Improving transitions of care

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• Improving transitions of care
• The Ontario FLO Collaborative
• Susan Taylor,
• Senior Consultant, Quality, Patient Safety
  Clinical
• Resource Management, Hamilton Health Sciences
• Kim Stelmacovich,
• Quality Improvement Consultant,
• Ontario Health Performance Initiative
• QHN 3rd annual Spring Symposium
• May 1, 2008

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• Introduction
• Description of The Ontario Health Performance
  Initiative (OHPI)
• Flos story
• Overview of the Flo Collaborative rationale,
  methodology, Project Aim
• Featured Flo Collaborative partnership HHS/HNHB
  CCAC
• Infrastructure to support our efforts
• Overview of our approach
• Progress to date (Results!)
• Keys to Success
• Question period

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OHPI

• Mission To accelerate quality improvement in
  Ontario to improve system level outcomes in areas
  of provincial strategic priority.
• Achieved by
• Initiating and leading quality improvement
  projects focused on
• strategic priorities, and supporting providers
  and LHINs to improve
• specified indicators in these areas
• Working with senior leaders to build the case for
  quality
• improvement as a core business strategy (Return
  on Investment)
• Increasing the performance improvement capacity
  and capability of
• local providers and LHINs and
• Identifying policy barriers to improvement and
  communicating
• these to appropriate individuals within the MOHLTC

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A variety of system level initiatives have been
launched that target different components of the
care continuum
ED-GIM
Emergency Department
ER Wait
OR Efficiency Teams
Critical Care Strategy
Wait Times Initiative
The Flo Collaborative
OR
Critical Care
Inpatient Medical Unit
Home With Home Care
Specialist
OR Wait
Long Term Care
MRI/ CT
Diagnostic Imaging
CCC/ Rehab
Other
Safer Healthcare Now!
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Why patient flow improvement was chosen

• Alternate Level of Care (ALC) days are increasing
  and resulting in delays for patients in multiple
  areas of the system and contribute to reduced
  availability of inpatient beds for the community
• Duplication of effort among multiple care
  providers
• Lack of role clarity re who does what and when
• Need for system integration and collaborative
  problem solving

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What is the Flo Collaborative?
The Project Aim of the Flo Collaborative is
to improve the timeliness and effectiveness of
patient transition from General Medicine units
to subsequent care destinations (home
with/without homecare, LTC, CCC/Rehab, other).
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Overview

• 28 Partnerships (29 teams) distributed across all
  LHINs
• Acute care hospitals/CCACs
• Toronto Central ( 4 acute care hospitals
  partnered with rehab facilities)
• Senior Leadership and Improvement team roles
• Roles Improvement Advisor (IA), co-team leads,
  Improvement team members, Senior Champion, Senior
  Leader
• Design of Collaborative informed by pilot testing
  (June 2007- November 2007 at NYGH/Central CCAC
  and Hotel Dieu-Grace/Erie St. Clair CCAC)
• Official kick-off September 17/18 2007
• Metrics
• Core outcome measures Average LOS, bed turns,
  readmission rate within 7 days of hospital
  discharge, ALC days, average wait time in ED
  for admitted medical patients
• Target-unit level outcome measures ALC
  patients on a twice weekly basis, one additional
  outcome measure
• Target-unit level process measures to measure
  sub-aim achievement e.g. patients with an EDD
  assigned within 48 hours of admission

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Methodology 3 Streams of Activity
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Henderson General Hospital (HHS)

• HHS is family of 5 hospitals cancer centre
• Henderson Site is the host site for the Flo
  Collaborative
• 212 acute 56 rehab beds
• Programs
• Surgical Radiation Oncology (includes Critical
  Care)
• Systemic and Supportive Care Regional Programs
• Orthopedics (TJR) Medicine (includes ED)
• Rehabilitation
• Host hospital for Juravinksi Cancer Centre

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HNHB CCAC Hamilton Branch

• Hamilton Branch
• 11 Family Health Teams
• 9 Adult Day Services
• 9,000-11,000 clients serviced/month
• Long Term Care resources
• 28 Long Term Care Homes, 2 of which are
  culturally designated
• 3959 long term care beds
• 20 Short Stay (respite) beds
• 35 Convalescent Care Beds

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Infrastructure for HHS-HNHB CCAC Flo
Collaborative
Clinical Resource Utilization Management (CRUM)
Steering
Patient Flow Innovation and Learning Site
Steering Committee
Access to Care Steering Committee
Working Groups, including
Flo Collaborative Steering
Villa Operations Group
Improvement Team
Synchronizing ADT
Care and Discharge Coordinator
Working Group/ Consultations
Early Warning Response
CCAC/ED Partnership
Surgical Smoothing
Working Group/ Consultations
Admission Avoidance from JCC
Working Group/ Consultations
Schedule the Discharge
Dedicated Admissions Nurse
Others TBD
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HHS-HNHB CCAC Flo CollaborativeAim Statement

• Over the next 18 months, Hamilton Health
  Sciences and HNHB CCAC will improve processes of
  care to achieve more timely and effective patient
  transitions from medical units of the Henderson
  Site for all patients, regardless of the
  discharge destination planned.

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Progress Snapshot Tests of Change
Central Whiteboard
Bedside Whiteboard
Develop a change
Test a change
Implement a change
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Subaim 1 By May 2008, we will expedite
decision about the appropriate discharge
destination and increase accuracy of referrals.
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Subaim 1 By May 2008, we will expedite
decision about the appropriate discharge
destination and increase accuracy of referrals.
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Subaim 2 By May 2008, we will reduce delays in
discharge through improving accuracy of discharge
predictions and shifting the average time of
discharge from 2 pm to 10 am

• Patient will likely require 3 or more days of
  acute care before being ready for
  discharge

        Patient will likely be ready for
discharge within 2-3 days
         Patient will be ready for discharge in
24 hours
         Patient being discharged today
         Patient is now ALC
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Subaim 2 Reduce Delays in Discharge by
increasing accuracy of discharge predictions
(visual triggers)

• We predicted that the Red-Yellow-Green whiteboard
  could be incorporated into practice on A3 at
  Henderson
• Aside from some early inconsistencies, we have
  been designation 100 patients as
  Red-Yellow-Green and updating the whiteboard
  (weekdays only so far)
• The mean days yellow was 1.34 (target 2 days) and
  green was 1.26 (target 1-2 days) suggesting that
  we may be able to be more aggressive in
  identifying patients as yellow, but was
  reasonable for a new process.
• When we compared A3 to another medicine ward on
  site, found that predicted 88 discharges
  (compared to 65 discharges)
• We held Lunch and Learns on Ward A3 to ensure
  that each member of the team understands their
  role and to tie this in with other subaims
• If I am a nurse, and my patient is yellow what
  should I do?
• If I am a physician and my patient is green,
  what do I need to do?
• If I am the manager of the ward, and all of the
  patients are red, what does that mean for bed
  management?
• Feedback was extremely positive. Nurses offered
  to contribute by updating the whiteboard for
  their patients, and Business Clerk offered to
  help out with updating Bedside Whiteboards.
  Physicians asked to see how it works. Other
  medicine ward now asking to use it!
• Suggestions from the general team of staff from
  A3 included
• Incorporate the status (colour) into the Transfer
  of Accountability checklist and
• Add a sticker to the spine of the chart for quick
  reference

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Subaim 3 By April 2008, we will have a 25
reduction in the number of days from ALC
identification to completion of the placement
package for patients from Henderson ward A3.

• CCAC Case Manager attends rounds on Ward A3
  Mondays, Tuesdays and Thursdays (start date
  January 7, 2008)
• There were a total of 145 patients referred to
  CCAC from ward A3 between December 3, 2007 and
  March 31, 2008. Interestingly, only 27 of 145
  (18.6) were referrals for LTC Placement.
• A3 has established practice whereby patients are
  not referred to LTC unless other options have
  been explored and ruled out. Though difficult to
  measure, we are hoping to quantify the number of
  patients who averted LTC placement by including
  CCAC Case Manager in rounds.
• Completion of Placement Package is contingent
  upon completion of RAI (Eligibility) and Choice
  List. These two happen in parallel, so the
  latest date was used to calculate the interval.
• Median intervals are listed below

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Subaim 4 By May 2008, we will evaluate and make
recommendations for alternatives for
de-conditioned patients to trial rehabilitation
program so that they can return home and avoid
LTC admission.

• We predicted that the number of ALC-REHAB
  patients would decrease with focused and
  immediate problem solving to address
  implementation of revised access process
• A change in the role of the Rehab Nurse Clinician
  (summer 2007) facilitates communication and
  planning between rehab and acute services
• The median number of ALC-REHAB patients has
  decreased from 3 to 1.
• Concurrent work with the Innovation and Learning
  Site has been to facilitate real-time
  conversations between the rehab and acute
  programs to clarify plans for patient admissions
  to rehab.
• We predicted that there was a need for modified
  rehab services for de-conditioned patients.
• A total of 7 patients have been accepted to rehab
  with this test
• 4 of 7 were from ward A3
• Patient profile has been consistent with
  predictions
• Evaluation demonstrates appropriateness (benefit)
  to this population

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Outcome Measures Results!
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Next Steps

• Spread the post-acute Admission Criteria Matrix
  and algorithm to other areas of HHS
• Test the bedside whiteboards to enhance discharge
  communications and planning with patients and
  families
• Test incorporation of Red-Yellow-Green status
  into the Transfer of Accountability checklist for
  Ward A3
• Spread the Red-Yellow-Green central whiteboard to
  other Medicine ward at Henderson Site
• Continue to test CCAC Case Manager attendance and
  participation in rounds
• Continue to test rehab for de-conditioned
  patients (considering implementation of stream to
  address these patients)

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Keys to Success

• Culture team is engaged/willing to come to the
  table and try new ideas (can stop people in the
  hall and ask what do you think without awkward
  silence!)
• Creativity recognition that it wont be perfect
  first time round, so we will work together to
  come up with the answers
• Commitment to improvement team willing to look
  at past/current performance and engage in frank
  discussion about opportunities
• Synergies with previous and concurrent
  improvement initiatives
• Infrastructure of Innovation Learning Site
  corporate initiative in place prior to Flo
  Collaborative

Improvement of any system requires will, ideas
and execution. - Tom Nolan, PhD
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In Support of Flo the HHS-HNHB Experience

• The FLO Collaborative will come and go, but a
  foundation has been laid on A3, people have been
  educated and provided with tools to promote
  change. And that's pretty exciting to me!

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• Flo Improvement Team Members
• Mary Lou Meyers (Hospital Co-Team Lead), Clinical
  Manager, Ward A3
• Lori Phillips (Hospital Co-Team Lead), Medical
  Nurse Associate
• Karen Stickley (CCAC Co-Team Lead), Client
  Services Manager, HNHB CCAC
• Susan Taylor, Improvement Advisor (Senior
  Consultant, QPSCRM)
• Barb Ansley, Manager, Rehab Program
• Leslie Gaffney, Case Manager, CCAC
• Galen Gannon, Social Worker, Ward A3
• Nancy Henderson, Quality Facilitator, QPSCRM
• Lori McCall, Occupational Therapist, Ward A3
• Lynda Pliskevicius, Unit Leader, Ward A3 (RN)
• Cherilyn van Berkel, Transitional Care/Discharge
  Specialist (QPSCRM)
• Laura VanKuren, Decision Support
• Senior Champions
• Gail Johnson (HHS), Director Orthopedics
  Medicine Program
• Sherry Parsley (CCAC), Director Client Services
• Senior Leaders