Why We Care About Home Care

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Why We Care About Home Care

• Presentation to the Ontario Home Care Association
• 2009 Symposium
• By
• Cathy Fooks
• President and CEO
• The Change Foundation

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Presentation Overview

• Who is the Change Foundation and what do we do?
• Why a Focus on Community Care?
• What does our research tell us?
• Future partnerships?

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Who is the Change Foundation?

• Charitable, public foundation established in 1995
  by the Ontario Hospital Association
• Board of Directors sets overall strategic
  directions and small management team to implement
• 55 million endowment we spend the investment
  income annually (depends on the markets!)
• Recently established the Centre for Health Care
  Quality Improvement (CHQI) with 25 million from
  MOHLTC

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What Do We Do?

• Health policy think tank thus tag line
• Two areas of work looking at delivery models for
  integrated care AND supporting quality
  improvement activities in community care
• Combination of traditional policy research AND
  hands on, practical quality improvement redesign

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Why A Focus on Community Care?

• There is a growing body of literature
  internationally
• and in Canada that indicates that home care can
• be a cost-effective substitute for long term
  care
• facility care and acute care within an
  integrated
• system of care.
• Hollander et al, Healthcare Quarterly, 12(1), 2009

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Why a Focus on Community Care?

• Hugely important part of continuum of care for
  patients/clients BUT often ignored and
  under-resourced
• Lots of evidence that citizens wish to receive
  care in their homes, not in institutions/facilitie
  s when appropriate
• Not covered under Canada Health Act, thus no
  federal transfers, thus left to provincial
  coffers to fund or out of pocket

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Per Capita Home Expenditures in Ontario(adjusted
for inflation) Source CIHI, 2007
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Home Care of Total Health Care Budget,
OntarioSource CIHI, 2007
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Why a Focus on Community Care?

• In 2005, approximately 774,000 people used home
  care services in Ontario
• Population 65 and older more than doubles by 2031
• 2005 Ontario survey showed that 88 of those
  surveyed preferred home care as a place of care
  for themselves and 84 preferred for their loved
  ones
• 58 of ALC days in Ontario because home care
  services arent available or services have not
  been finalized

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What Does Our Research Tell Us?

• Focus on integration look at all services from
  the patient/client perspective
• Puzzlemaker Report Patient and Caregiving
  Perspectives in Navigating Ontarios Health Care
  Services
• Having Their Say, Choosing Their Way voices at
  the transition points

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Why a Focus on Integration?

• Health care can be fragmented
• Seams in between programs and sectors can look
  more like canyons
• Authority can be dispersed - autonomy is more the
  norm especially for health care professionals
  who are often independent practitioners

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Why a Focus on Integration?

• Variations in practice patterns can raise issues
  of quality
• Everyone is working hard but whole is often less
  than the sum of the parts
• Ontario has a legacy of provider silos no ones
  fault, the system has been designed and funded
  that way

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Results of Lack of Integration?

• Confusion among public, patients and providers
  not sure who should be responsible
• Care remains largely uncoordinated
• System capacity is used inefficiently

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Results of a Lack of Integration?

• Quality issues surface
• Complaints
• Seems to be particularly difficult at points of
  transition from one service provider/professional
  to another

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Research on Patient Perspective

• Three separate projects
• Literature review on patient and families views
  on navigating the system
• - systematic review at University of Calgary
• - limited to empirical studies of expectations
  and experiences of integrated health care since
  1997
• - 53 studies were included, 12 of which were
  Canadian

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Research on Patient Perspective

• 2) General population survey about information
  flow and communication across transition points
• - 1015 Ontarians aged 18 and over at the end of
  April 2008
• - asked about information flow and
  communication provider access to information
  coordination of care whether the health system
  values their time

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Research on Patient Perspective

• 3) Ten focus groups with regular users of the
  health care system (minimum of six interactions
  in last 12 months with different providers) and
  caregivers
• - divided between patients and caregivers
• - caregivers had to participate in appointments

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What Did We Find?

• In general
• Patients have reasonable expectations
• Strongly support their health care providers and
  professionals
• Understand the governments concern about ever
  increasing resources directed at health care
• BUT
• They see where things break down and can identify
  clearly where things dont make sense

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Four Common Themes

• Navigating the System is anybody joining the
  dots?
• Dealing with Repetition, Redundancy and Delay
  could it be a bit more logical?
• Worrying about Communication is anybody
  listening?
• Getting Lost in the Transition who is the
  puzzle maker?

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System Navigation

• 54 of people surveyed reported they were not
  confident that there was a single, lead person in
  charge of coordinating their health care services
  (S)
• Patients and families report that as they move
  across services, they are left to make their own
  way through the continuum without the skills,
  support or confidence to do so - this was
  particularly true for parents with special needs
  children and families dealing with chronic,
  debilitating illness (LR)

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System Navigation

• Patients report that they understand they must
  shoulder some responsibility for their care but
  are looking for a partnership (FG)
• Patients receiving care in clinics featuring
  multi disciplinary teams reported higher levels
  of satisfaction and less difficulty navigating
  services (LR and FG)

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Tanya from Kingston

• The difficulty was the coordination of care
  once she got home from hospitalThere just
  doesnt seem to be a good flow of information
  between specialists. And so its a bit difficult
  to navigate. I thought it would be helpful to
  have someone sort of helping us with that.

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Repetition, Redundancy, Delay

• 41 of those surveyed reported they do not feel
  the health care system values their time (not
  seen at time of appointment, allowed only one
  issue to be discussed at each appointment, short
  notice appointment during work hours) (S)
• Patients report
• having to convey the same information repeatedly
• being sent for duplicate tests (first results
  were not available or too much time had passed
  between test date and appointment)

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Repetition, Redundancy, Delay

• Patients report
• appointments or procedures being cancelled after
  patient arrived onsite
• rebooking an appointment because provider did not
  have adequate information at the time of the
  appointment (LR and FG)

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Keith in Toronto

• With my Dad, every time Ive gone, and hes
  been to various places and Ive been there, we
  have the big file. Now if I wasnt educated and
  he wasnt organized
• Every time you have to fill in the forms again.

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Communication

• Most common area of concern from all three
  sources
• 1) Information at point of services
• 41 of those surveyed reported they did not think
  their health care practitioner had access to all
  information, tests and records related to their
  health (S)
• Misplaced records (LR)
• Incomplete information sent (LR)
• Patients deliver their own test results (FG)

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Communication

• 2) Clarity About Next Steps in Treatment
• - 30 of people surveyed reported that they
  sometimes received instruction about symptoms to
  watch for. 35 reported they occasionally, seldom
  or never received such instructions (S)
• - 27 of people reported they sometimes received
  instructions about where to seek further care if
  needed. 30 reported they occasionally, seldom
  or never received such instructions (S)

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Communication

• 3) Communication Between Health Care Providers
• - perceptions of coordination are directly
  linked to perceptions of the extent of
  communication between providers (LR)
• - numerous instances of a provider not knowing a
  patient had been seen elsewhere, not having
  results of the episode elsewhere (FG)

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Transition Points

• Emphasis in both the literature review and the
  focus groups that the problems (navigation,
  repetition and communication) are acute at points
  of transition
• Relates to another project we are doing with
  CCACs

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Joy in Kingston

• People are leaving the hospital and then
  theyre kind of on their own. When theyre out
  theres home care, but only for so long and
  thenits unloaded deeply on families. Honestly,
  if you dont have daughters or sons close by, you
  are on your own.

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Carmen in Toronto

• They asked my father Is there someone at home
  who could take care of you? And he said, Yes,
  my wife. But my mother is blind, she has
  mobility issues. I said, He cannot come home
  under these circumstances. So they told me I was
  the primary caregiver.

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Solutions?

• Research and public agree
• Speed up EHR implementation
• Designate navigators or care coordinators across
  continuum
• Increase use of multidisciplinary teams
• Better support for caregivers
• Better connect primary care practitioners to rest
  of system
• Undertake QI process mapping at transitions
• Coordinate/integrate care maps across providers

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Having Their Say, Choosing Their Way

• Quality improvement project working with the
  South East CCAC and Trenton Memorial Hospital to
  improve the transition from hospital to home
  (defined as home care or LTC placement)
• Process mapping with the staff actually
  observing and mapping all the steps involved in
  discharge planning and placement
• Interviews with patients/clients and their
  families

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Having Their Say, Choosing Their Way

• Basic focus on improving efficiency, length of
  time and communication
• What can we stop doing?
• What should we start doing?
• What prevents change?

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Having Their Say, Choosing Their Way

• Population Studied
• Average age 81
• 73 female
• 31 receiving home care prior to hospital
  admission
• 40 LTC application completed prior to hospital
  admission
• 47 living with a family member

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Metrics What Did We Find?

• Total of 160 steps
• 69 handling steps
• 36 forms originated
• Minimum of 4 family trips to hospital to meet
  staff
• 15 points where delays occur
• 5 staff involved

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Metrics What Did We Find?

• 15 points of delay
• Assessments filled out electronically but then
  printed and faxed or sent by courier
• One part of the assessment changes and a whole
  new assessment is printed and sent without
  indication as to what has changed
• Clients entered into a tracking tool five times

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Patient/Client Voices

• I want accurate information that I can
  understand at the right time and place, including
  viable options, so my family and I can make the
  right decision for us. I want to feel confident
  that people care and to be treated with respect.
• I dont want to make a decision out of fear,
  inadequate care, or surprises.

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What Has Changed?

• Local staff decided on the following
• Prebooked meetings with CCAC case manager
• CCAC case manager meeting with high risk elderly
  in the ER
• Elimination of approval steps for in-home
  authorizations
• Adding personal support works in hospitals
• Discontinue requirement for hospital case
  managers to seek management approval for
  authorizing personal support
• Phase two in Toronto just completed

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Future Partnerships

• Working with Community Provider Steering
  Committee to develop a survey of providers to
  look at these issues (committee is supported
  through the OACCAC)
• OHCA co-chairs the Committee
• Planning to develop a quality improvement project
  focused on the CCAC community provider interface

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