200810 HAPSHSAA Developmental Indicators: HospitalCCAC Integration

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• 2008-10 HAPS/HSAA Developmental Indicators
  Hospital-CCAC Integration

Gavin Wardle, Consultant to JPPC Don Ford,
Executive Director, Central East CCAC August 2007
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Overview

• This e-learning session covers developmental
  hospital-CCAC system integration indicators in
  2008-10 Hospital Annual Planning Submission
  (HAPS) Guidelines and Web-Enabled Reporting
  System (WERS)
• Aimed at hospital and LHIN staff involved in the
  preparation and review of HAPS CCAC staff
• Updated and expanded as needed

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Outline

• Context for Developmental Hospital-CCAC
  Integration Indicators
• Proposed Indicators
• Specification
• LHIN Level Results
• Interpretation and Caveats
• Next Steps

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2008-10 HAPS/HSAA Indicators Domains
Training Development
Financial Health
Organizational Health
Capital Health IT/Med Equipment
Turnover Rate
Paid Sick Time (Full-time)
Operational Efficiency
Vacancy Rate
Paid Overtime (Full-time Part-Time)
Capital Health Facility Condition Index
Nursing FTE
Current Ratio Consolidated
Staff Satisfaction
Total Margin Sector Code 1
Workplace Safety Indicators
Total Margin Consolidated
Readmissions to Own Facility
Readmissions (All Facilities CHF Only)
CCC Skin Ulcers
Mental Health
CCC Index Indicators
ALC Indicators
Volumes
Rehab Indicators
ED Indicators
Stroke Care Index Indicators
Patient Safety
Hospital-CCAC Integration Indicators
System Integration
Patient Access Outcomes
HSMR
Adult IP Sat Indicators
ED Sat Indicators
Paediatric Sat Indicators
Patient Experience
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Recall 07/08 System Integration Indicators
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Focus of System Integration Indicators

• Main issue Post-acute transition
• Two sub-issues
• Post-Acute care continued inpatient acute
  hospital care for patients with post-acute
  healthcare needs
• Safe handoff to community-based care patients
  with (complex) chronic disease at high risk for
  readmission (mortality) in the immediate
  post-hospitalization period

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Definition of System Integration

• Health system integration refers to the extent
  to which health services are received as part of
  a coordinated and uninterrupted succession of
  events consistent with the medical needs of
  patients

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Policy Context

• 2000 First Ministers call home care a critical
  component of a fully integrated health system
• 2002 Kirby report calls for public coverage of
  PAHC
• 2002 Romanow report calls for expansion of
  Canada
• Health Act to include PAHC
• 2003 First Ministers identify home care as one
  of three
• priority areas to be funded under the
  Health Reform Fund
• Short-term acute home care and end-of-life care
  home care

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Policy Context (contd)

• Home care has also been ongoing focus of Ontario
  government and ministry initiatives. For
  example
• Increases in funding for CCACs
• Targeted for acute home care, end-of-life care,
  and chronic home care services
• LHINs
• home care is a key element in the ongoing
  transformation to a more community-based system
  of care

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Evidentiary Basis Literature Review

• Focused interventions
• Dramatic results with focused supportive
  post-discharge manoeuvres for high-risk
  populations
• Home-Based Interventions
• Early supported discharge
• RCT evidence
• Multiple disease states
• These interventions are generally studied vs. a
  usual care home care control

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Empirical Basis Analysis of Ontario Data

• Usual care home care vs. no formal home-care
• Confounding of home care referral as risk marker
  for worse health status and protective effect of
  home care services
• The marker of Home Care Referral is a strong
  indicator of readmission risk
• Patients Referred to Home Care have longer
  inpatient lengths of stay
• Early (within 3 days) nursing Home Care is
  associated with lower readmission risk for some
  cohorts (e.g. CHF, COPD)
• Additional nursing visits within the first week
  are associated with additional decrease in risk

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Risk of Readmission Profile for Selected
Conditions
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Developmental Hospital CCAC Indicators

• Focus on Post-Acute transition
• Safe handoff from acute to community-based care
  of patients with chronic disease at high risk for
  readmission in the immediate post-hospitalization
  period
• Theoretical Basis
• Timely home care services can improve the safety
  of hospital-home transition for high risk
  patients
• Focus on cohort of hospital patients at high risk
  of readmission
• Focus on delivery (receipt) of post-acute home
  care services in the immediate post-hospitalizatio
  n period

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Validity of DAD Referral Flag Time to First Visit
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Data

• Focusing on linking Hospital and Home Care data
  sets using unique patient IDs
• DAD and Home Care Client Database
• Linked data facilitates
• Testing of the concordance of hospital referral
  flags with reported home care services
• Measuring the intensity and type of home care
  services
• Measuring the timeliness of the first post-acute
  home care visit
• Investigating the protective effect of home care
• All indicators presented at the facility
  (hospital) and LHIN levels

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Home Care Activity by Clinical Cohort (Groupings
of High Risk of Readmission CMG)
Provincial average attainment of nursing home
care 12
Population of interest for Integration indicators
are the cohorts with higher than average
attainment of nursing home care AMI, CHF, COPD,
DM, CVA, PNEU
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Home Care Activity by CMG (indicator cohort)
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Proposed Developmental Indicators

• Receipt of first nursing home care visit within 3
  days of discharge
• low attainment of post-acute home care may
  indicate poor coordination and integration of
  patient care
• Time to first nursing home-care visit post
  hospital discharge
• hospitals have some responsibility to ensure that
  referrals are executed in a timely fashion
• Frequency of nursing home care visits in
  post-acute period
• number of days on which at least one nursing
  visit occurs appears to be associated with better
  readmission outcome
• Proportion of DAD-coded referrals who receive
  first home care visit
• hospitals with high false positive rates should
  work with CCACs to ensure that referrals get
  executed and should focus on accurate recording
  of referrals to home care

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Universal Inclusion/Exclusion Criteria

• Exclusion Deaths, Transfers, Sign-outs
• Inclusion Discharged to home or home care using
  Discharge Disposition (04,05)
• Exclusion All discharges from March 2006 because
  of lack of Home Care data for April 2006
• Exclusion Same day readmissions
• Potential uncoded transfer or no opportunity for
  home care to execute referral
• Out of hospital deaths within 3 days of discharge
  recorded in the Home Care Client Database

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Indicator 1 Receipt of first nursing home care
visit within 3 days of discharge

• Timely visit defined as within 3 days of
  discharge
• Exclusion if death recorded in HCD and death
  occurred within
• 3 days of discharge
• Probability of Timely HC cohort, age, risk of
  readmission
• By design, the number of observed timely nursing
  visits is
• equal to the expected number of timely visits at
  the provincial level
• This was required because of uncertainly around
  need for timely nursing visit
• alternative is to compare to absolute standard of
  (e.g. 100)
• Results flag variation in likelihood of timely
  visit across hospitals/LHINs and not variation
  from a gold standard or what may have been
  required clinically

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Indicator 1 Results by LHINReceipt of first
nursing home care visit within 3 days of discharge
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Indicator 2 Time to first nursing Home-Care
Visit Post Hospital Discharge

• Include only those patients who received a
  nursing visit within 30 days of discharge
• Calculate mean number of days to first visit by
  facility
• Calculate 90th percentile days to first visit
• of post-acute nursing recipients, 90 of patients
  receive first visit by this day
• No adjustments made for case-mix

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Indicator 2 Results by LHINMean and 90th
Percentile Time to First Nursing Visit among
patient who received at least one nursing visit
within 30 days of discharge
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Indicator 3 Frequency of Nursing Home Care
Visits in Post-Acute Period

• Recall that Frequency is measured as number of
  days on which at least one nursing visit was
  received
• Frequency cohort, age, risk of readmission
• Calculate actual and expected frequency at 14
  days and 30 days
• As with indicator 1, these indicators assess
  variation from provincial mean frequency rather
  than comparison to clinical standard
• Include only patients who received a post-acute
  nursing visit within 30 days of discharge

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Indicator 3 Results by LHINFrequency of Visit
within 14 and 30 days of discharge
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Indicator 4 Proportion of DAD-coded Referrals
who Receive First Home Care Visit

• Proportion of DAD-coded referrals who receive
• timely first home care visit
• Still consider only the high risk of readmission
  cohort
• Difference from previous measures is that all
  types
• of home care visits are included
• This is primarily a data quality indicator to
  assess the
• validity of the referral to home care flags in
  the
• hospital data
• Include only patients with referral to home care
  flags
• in DAD and count number who receive a home care
• visit within 30 days.

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Indicator 4 Results by LHINProportion of
Referred Cases Receiving any HC Visit within 30
Days of Discharge
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Expert and Stakeholder Review Process

• JPPC convened a multi-stakeholder Expert Panel
  and sought the input of representatives from the
  CCACS
• Both groups recommended that the proposed
  indicators be included in the agreements as
  developmental indicators
• This recommendation was primarily based on the
  notion that the proposed indicators represented a
  starting point for the measurement of
  hospital-CCAC integration
• Sole purpose of the indicators at this point is
  to prompt dialogue and collaboration between
  hospitals, CCACs, and the Ministry
• Indicators are new and untested in the field and
  must be interpreted with caution the indicators
  should not be used to assess performance, or to
  induce changes in the delivery of care without
  additional careful investigation

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Expert and Stakeholder Review Process (contd)

• Despite recommending the inclusion of the
  indicators in the agreements, the Expert Panel
  and Stakeholders identified four concerns with
  the indicators
• Limited ability of hospitals to independently
  influence the outcome of the proposed indicators
• Relatively narrow focus of the proposed measures
• Focus relates to a narrow conceptualization of
  integration
• Relevance of some of the CMG in the high risk of
  readmission cohort
• Addressed by focusing readmission cohort to be
  more relevant to home care
• Potential perverse consequences due to incentives
  associated with the proposed indicators

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Recommendations for Ongoing Development Work

• Panel pointed to priorities for future work
• Consider a second cohort based on highest
  receivers of home care and assess efficacy (e.g.
  shortened hospital LOS, reduced hospital cost)
• Investigate measuring hospital-CCAC integration
  through early discharge planning (in-hospital
  assessments)
• Develop counter-balancing measures to
  monitor/mitigate unintended consequences of
  incentives associated with the proposed set of
  indicators (dilution of services, shifting of
  resource allocation)
• Need to consider integration on the pre-acute
  phase (e.g. avoidable admissions, ED use)

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More Information

• See Proposed Developmental Indicators of
  Hospital-CCAC Integration for the 2008-10
  Hospital Service Accountability Agreement
  Process Report of the JPPC System Integration
  Virtual Team and Hospital-CCAC Expert Panel (June
  2007) on www.jppc.org for more information on
  these indicators.
• Other e-learning sessions and background
  materials in this series are posted on
  www.oha.com, with links on WERS, FIM, LHIN and
  JPPC websites
• If you have questions, please contact your local
  LHIN www.lhins.on.ca

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We Welcome Your Feedback

• For more information on this e-learning series or
  other initiatives of the LHIN-JPPC Communication
  Education Work Group please contact
• Mimi Lowi-Young, Chair
• c/o Ontario Joint Policy and Planning Committee
  (JPPC)
• 415 Yonge Street, Suite 1200
• Toronto, ON M5B 2E7
• Tel [phone] Fax [phone]
• www.jppc.org