Home At Last

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Home At Last
Community And Hospitals Working Together For A
Smooth Transition Home

• Links2Care
• Linda Gordon Regional Coordinator
• Community Care Concepts
• Veronica Macdonald Executive Director

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Ontario, Canada
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The Ontario Health Care System

• Ontario
• Central province and business heart of Canada
• 1.08 million sq. kms larger than France Spain
  combined
• 12.8 million population - number of seniors
  (baby boomers) doubling over next 25 years
• Publicly-funded health care system (38 billion
  annually)
• 21,000 fee-for-service physicians funded by the
  Ontario Health Insurance Plan
• 154 hospitals
• 14 Home Care Programs
• 36 Public Health Units
• 700 community support service agencies (CSS), 300
  mental health agencies and a small number of
  child treatment centres

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A System In Transition and Under Pressure

• Transition towards local health authorities - 14
  LHINs (Local Health Integrated Networks)
• Move planning, coordination decision-making
  closer to the community
• Very new established March 2006 fully
  operational March 2007
• Integration, innovation new ways of doing
  business are at the forefront
• Pressures on hospitals
• Emergency departments bursting at the seams
• Hospitals beds occupied by patients who could be
  cared for at home
• Greater efficiencies in patient flow-through
  needed
• Home Care and Community Support Services
  chronically under funded hospitals receive the
  bulk of the funding
• Looking for integrated community solutions

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The Aging At Home Strategy

• New funding - 700 million over 3 years
• Provide seniors and their care givers with a
  continuum of community-based services they need
  to stay healthier and live more independently in
  their own homes
• Increase community-based services for seniors and
  involve non-traditional service providers
• Relieve pressures on hospitals and long-term care
  beds
• Looking for a comprehensive mix of community
  services, integration and innovation being key
• LHINs are in charge
• There are high expectations from the LHIN to
  provide innovative and integrated solutions .

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AN AGE OLD ISSUE

• As early as 1885, the need for effective
  discharge planning was recognized
• There is a need for someone at the hospital to
  direct the patient, to represent the patient and
  his interests someone instructed as to all
  existing means of preventing and treating
  illness. He should help to make those who can
  become self-reliant or obtain help for those who
  need it or else medical care may fail of its good
  purpose.
• Sir Thomas Locke

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Setting the Scene Integration on the Ground

• Health services operate in silos and government
  policy directs system focusing on elimination of
  silos, joint solutions and service integration
• CSS agencies are junior players in a big playing
  field
• Hospitals are under pressure land lack
  partnerships to offload those pressures
• Home Care is focused on more direct service
  delivery and they are not focused on coordinated
  care.
• There is a disconnect between community agencies
  and hospitals
• Historically a provincial wide strategy has not
  been in place to bridge gaps, however with LHINs,
  the pressure is on to work together and integrate
  services but experience is lacking
• In particular, the Mississauga/Halton LHIN are
  champions of change and are advocating for new
  and innovative ideas, especially Home At Last

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Why Home At Last

• Hospitals and community agencies realized that
  joint planning could improve transition from
  hospital to home utilizing multi-disciplinary
  hospital and community team works to streamline
  the discharge process
• Improved patient throughput had potential to
  decrease the number of days that hospitals were
  experiencing critical bed shortages
• Transition from hospital to home difficult for
  some patients
• Safe transition often a barrier to discharge
  resulting in increase length of stay in hospital
• Some families and patients falling between the
  cracks when discharged (into an abyss)

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Role of Program Partners

• Hospitals change their discharge processes to
  achieve a pre-determined daily discharge time
  that supports patient flow
• Lead Community Agency coordinates required basket
  of services for the patient to remain safe and
  comfortable at home
• Home Care provides nursing and support with ADLs
  and develop and monitor the basket of services if
  the client is eligible for their services

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Home At Last - Eligibility

• Client Characteristics
• 65 years
• Lives in service area
• Able to direct own care, e.g. medications,
  self-administer insulin injections, oxygen etc.
• Medically stable, not in need of immediate
  medical home care intervention
• Mobile weight bearing with a minimal assist of
  one person and are able to get into vehicle or
  home with the assistance of one person

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Home At Last Process
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Home At Last - Description

• Is an innovative partnership between community
  support service agencies, Home Care and hospitals
  to provide for planned, escorted discharge from
  hospital to home following their hospital stay.
• Helps patients make the transition from hospital
  to home safely, smoothly and comfortably. The
  program ensures that patients need not feel
  vulnerable and alone after their hospital stay,
  but instead have the support they need.
• Designed for seniors living alone, with an older
  or frail caregiver, or with family away all day.
• There is a 24 hour pre-determined/coordinated
  discharge to minimize delays in hospital
  discharge and preventable readmissions
• Care Coordinator and front line staff assess home
  environment and ensure community care supports
  are arranged to ensure the person is receiving a
  basket of services which will enable them to
  remain in their home as long as possible.

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Results and Benefits

• Model for hospital-community integration, working
  together to improve health system performance
• Decrease length of stay (every hour counts)
• Decrease risk associated with complex discharges
• Improved patient satisfaction with discharge
  process
• Improved patient safety beyond the hospital
  walls
• Increased engagement of patients and physicians
  in the discharge process
• Supported the philosophy and belief in seamless
  care between community and hospital
• Reduction in re-admissions
• Improved identification of and response to
  patient needs appearing after the return home

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Challenges and Helpful Hints

• Hospitals can be hesitant to involve
  non-traditional partners and may not recognize
  benefits to their business
• Hospitals are large and complex and it is vital
  to the program to identify an hospital champion
  who can effect change
• Hospitals need to make changes on their end to
  enhance discharge - this is no small task - be
  patient
• Program required units with good care paths help
  to identify an expected date of discharge and
  thus able to meet a pre-determined discharge time
• Educate, inform and update doctors and all levels
  of hospital staff on the program and encourage
  them to provide 24 hour notice of discharge

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Program Evaluation

• Evaluation Objectives
• Describe the services provided
• Identify impacts
• Provide feedback on the development and
  implementation
• Evaluation Methods
• Discharge and service tracking
• Discharge Patient Satisfaction Surveys
• Follow-up Patient Satisfaction Surveys
• Caregiver Satisfaction Survey
• Focus Group Interview with Key Stakeholders and
  Frontline Workers

• Project Potential Outcomes
• Reduce length of hospital care
• Reduced delay in hospital discharge
• Improved discharge processes with respect to
  hospital flow
• Reduced challenges associated with the transition
  from hospital to home
• Increased access to community based services
  following discharge
• Reduced stress and burden of care for informal
  (family) caregivers
• Patient and caregiver satisfaction with discharge
  process and transition to home
• Reduced re-admissions to hospital

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Integration Key Learnings

• The first steps in developing the program are
  difficult and time consuming
• The community sector is often primary leader and
  most often makes the first move to initiate the
  program
• Improving health care/hospital performance can
  strengthen the case for reinvestment of funding
  dollars into community services
• Other hospitals watch for positive outcomes and
  once those happen are quick to adopt innovative
  solutions such as Home At Last
• In the end hospitals learned to look beyond
  traditional boundaries and that innovative
  solutions and partnerships enhance care and
  improve outcomes in a cost effective wayEveryone
  wins!

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Contact Information

• Contact for information on the Home At Last
  Program
• Links2Caresmelhuish_at_links2care.ca
• Community Care Concepts
• Veronica MacDonald
• ccc1_at_golden.net
• Grand River Hospital
• Gloria Whitson-Shea, VP, CNO
• gloria.whitson-shea_at_grhosp.on.ca

• Ontario Community Support Association
  www.ocsa.on.ca
• Contact for information on the Aging At Home
  Strategy
• Ontario Ministry of Health and Long-term Care
  Aging At Home Strategy www.health/gov.on.ca