion Target intervention to reduce high risk group Prevention Reduce CTAS 4,5 (Enhanced Primary Care) Follow up of all 75+ upon discharge from ER Hospital Pay for Results Reduce ER by LTC Nurse led Expanded Frail Elderly Geriatric Clinics Psychogeriatric Outreach Increase Home Care for Seniors Stay at Home Community Based Palliative Care Divert Use of ER Freq. Flyers Ref to CCAC SDL as First Responder Orphaned Patients CCAC Case Mngrs in Primary Care Better Mgnt of CDPM: Diabetes Registry Falls Prevention Comm. & Linkages with Urgent Care Increase Community Program Capacity ED Pay / Perf CCAC ED Fund THC (Phase 1) CVH & HHS (Phase 2) A@H ER Pay / Perf. A@H A@H ED Pay / Perf & CCAC A@H Yr 1 & 3 CCAC Operations SDL TBD CCAC Operations Provincial Roll out A@H Public Awareness by Hospitals A@H Areas of focus determined by CE Findings CTAS 4,5 (2007/08) MH LHIN 33.8 % Province 49.5 % RANK 3rd (lowest)

56 Transitional Care As Part of Continuum of Care: Need for post- acute sub-acute bed capacity as part of continuum of care (MLC Restorative Program )-26 beds Need for on-going transitional care in community (24/7)-transformation of supportive housing to Supports in Daily Living spaces (over 780 spaces (<75% increase) to be created by end of 09/10) Transitional beds (more hospital beds or interim LTC beds): Time-limited to address immediate needs for LHINs with very high acute care bed occupancy and high growth -40 beds

57 Transitional Care - Initial SDL Performance Outcomes (3 months results)-2 HSPs Reporting Requirements YTD Total (2 SDL Agencies) Impact on Hospital (ER, ALC, General Beds) # of ALC clients taken out of hospital into SDL (not previously SDL clients new) 7 # of days reduced from hospital LOS (as a result of the new 2-bed unit at OSCR) 164 # of ER visits diverted (SDL 24-hour response) 25 # of clients returned back to SDL from hospital (clients on SDL services prior to hospitalization) 66 # of general hospital clients taken into SDL (not previously SDL clients new) 5 Impact on LTC Homes # of clients taken out of LTC homes into SDL 6 # of clients that came off of the LTC waitlist 5 # of clients diverted from LTC (may or may not be waitlisted: avoidance of crisis placement) 39

58 Transitional Care - Mississauga Lifecare (Restore Program) Performance Direct Impact ADMISSIONS # CLIENTS DISCHARGES % Trillium 83 Home 80 % Credit Valley Halton Healthcare 29 LTC 4 % 7 Hospital 13 % Other Hospitals 1 Deceased 3 % Community 7 TOTAL The target length of stay is days. The average length of stay for the first 10 months on the Program is 34.5 days with a range of 2 to 89 days.

59 Overall System Performance Measures and Expectations Reduce % of ALC patient days in hospitals Reduce ER Wait time to target Sustain % of ED visits that could have been managed elsewhere Reduce or Maintain Number on Waitlist for LTC Homes Reduce Median Wait time to LTC Home

60 HSP - H Investments Performance Requirements Reduce unnecessary Emergency Department (ED) visits by seniors Increase referrals from inpatient acute care (reduce LOS & ALC days) and ER Increase capacity for at risk seniors in the community (to age at home ) as an alternative to ALC, unnecessary ER use and to avoid LTC placement unless needed Reduce reliance on LTC homes as the only option to it being the last option in the continuum of post-acute care

61 Go Forward Strategy Next Two Years ( ALC and ER) Fully implement and monitor performance of several innovative approaches to support seniors to age at home e.g. for SDL do a comparison with baseline (2008) after 18 months with Dr. Hirdes group Reduce creation of ALC in hospitals with Home First and other strategies Optimize and increase the capacity of community services within the LHIN to address the aging Reduce reliance on LTC beds and hospitals Engage our seniors and their families / caregivers to understand their needs to age at home with dignity Preventive and wellness services to reduce unnecessary ER visits or premature institutionalization Culturally sensitive options to meet needs of the LHIN with one of the most diverse populations

Hips & Knees Priority Action Team

Hips & Knees Priority Action Team Current State Data Refresh September 5, 27 Overview Population Profile Health Status Utilization of Hip & Knee Total Joint Services 1 1 Population Profile 2 SouthWest