Seniors and Adults with Complex Needs

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Seniors and Adults with Complex Needs

• A Healthier Tomorrow

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Welcome

• Objectives for South West LHIN Webcast Series
• Inform partners of LHINs vision, mission,
  values, and health system improvement goals.
• Inform partners of how the Priority Action Teams
  future directions align with the LHIN goals and
  how recently funded projects move us closer to
  the desired state identified by the Priority
  Action Teams (PATs).
• Acknowledge contributions of volunteers and
  partners who were actively involved in defining
  the development of the LHINs work.

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The South West LHIN Webcast Series

• Health System Integration January 9
• Health System Design January 23
• Health Human Resources February 6
• Seniors Adults with Complex Needs February 20
  
• Primary Health Care and Chronic Disease
  Prevention Management March 6
• eHealth Strategy March 27

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Purpose of this Presentation

• Review key directions from the 3 Seniors and
  Adults with Complex Needs PATs
• Enabled by the PAT framework, describe Aging at
  Home and ER/ALC financial investments that move
  us closer to achieving the South West LHIN system
  level goals and government priorities
• Describe the mechanism to guide, lead and provide
  oversight for the projects and initiatives
  currently underway

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Seniors Adults with Complex Needs Priority
Action Teams

• Continuum of Care PAT
• Access to Long Term Care Services PAT
• Rehabilitation PAT

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High-level Overview

• Target Populations
• 1. All Seniors and their Caregivers
• 2. Adults with Complex Needs

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Target Population
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High-level Overview

• Target Population
• All Seniors and their Caregivers
• PAT working definition individuals 55 years of
  age or older
• Functional model of health and aging
  acknowledges a wide range of individual
  difference in the incidence of acute and chronic
  conditions, in their effect upon the individual,
  in the availability of health care, and in the
  reactions to declining health (McPherson, 1998)
• vs. Medical Model (disease or condition focus)

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Target Population (continued)

• Adults with Complex Needs
• Based on the presence of physiological,
  cognitive, psychological, social and situational
  high risk factors, at a point in time, rather
  than the presence of a particular condition or
  disease
• In some instances, can be individuals as young as
  16 (e.g. attendant services)

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Points of Access/Entry, Care Coordination and
Information Flow

• Combination of single point of entry (knowledge
  broker not gatekeeper) and every door is the
  right door to access information and links to
  services
• Care Coordination involves 2 streams
• Simple Supported self care
• Complex Disease specific protocols,
  identification of risk factors (e.g. multiple ER
  visits, hospitalization, accessing 4 or 5
  community support services) that would trigger
  enhanced case management, care planning and
  monitoring
• eHealth record shared electronic tracking and
  triggering of risk factors and services, with
  outcomes measured and monitored

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Scope of Services Range of Services
Individuals Access the Services They Need from
across the Continuum when NeededAccessible
Affordable Examples are provided to help
define what is meant by some broader categories
of services and are not limited to only those
identified
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Aging at Home and ER/ALC

• Investments targeted to begin to transform the
  system

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MOHLTC Transformation Agenda The Current
System...
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MOHLTC Transformation Agenda The Transformed
System...
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Complementary Strategies to tackle ALC

Preventive Providing a person with innovative
and enhanced community supports to keep them at
home and independent To avoid inappropriate
long-term care home or hospital admission.
Targeted Funding
A_at_H strategies
Direct Impact Moving someone who has completed
their acute care treatment phase to a more
appropriate location for care. Diversion Providi
ng a person who might have been admitted to
hospital without additional supports to keep
them at home as an alternative to hospital
admission.
Targeted funding
UPF Core Allocation
UPF ALC Allocation
LHIN Discretionary ( broader than ALC criteria,
but could also be used for ALC)
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Aging at Home Strategy- Unprecedented 700 M
investment over next three years

• 2009 - 2010
• Address Emergency Department wait times and
  Alternate Level of Care days through Aging at
  Home and other initiatives
• Uncertainty of funding with recent economic
  downturn

• 2008 - 2009
• Increase the overall mix and quantity of services
  that allow seniors to stay healthy and live with
  independence
• Innovative approaches and non traditional
  partnerships
• Community economic development approaches
• Linkages to primary care, CHCs, FHTs, etc.

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South West LHIN Priority Directions 2008/09

• Supporting those at risk of long-term care home
  placement and hospitalization (direct and
  diversion)
• Promoting wellness and healthy living
  (prevention)
• Supporting and caring for caregivers (prevention)

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AAH Approved initiatives

• 27 projects approved to move forward in 2008/09
  2010/11
• Approximately 4.8M (69) support seniors at risk
  of LTC home placement and hospitalization (e.g.,
  HAL, Safe at Home, Community Stroke Rehab,
  Supportive Housing, Adult Day Programs and Home
  help)
• Approximately 1.2 M (17) to promote wellness
  and healthy living (e.g., wellness programs,
  Immigrant and Francophone wraparound)
• Approximately 1 M (14) to support caregivers
  and improved infrastructure (e.g., information
  and respite services, transportation coordination)

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Status of Year One Projects

• Many received funds in July but some in
  September, 2008
• 2nd quarter financial reporting received in
  November for Aging at Home
• Planning and staff recruitment stages completed
  for most, many have been providing services for
  3-4 months
• 4th quarter request to complete a status report
  template

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Year 2 Aging at Home Allocations

• South West LHIN 3-year Allocation
• 2008/09 7M
• 2009/10 17.4M (increase of 10.4M)
• 2010/11 30.7M (increase of 13.3M)

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Year 2 AAH Strategy Influencers

• Finalization of mining the Aging at Home
  Proposals from Year 1
• PAT Recommendations
• MOHLTC ER/ALC Strategy
• MLAA Performance Targets ALC, Mean wait time
  LTCH placement
• Making decisions without the benefit of Year 1
  implementation and performance monitoring,
  Blueprint, Balance of Care
• Health Service Provider fatigue Year 1
  projects, MIS, CAPS/MSAA

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Year 2 Aging at Home

• What does this approach accomplish
• Provides some time to gather needed information
  to make better decisions (performance of Year 1
  Aging at Home, Balance of Care results, Blueprint
  inventory)
• Allows us to prolong aging at home funding
  decisions for different uses as better
  information and evidence unfolds (e.g. interim
  LTC home beds, interim retirement home subsidy)

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Year 2 - Aging at Home - 10.4M

• Combination of
• Expansion of Year 1 projects6.84M
• Transfer of some ALC funded projects to Aging at
  Home funded projects..2.49M
• Targeted new projects based on PAT
  recommendations (e.g. Share the Care) and mining
  proposals (e.g. First Link)... 0.75M
• Total..10.08M
• Balance of Care, InterRAI Suite of Tools,
  Information Database

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Year 3 Aging at Home Process

• Balance of Care Project unfolding long stay and
  LTCH waitlist to be analyzed for ADLs, IADLs,
  confusion, and living with a caregiver to
  determine the best package of service
• Spring 2009 - Potential for Balance of Care
  results to be used to guide Aging at home process
  for Year 3
• Information from PAT recommendations, Balance of
  Care, Blueprint, FLO, alignment with LHIN system
  level goals and other projects to influence Aging
  at Home process and targeted investments for year
  3

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Balance of Care Research Group

• CIHR Team in Community Care Research Leads
• A. Paul Williams, University of Toronto
• Janet Lum, Ryerson University
• Karen Spalding, Ryerson University
• Raisa Deber, University of Toronto
• Research Associates
• Jillian Watkins, U of T
• Kerry Kuluski, U of T
• Frances Morton, U of T
• Allie Peckham, U of T

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Targeted, Integrated, Managed Care
Kaiser Permanente Triangle Source UK Department
of Health (2005)
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Balance of Care

• Personal Social Services Research Unit (PSSRU),
  University of Manchester
• Balance of Care (BoC) aims to determine most
  appropriate mix of institutional and community
  resources at the local level to meet the needs of
  an aging population
• Source Dr. David Challis -- go to www.CRNCC.ca

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Balance of Care Key Assumptions

• What determines optimal balance of institutional
  (LTC beds) and HCC at the local level?
• Demand side
• Individual characteristics physical, mental and
  social needs
• Support from/of carers
• Supply side
• Access to safe, appropriate cost-effective HCC
  within broader continuum

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LTC Wait Lists

• Waterloo 811 (Dec. 2006)
• Toronto Central 1571 (Oct. 2007)
  utilization/evaluation
• Central 2631 (June 2008) urban/rural/remote
• North West 864 (Jan. 2008) rural/remote
• North East 1463 (Oct. 2007) supportive
  housing
• Central West 300 (estimated) diversity
• South West 2300 (Nov. 2008) supportive
  housing/MH
• North Simcoe Muskoka TBD ER/ALC
• How many wait-listed individuals could be
  diverted safely, cost-effectively to home and
  community?

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South West Focus on Supportive Housing

• Growing interest in combinations of housing,
  services, and case management to support
  vulnerable populations
• Mental Health, Cognitive Impairment, Disability,
  Frailty
• Potential to serve in a cost effective manner
• Service flexibility, 24 hour coverage, reduced
  travel costs, reduced reliance on ER

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Balance of Care Project Steps

• Step 1 Use CCAC Resident Assessment Instrument
  for Home Care (RAI-HC) data to categorize
  individuals on LTC wait list into 36 relatively
  homogeneous groups
• Cognition
• Activities of daily living (ADL) difficulty
• Instrumental activities of daily living (IADL)
  difficulty
• Presence of a caregiver in the home

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Balance of Care Project Steps

• Step 2 Determine how many individuals fall
  into each sub-group
• Select sub-groups with more than 2.5 of
  population
• In other BoC projects, 13 - 14 groups include
  90 of those waiting

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Central Sub-Groups (1 14)
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Central Sub-Groups (15 28)
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Central Sub-Groups (29 36)
Total Number Wait Listed 2,631 Included in
Analysis 2,374 (90.2)
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Balance of Care Project Steps

• Step 3 Develop vignettes for typical
  individuals in each of the sub-groups
• Based on actual RAI-HC assessments
• Individuals at 75th percentile within each
  sub-group (i.e., higher than average level of
  need)

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Created Vignettes for Central Sub-Groups
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Balance of Care Project Steps

• Step 4 Cross-sectoral expert panel reviews each
  vignette
• Constructs appropriate and safe care packages
• Cost not considered

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Toronto Central Care Package Examples for
Copper
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Balance of Care Project Steps

• Step 5 Estimate HCC package costs compared to
  LTC Home placement for 13 week period
• Ministry of Health data
• Calculate cost of each service based on Central
  average
• To ensure apples-to-apples comparisons, use
  only Ministry contribution to LTC (80/day) and
  home and community care

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Sample Care Package for Copper (N 75, 4.5)
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Balance of Care Project Steps

• Step 6 Calculate divert rate based on
• Safe, appropriate care
• Lower or comparable costs (LTC as cost base)

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Sample Divert Rates Line-by-Line and SH
Line by Line Diversions highlighted yellow
Supportive Housing Diversions highlighted purple
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Opportunity Knocks

• Ontarios LHINs and Aging at Home strategy offer
  the opportunity for cross-sectoral thinking and
  action
• Balance of Care projects aim to inform
  decision-making by bringing together the best
  available evidence, and the most experienced
  professionals at the local level

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The South West LHIN Approach to ER/ALC

• A systems approach with a person centered focus
  that leads people to receive timely access to
  care in the most appropriate setting to meet
  their needs.

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Percent of Acute Care Beds Occupied by ALC
PatientsBy LHIN (OHA Survey Dec/08)
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
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Percent of ALC Patients in Acute Care Waiting for
Long-Term Care by LHIN (OHA Survey Dec 08)
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
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ER/ALC Goals - Short and Medium Term

• Short Term Goals (benefits within 1 year)
• Provide immediate and direct impact by increasing
  post acute capacity and ER diversion supports
  through a targeted approach (hot spots) based on
  current ER/ALC data
• Maximize our return on investment (ROI) by
  impacting the greatest number of individuals cost
  effectively
• Maintain a quality of care focus

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Complementary Strategies to tackle ALC

Preventive Providing a person with innovative
and enhanced community supports to keep them at
home and independent To avoid inappropriate
long-term care home or hospital admission.
Direct Impact Moving someone who has completed
their acute care treatment phase to a more
appropriate location for care. Diversion Providi
ng a person who might have been admitted to
hospital without additional supports to keep
them at home as an alternative to hospital
admission.
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Direct Strategies
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Direct Strategies
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Diversion Strategy
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Prevention Strategy
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Reaching our Medium and Long Term Goals
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Percentage of Alternate Level of Care (ALC) Days
By LHIN InstitutionSouth West LHIN
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Performance and Oversight

• ER/ALC Lead - regular engagement and monitoring
• Projections for ALC days saved for Direct
  strategies
• Performance Lead - quarterly and/or monthly
  report monitoring - performance metrics that
  inform MLAA performance targets and trends,
  particularly
• Percentage of ALC Days,
• Rate of ED Visits that could be Managed
  Elsewhere,
• Median Wait Time to LTC Home Placement

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Performance and Oversight

• Best Level of Care and Quality Steering Committee
  provides leadership, guidance, and oversight to
  current and future projects through
• Comprehensive approach to address patient/client
  flow
• Data mining
• Best practice and continuous improvement
  strategies
• LHIN wide approach to assessment tools, service
  definitions, best care criteria, standardized
  indicators and triggers and
• Performance tracking and monitoring of strategy
  implementation.

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Key Messages

• A Continuous Journey

• Targeted, integrated care

• Performance monitoring

• Increase pre and post acute capacity

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Partnerships

• Nothing great was ever achieved without
  enthusiasm.
• Ralph Waldo Emerson

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Survey
Your feedback is valuable to us. Please take a
few moments to complete our short Online Survey
about this webcast. Just go to the South West
LHIN website homepage, and click on the link to
the survey.
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Please join us for our next Webcast

• When March 6, 2009
• Time 930 1100
• Topic Primary Health Care and Chronic Disease
  Prevention Management
• Details See the South West LHIN Website
  www.southwestlhin.on.ca

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Questions
Dial 1-866-507-1212 and ask for South West
Local Health Integration Network Please note
If you have questions after the webcast, feel
free to email questions in to southwest_at_lhins.on.
ca. A full QA document will be posted on our
website at the end of the webcast series.
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Thank you for joining us!