Improving Acute Care Access through

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HIC 2004 Tutorial Session
Improving Acute Care Access through Web Based
Bed Management
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Tutorial Background The Problem
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2
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Admission
Discharge
ED
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LTC Beds

• Broadly Defined Causes of Access Block
• Increased visits to the ED
• Limited inpatient beds
• Added workforce strain
• Inadequately resourced LTC

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Tutorial Objective Innovation Solutions
Admission
Discharge
ED
Primary Care
Community Care
Residential Care
Home Care
Nursing Home

• PathWays Project Moving Downstream to Accelerate
  Patient Flow
• Pull patients from acute
• 100.. utilization throughout continuum of care
• Measure patient needs by case, clinical
  population, location
• Establish proactive planning for the future

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Multidisciplinary Collaboration
Dept of Health Modernization Agency
Primary Care Doctors/GPs
ED Hospital/Acute
Community Care Bed Management
Residential Care
Home Care
Nursing Homes
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To Qualify our topic

• Big IssuesQuick Easy Fixes?

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Consider issues in the World today, clearly no
lack of tough challenges!
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From policy to address Global Warming
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..to initiatives securing Participative
Sustainable World Aid
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From establishing well planned World Economics
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to Cleaning Up Corporate Boardrooms!
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From the scare of energy shortages
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..to its impact on consumers!
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And from Global economies vs. Global issues
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To Emerging Markets even Submerging Markets
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Eventspuzzling to even the most predominant
Economists of our time!

if I turn out to be particularly clear, youve
probably misunderstood what Ive said
Allan Greenspan
Big Issues NO Quick Easy Fixes
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For Health Institutions its a bit like
Walking a Tightrope
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Dealing with Ageing Population Demographics
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Poor Eating Habits
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and even Poorer Addiction Habits
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All the while, Clients having Higher Expectations
Healthcare
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An off the shelf Fix All solution would be
great.
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However, no one has found one yet!

• Hence, HICs theme in 2004 is so appropriate
• to make a Difference!
• CHR Strata Healths PathWays Project has made
  a significant impact Lets look at how

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Dr. Larry OhlhauserPresident CEO, Ohlhauser
Assoc.

• Industry Overview
• Todays Reality
• Project Relevance
• Canadian Perspective

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Mr. Howard WaldnerCOO Executive VP, CHR

• CHR Experience
• The Need/Purpose
• The Decision
• The Outcomes

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Mr. Don SchickPresident CEO, Strata Health

• The PPP
• (Public Private Partnership)
• CHR Strata Health
• The Risks
• The Rewards

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PathWays Demo

• QA Session

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Access Waiting for Health Services

• Dr. Larry Ohlhauser
• President CEO
• Ohlhauser Associates

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Canada A Snapshot
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Wait list management

• Why wait lists?
• Why manage them?
• What are some solutions?
• -The Alberta Experience

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Why wait lists?

• Waits, delays, cancellations
• -So common in health care
• -Assume its part of the care process
• -Patients, providers and policy makers

• OECD paper Hurst and Sicilian
• -Tacking Excessive Waiting Times for Elective
  Survey 12 OECD countries
• -Mean waiting times for elective surgery - 3
  months stretch into years

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Why wait lists?

• Optimizing Patient Flow
• -Moving patients smoothly through the system
• -IHI
• Bottle necks
• -Emergency rooms and admission
• -Operating Rooms and Intensive care
• -Inpatient to community
• -Non interchangeable resources
• -A system or isolated departments

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Wait lists - why manage them?

• The costs of delay
• -ER and ICU is an expensive and inappropriate
  holding area

• Parking patients awaiting transfers in ER
• -Affects service, care and safety

• Empty community beds block acute beds
• -Need manage discharges
• -Transition PathWays

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Optimizing Patient Flow

• Optimal patient flow supports optimal patient
  care
• -Increased access
• -Shorter waiting times
• -Lower costs
• -Better outcomes

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Access to Health Services in Canada

• National and provincial reports
• -Five provincial
• -Three national
• Canadas First Ministers Feb 2003
• -A new health plan
• -Improve access
• -Improve quality of care for all Canadians

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Access to Health Services in Alberta

• Premiers Advisory Council on Health
• -Patient/customer focus
• -Sustainability
• -Accountability
• -Infrastructure support
• Its time to put the customer first
• -Guaranteed access with in 90 days
• -Centralized booking
• -Posted wait times
• -Primary Care Reform
• -Geographic Access Standards

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Access standards

• Changed from guarantee to access standards
• Working group established
• -Principles
• -Assumptions
• -Selection Criteria

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Principles

• Patient urgency and tolerance of waiting
• Optimize health status and outcomes
• Best clinical evidence
• Applied strategically
• Patient and provider choice
• Need for flexibility in the system
• Improve delivery and access

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Assumptions

• Access targets developed for a selected services
• Access targets determined for care paths
• Waiting times not limited to 90 days
• Targets may be changed or withdrawn
• Right to chose and no preference may have
  different access times
• Qualified professionals provide the service

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Selected Health Services

• Breast and prostate cancer
• Diagnostic Imaging
• -MRI's and CTs
• Major joint replacements
• Cardiac services
• -CABG and angioplasties
• Childrens mental health

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Selection Criteria Development

• Priority rating scales
• -Availability/acceptability
• Effects of waiting for services
• -Availability of information to access effects
• Clinical practice guidelines/care paths
• -Availability to suggest maximum wait times
• Monitoring and reporting systems
• -Currently existing
• Access standards
• -Start and end definitions

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What was found

• Improving access for all selected services
• Not about business as usual
• Not about simply adding dollars
• Improving access
• Fundamental service delivery change
• Probability of success
• All services providers needed to work together on
  the approach

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Cardiac Services

• Findings
• Most open heart patients waited in hospital
• Even after being stabilized
• The patients blocked beds on units
• Grid lock created
• Affected numbers of surgeries completed
• Process
• Engaged surgeons, cardiologist, managers

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Cardiac Services

• Recommendations
• Stabilized patients be sent home
• Intense home care
• Anticoagulant therapy
• Booked OR time
• Expected outcomes
• Increased bed capacity
• Decreased waiting times
• Pilot the delivery model

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Breast Cancer Services

• Need to decrease fragmented care
• Delays in care pathways
• Screening
• Diagnosis
• Surgical consultation and Surgery
• Oncology consultation and treatment
• Build on current initiatives
• Integrated treatment program
• Patient centered, timely, high-quality multi
  disciplinary care, seamless and integrated

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Major Joint Replacements

• Improving access needs more that increasing
  resources
• Evaluate current delivery
• Systematically redesign service model
• Improved assessments by referring physicians
• Improved booking services electronic
• Create standards of care
• Bone and Joint Institute
• Promotion, prevention excellence in patient care
• Research and education

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Summary

• Improved access
• Involves many initiatives
• Additional resources alone, not the answer
• Requires service re-engineering
• Requires involvement of all stakeholders
• Improved access has many factors
• A better understanding of patient needs
• Clinical input
• Operational research and modeling
• Building relationships
• IM/IT support

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Time to Make a Difference!

• Mr. Howard Waldner
• Executive Vice President Chief Operating
  Officer
• Calgary Health Region
• Alberta, Canada

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Canadas Health Care System

• Funding comes from both federal and provincial
  governments
• Policy comes form both as well
• Federal Canada Health Act
• Provincial Delivery
• Ongoing dialog and challenge as to

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Whos in Charge?!
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Calgary Health Region

• Largest Integrated Teaching Health Region in
  Canada
• AUS 2.7 Billion Annual Budget
• 23,000 staff
• Services a Population of 1.5 M (200 sq miles)
• Annual population growth of 3
• debt free province oil gas!
• 7,000 beds 2,500 acute / 4,500 Community
• 17 hospitals, 4 urban teaching hospitals
• 5th major hospital to open soon!

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NHS Personal Experiences

• Evolution Innovation go hand in hand
• Must Make a Change to Make a Difference
• The focus on Clinical expertise is crucial
• Yetwe cant neglect the need for a competitive
  business model in the delivery and logistics of
  healthcare

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The Challenge

• The Ongoing is to Do Morewith Less!
• The secret of success is to optimize the use of
  resources and to get.
• The Right Client, in the Right Bed, in the Right
  Level of Care, at the Right Time

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And of course, Demographics!

• World populations are aging at a rapid rate
• Canada 65 will almost double by 2026
• Australia similar situation
• Relative tax base will decline as Baby Boomers
  retire
• Per capita health care expenditures will increase
  dramatically

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Do We Really Need to Focus on Processor just
build Capacity!

• Capacity is a scarce commodity that must be
  optimally planned
• We need to grow capacity across the entire
  continuum of care, with considerations for
  socio-economic ethnic needs
• A hit miss approach will
• Never optimize available resources
• Result in incorrect timing inappropriate
  clinical resource, potentially in the wrong areas
• Will ultimately fail

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Whats the Solution?

• So, there is no one Fix All approach
• Our care system will continue to grow for the
  next quarter century at a rapid pace
• Necessity of an Action Plan is Now
• - Not a matter of IF but rather When and When
  is NOW!
• A successful solution with be a compilation of
  initiatives by those organization ready to make a
  difference!

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Whats Been Accomplished to Date

• In broad terms
• Primary Care initiatives aid in keeping those
  patients that may not require acute care out of
  the ED.
• Capacity is being expanded where possible

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Patient Flow the Pull Concept

• Our association with Don Berwicks IHI taught
• managing flow within current resource was as
  important as building new facilities
• Moving downstream to optimize flow would pay
  dividends at the front end with increased acute
  access
• Pulling patients from the ED ensures
• The entire continuum of care is bearing the
  workload
• Patients are indeed in the right level of care
  hence will see better case management results
• Current available resources are optimized

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Operations Working as a Team

• To achieve true patient flow across the continuum
  of care, we had to commit to involve the entire
  continuum of care
• Acute / ED
• Community Care
• 3rd Party Venders/Providers
• The perception that Capacity is 100 full
  being optimized - WRONG!!
• We had 10 of our acute beds blocked with
  inappropriate patients
• I needed proofI wanted an objective measurement
  of what was occurring in my Region!

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What were the Options for Action?

• RFI for Boxed Product Did not exist
• Consultants offered to research building it!
• Our IT could build it wrong!
• but it was clear we needed a solution as the
  transition department just could never quite
  catch up even with added resource

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The PPP Proposition!

• 2000 Strata Health approached me with an idea
• I agreed under the follow parameters
• My investment was clinical system expertise
• Their contribution was to build the tool
• I would embrace the system if it worked very well
  walk briskly away if it did not!
• With a joint MOU signed, we embarked on the
  Project vs. letting bureaucracy reign
• A few detractors and Nay Sayers!

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Innovate or Hibernate?

• Often easier to turn away risk and avoid the fall
  out that can accompany failure
• The Question then
• Will our organizations dare to take decisions
  that accept risk in return for make a real
  difference to the future of healthcare?

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Next Steps

• With my sponsorship and my teams intellectual
  property
• Strata Healths money and
• CHRs risk cappedwe took a calculated risk to
  actively support the project.
• Vapor Ware or a meaningful solution?
• Stay tuned after our break to see the results in
  detail!

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- Break for Tea -

• Real Value vs. Vapor Ware?
• OR
• Would we make a difference?

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Vapor Ware ?
Barb Korabek Director Home Care Services
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Why be concerned about Vapor Ware?

• All IT projects succeed dont they????
• - the Real World experience program
  concept
• - immediately understood supported at
  front-line?
• - great reporting vs. same bad news .
  just sooner?
• - has traction right through the
  Organization?
• In fact, reality is.
• OPERATIONAL SOFTWARE FAILURES ARE FREQUENT
  TEND TO BE DRAMATIC especially in Health Care

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IT Potential to Make a Difference Massive

• Technology innovation Front-Line
  Professionals

-Accelerate patient care excellence quality of
life -Improve front-line staff work
environment -Impact critical performance targets
of Health Region
So was our joint initiative going to
deliver. Vapourware?? Or Dramatic
Positive Change??
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SUCCESS vs. FAILURE

• Transition PathWays a quantitative
  qualitative success
• WHAT DETERMINED THE PROJECTS SUCCESS?

In assessing the CHR Strata Health strategic
partnership
6 key points of learning stand out
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1. CONFIRMATION of PRIORITY.

• Was it important? Critical Analysis for CHR
  Strata Health
• 1. Calgary operating performance significantly
  impacted ?
• -Hospital Alternate Level Care days soaring.
  Bed blocks
• -Transition Nursing work environment eroding
  hiring up
• -Care Centre performance occupancy
  inconsistent to contracts
• -Potentially inconsistent application of Region
  placement policy

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Decision High Priority
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1. CONFIRMATION of PRIORITY

• 1. Calgary Region operating performance
  significantly impacted ?
• 2. Economic Benefit for both partners
  achievable ?
• -Strata Health - best practice approach to
  Transition Management
• -Calgary Health - rapid staffing capacity
  gains
• -Calgary Strata to benefit from CHR Reference
  site status
• Decision mutual opportunity defined

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1. CONFIRMATION of PRIORITY

• 1. Calgary Region operating performance
  significantly impacted ?
• 2. Economic Benefit for both partners
  achievable ?
• 3. Client care experience Quality of Life
  improved ?
• - improved privacy safeguards
• - Consistent administration of placement policy
  for all
• - reduced hospital delays for Right Care
  environment
• -more streamlined admission to variety of
  Community streams
• Decision Significant client benefits defined

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1. CONFIRMATION of PRIORITY

• Was it important? Critical Analysis for CHR
  Strata Health
• Calgary Region operating performance
  significantly impacted ?
• Economic Benefit for both partners
  achievable ?
• Client care experience Quality of Life
  improved ?
• Was Transition Management a priority across
  Health Region ?
• Community Acute Operations Groups
• Strategic Executive Team
• Information Technology
• Front-line Transition Professionals Nurses

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2. Strong Executive Backing Key

• 1. The project agreed to be high priority
• 2. Strong Executive Sponsorship delivered
• -Leadership created expectation of success
• -Shared risk embraced - benefits emphasized
• -A culture of enthusiasm shared interest
  created
• Strong Leadership Delivered Innovation

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• A CONUNDRUM FOR CONFERENCE
• WITH INNOVATION RISK

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• A CONUNDRUM FOR LEADERSHIP
• WITH INNOVATION RISK
• WITH RISK INNOVATION

Strategic Partnerships can make a difference !
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3. Leveraging Partners Investment

• 1. The project agreed to be high priority
• 2. Strong Executive Sponsorship delivered
• 3. Both partners invested in the Vision

financing
Clinical expertise
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Each Partner Invested in the Vision

• Strata Health
• A partnership is not a pay us we will build
  it scenario
• Entrepreneur must accept financial risk for
  long-term return .
• Provision of dedicated technical change
  management expertise
• Calgary Health Region
• Access to seasoned clinical professionals for
  design change management
• Delivery of the critical Pilot environment
• Long-term financial commitment only POST
  successful pilot

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4. Once expertise is accessedlisten to it !!

• 1. The project agreed to be high priority
• 2. Strong Executive Sponsorship delivered
• 3. Both partners invested in the Vision
• 4. Leveraged expertise via strong working group

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Shared expertise mined within Key Committee.

• Joint Steering Committee charged with
• - delivery of success
• - accountability to executive sponsors
• - equity consistency of membership
• (Directors - Vendor - Nurses)
• Frequent meetings effectively built
• - expertise rapport
• - openness debate
• - ownership to milestones objectives
• - timely reporting to Executive Sponsors

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Nurses on Steering Committee Key Force

• Change doesnt come easily to a decades-old
  business process.
• How was the average 46 year old Canadian nurse
  just prescribed reading glasses who may or may
  not use the internet at home.introduced to
  web-based business technology successfully?

BY INCLUDING THEM IN THE CHANGE !
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Steering Committee Focus

• Strata Health had to remember that successful
  software deployment has less to do with product
  than change management execution.
• Steering Committee Focus on
• Intensely mapping existing PROCESS
• Becoming expert on POLICIES that guide
  process
• Documenting PROGRAMS counted on to support
  the policy
• Capturing PRACTICES used day-to-day to get
  job done in Real-World
• Product - Configuration - Change Management -
  Documentation

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A Key lesson for Vendors

• Long-Term Success is
• not driven by product features benefits
• Driven by passionate change management
• Achieved in the details of deployment execution
• Transition PathWays success depended on

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Deployment Learning

• Create effective learning environments
• use small classes dont mix topics
• schedule well ahead of time deliver reminders
• Ensure training atmosphere positive
• varied skills levels guaranteed ...
  buddy-system works
• Training room must be appropriate bright cool
• Test and recognize achievement
• Follow-up computer learning modules ?
• A bit of Fun never hurts !
• Food works 21 cheesecakes 6 pizza parties
• candy quizzes

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Confirm Message then Get It Out There !

• 1. The project agreed to be high priority
• 2. Strong Executive Sponsorship delivered
• 3. Both partners invested in the Vision
• 4. Leveraged expertise via strong working group
• 5. Communicate - Communicate - Communicate

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Were all so busy - no time to listen?!

• Public Health Organizations Entrepreneurs
• Different perspectives priorities
• Different velocities of decision making
• Dont assume dont give up dont get
  frustrated
• open dialog around mutual milestones was the
  answer
• Communicate across total Region
• Region PR to hi-lite success applaud
  risk-takers

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Calgary Health Frontlines Newspaper.

• - Great motivator for CHR team
• MembersHey, what Im working
• on is important!!
• General morale booster.Hey, I know her. Calgary
  Health is really doing cool stuff ! This is a
  great place
• To work!
• -Positive public communication Hey, these guys
  are making a difference for me

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6. Finally, Promises are Fine but
Delivery is Better !

• 1. The project agreed to be high priority
• 2. Strong Executive Sponsorship delivered
• 3. Both partners invested in the Vision
• 4. Leveraged expertise via strong working group
• 5. Communicate - Communicate - Communicate
• 6. Delivery on Promises Breeds Culture of
  Success

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Hold to Plan . Get it Done

• Understand the partnership roles Strata was
  there to deliver for Calgary Health
• LIMIT HOLD SCOPE
• -if the development goals keep changing will
  never be met
• -Strong Steering Committee invaluable to draft
  clear Project Charter
• -Scope can articulately evolve through future
  Versions

NOTHING DELIVERS VAPOURWARE LIKE SCOPE CREEP
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Nothing Breeds Success...Like Success.

• Meeting Beating Milestones.
• -Builds momentum
• -Turns dissenters to cheerleaders
• -delivers the objectiveon time on budget
• - A GREAT EXCUSE TO CELEBRATE

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Key steps on path to success

• 1. The project agreed to be high priority
• 2. Strong Executive Sponsorship delivered
• 3. Both partners invested in the Vision
• 4. Leveraged expertise via strong working group
• 5. Communicate - Communicate - Communicate
• 6. Delivery on Promises Breeds Culture of
  Success

But remember the concerns around Vapourware ?
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Real Solutions
Barb Korabek Director Special Projects
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From Vision to Reality through Partnership..
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PathWays Live Demo

• Mr. Clint Schick

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4 Modules 1 Application
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Transition PathwaysStreamlines the Process
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Captures Client Needs profile Configurable to
AHS Requirement
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Captures available Bed Resource
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AHS Priorities establish the Matching Criteria
all in real time
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Once Matched, the Patients Family can be
consulted prior Admission
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Details are Time stamped, enabling Robust
Reporting
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Match Status Intervals define the Process!
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Reporting on Intervals just 1 way to Monitor
Performance Benchmark!
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PathWays Log In!

• From anywhere an internet connect can be accessed!

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From Pilot to Practice.
The Right Client in the Right Place at the
Right Time Cared for by the Right Provider
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Transition Pathways Deliverables

• For the Patient/Client
• Placement decisions reflective of policy
  preference
• Substantive gains in patient/client privacy
  versus manual processes
• Best Fit placements matching patient/client needs
  to available resources
• Effective Client resource status tracking and
  controls
• For the Health Region
• Reduction of waitlist time from acute care to
  alternate supported living
• Expanded acute bed access better utilizing
  existing resources
• Easing of manual administrative process on
  frontline staff
• Ensuring consistency objectivity within
  placement protocol
• Building integrity in data reproducible
  processes
• Enabling fact-based decision making via
  configurable data reporting
• For the Facilities
• Enhanced capacity management
• Easing manual administration
• Detailed report record keeping

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PathWays Targeted Pilot Outcomes

• Target 1 Implementation
• All Region sites Transition ftes engaged by
  12/02
• Alpha Trial sign-off by 05/21/02 05/21/02
  complete
• Beta Trial sign-off by 07/21/02 07/14/02
  complete
• CareWest Implementation by 09/15/02 09/08/02
  complete
• Transition Coordinators by 10/01/02 10/03/02
  complete
• Full deployment by 12/21/02 12/12/02 complete

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PathWays Targeted Pilot Outcomes

• Target 2 Improved Region Capacity
• When I arrived in Calgary in 1999, 10 of our
  acute beds were blocked by patients whos acute
  episode of care was complete. These patients
  were awaiting a discharge into an appropriate
  supported community environment.
• 2000 acute beds
• 120 170 blocked at any one time
• On average 7 of our total acute bed availability
• Between 20 25 million dollars operating
• The Outcome..today on average 1.5 of our acute
  beds are blocked (20 - 30 beds)!

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PathWays Targeted Pilot Outcomes

• For the comparative period APRIL thru SEPTEMBER
• - All staff vacation requests accommodated
• - Less relief staff utilized
• - Placements continued despite senior staff
  vacations

Net Result 28 more client transactions
processed
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PathWays Targeted Pilot Outcomes

• Target 3 Improved Transition Efficiencies
• Timelines for key bed intervals to be reduced
• Average ALC days / client placement to be reduced
  by 10
• CareWest utilization to achieve 98.5 or better

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Average Days From Posted To Admitted
Admitted
Posted
Pending
Accepted
Pending Accepted
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Acute ALC days trending downward
01/02
02/03
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Real world snapshot Productivity gains for the
CHR in comparative Q3s
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PathWays Targeted Pilot Outcomes

• 8 x CareWest Centre Utilization
• Goal 98.5
• Oct02 99.0

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PathWays Targeted Pilot Outcomes

• Target 4 Improved Reporting Standards
• Real-time access to information
• 1) Strategic Service Planning
• 2) Utilization Management
• 3) Managing Service Expectations Contracts
• Provider / Health Region

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Calgary Health Progress to Date ...

• LTC - Acute Admissions accelerating
• bed turnover impacted positively across
  continuum - delivering on Region priorities
• System productivity expanding
• Economic Capacities growing positively
  quantitatively with expansion to RCTP - Assisted
  Living underway Palliative on the horizon
• Vendor productivity documentation improving
• Benefits realized by Region - Client - Vendors
• Reports delivering highly actionable field data
  and trends
• report formats evolving to optimize usability at
  all levels
• Project scope expanded to include new joint
  initiatives .
• Home Care contract care plan management
  launched - Home CareFirst
• Acute Access and Bed Flow modeling strategy
  being explored

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RISK - A Hair Raising Experience!!
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Making a Differencethe future is in our hands!
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Final call to action
"One of the true tests of leadership is the
ability to recognize a problem before it becomes
an emergency." Arnold H. Glasgow
Lets All Make a Difference and take on new
initiatives to find workable solutions to the
problems and avoid the emergencies!
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Q A

• Thanks for your Attention

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CareFirst Homecare Contract Management