Presentation on theme: "July 13, FINAL Malcolm Moffat, Co-Chair Helena Hutton, Co-Chair"— Presentation transcript:
1 CLHIN Hospitals ALC Rehab Steering Committee Phase One Report – Orthopedics July 13, FINALMalcolm Moffat, Co-ChairHelena Hutton, Co-ChairZenita Hirji, Executive Project Lead
2 Presentation Outline Provincial Context/Background Overview of ALC Rehab ProjectPurposeKey areas of focusSteering Committee compositionDraft workplanOverview of Current State of Rehab in CLHINDraft ALC Rehab Survey ResultsPerformance TargetsOrthopedic SymposiumDraft Recommendations on Orthopedics
3 Total Joints, Hip Fracture and Stroke Three of the four conditions, knee replacements excepted, contribute significantly to the ALC challenges faced by acute care hospitals.Collectively, they consume a significant amount of rehabilitative resource (55% of rehab provincial patient days)They have well developed, recognized best practice guidelines for rehabilitative patient careUptake of the best practices across the continuum has been inconsistent throughout the province.Challenges faced in the implementation of these best practices are indicative of systemic challenges in rehabilitative care.
4 Ontario studies provide strong evidence on the effectiveness of home-based rehab protocols following TKR/THR“IP compared with home-based rehab following primary unilateral THR or TKR: a randomized controlled trial” N. Mahomed et al, 2008CONCLUSIONS: Despite concerns about early hospital discharge, there was no difference in pain, functional outcomes, or patient satisfaction between the groups. We recommend the use of a home-based rehab protocol following elective primary joint replacement as it is the more cost-effective strategy.
5 …with no observed relation to quality measures or length of stay Correlation of % Joint Replacements Discharged Home & Readmissions/Revisions (2009/10)Top 15 Hospitals by Volume (2009/10)5
6 In January, the Orthopedic Expert Panel made recommendations to the Ministry on provincial targets for discharge disposition and length of stay for THR / TKR patients
7 Overview of ALC Rehab Project Goal: To reduce ALC days related to lack of access to Rehab by developing a systematic approach to facilitate equitable access to appropriate rehab at the appropriate timeFour clinical areas that are identified as being the greatest contributors to the ALC challenges:hip replacement, knee replacement, stroke, and hip fracture.
8 ALC Rehab Steering Committee Steering Committee established in January 2012Reports up to CLHIN Hospital/LHIN/CCAC CEO Leadership ForumMalcolm Moffat – Co-chair, CEO, St. John’s RehabHelena Hutton – Co-chair, VP, Southlake Regional HCAlexis Dishaw, HRRHAnnette Marcuzzi, CLHINDr. Brian Berger, YCHDr. Daniel Wong, NYGHDr. Roshan Shafai, SRHCJulie Sullivan, MSHShannon Landry, SMHVal Thompson, NYGHWinston Cheuk, YCHYvonne Ashford, CCACZenita Hirji, Executive Project Lead
9 Workplan Phase One – Orthopedics (TJR and Hip Fractures) Focus of phase one report will be on:Reviewing the current state of TJR and Hip Fractures care management in CLHIN hospitalsIdentify of gaps in best practice guidelines and achievement of performance targets, in this patient populationCapacity assessment and recommendations on strategies aimed at reducing ALC days for rehab and improving hospital performance on key metrics for TJR and Hip FracturesPhase Two – StrokeFocus of phase two report will be on:Reviewing the current state of stroke care management in CLHIN hospitalsCapacity assessment and recommendations on strategies aimed at reducing ALC days for rehab and improving hospital performance on key metrics on stroke care
11 HOSPITAL ALC REHAB SURVEY RESULTS Purpose - To develop a Central LHIN snapshot of:Inflow into IP Rehab - Patients designated as ALC and awaiting placement in an inpatient rehabilitation bed/facility (Survey One)Outflow from Rehab - Patients in designated rehab beds awaiting placement in another care setting (Survey Two)2 surveys to be completed over two separate weeks: Week One - Jan. 30th to Feb. 5th) and Week Two (Feb.13th to 19th)Total of 156 patients during two week periodSimilar response rates for each weekSurvey was designed by (and has previously been used in another study conducted by) the GTA Rehab Network
12 Summary of Primary Diagnoses – ALC Rehab Top 70% of Primary Diagnoses associated with patients designated as ALC awaiting IP Rehab care - summarized in tableStroke and Hip Fractures comprise 31% of survey diagnosesNo major ALC issues regarding access to IP rehab for primary hip and knee replacements
13 Referral to Rehab Reasons for “no referral” included the following: Awaiting nursing and PT forms to be completedWaiting nursing/PT/medical forms to be donePt. already applied to LTC -also applying to LTLD as per family's requestApplication in process (waiting for medical, nursing, and PT forms)RMR initiated. Forms being completed by team & MRP. Will "send" RMR as soon as all forms completed by team & MRP47% of patients were referred to more than one rehab facilityMajority of patients referred to only one rehab facility
14 Waits associated with ALC Rehab… ALC Designation Date1st Referral to RehabResponse from RehabWait OneWait Two
18 Survey Results Summary Hip Fractures and Stroke comprise 31% of the patient population designated ALC and awaiting placement in an IP Rehab facilityNo major ALC issues regarding access to IP rehab for primary hip and knee replacementsFor the most part, we know that the following special care needs comprise the highest volume of ALC patients waiting IP Rehab careIncontinenceWound CareIV PeripheralWait times vary by age group and significant variation exists in wait times by facility (for both wait 1 and wait 2)Wait 1 (ALC Designation to Rehab Referral)70% of Patients are referred to an IP Rehab facility within 3 days of being designated as ALC58% are referred within 1 dayWait 2 (Rehab Referral to Acceptance)80% of Patients had referral response times of 2 days or lessGeriatric, Stroke, and MSK represent 62% of the most common type of rehab being referred toLow volume of Rehab patients that are designated ALC and awaiting placementaverage number of days waiting varies by facilityLonger waits for Home care and LTC placement from IP Rehab units/facilities
19 CLHIN Hospitals Rehab Current State & Performance Indicator Results
20 IP Acute - Overall TJR Volumes by Hospital Note projected volume increase for 2011/12. Straight-line annualization which usually slightly under-estimates due to lower volumes in the summer.As per Jeff Kwan – funded additional 540 joints for fiscal 2011/12. So 2,813 is likely understated.Data Source: CIHI DAD – TJR includes primary, unilateral ,elective hip/knee replacementsMajority of discharges (65%) are TKR patients
21 Inflow-Central LHIN TJR Surgeries by Patient Residence Can show this by hospital if desired; add total from other LHINWill patients get their Home care / OP rehab closer to home?Data Source: CIHI DAD – TJR includes primary, unilateral ,elective hip/knee replacementsApproximately 900 to1000 patients who live outside the Central LHIN, get their TJR procedure done at a Central LHIN hospitalImpact on CCAC and OP Rehab Services
22 Outflow – Central LHIN Residents who go Outside LHIN for TJR surgery Data Source: CIHI DAD – TJR includes primary, unilateral ,elective hip/knee replacementsOver 1000 patients per year that live in the Central LHIN get their TJR procedure at a hospital outside the Central LHINInflow/Outflow almost balance – net zero effect
23 % of Patients Discharged Home by LHIN Useful to look at this in tandem with Adm FIM scores and Adm Age (NRS dataset); Note that balances to ortho scorecardData Source: CIHI DAD – TJR includes primary, unilateral ,elective hip/knee replacements. Includes patients discharged home with or without services as per Orthopaedic Scorecard /HSAA definition
24 IP Rehab - TJR Average Admission Age by LHIN Data Source: CIHI NRS, 2010/11
25 IP Rehab - TJR Median Admission FIM by LHIN To support recommendation that 90% are able to be sent home with support (% with FIM score >90) – what is the best practice research on this?Data Source: CIHI NRS, 2010/11
26 IP Rehab – Hip Fracture Avg Admission Age by LHIN (2010/11) Data Source: CIHI NRS, 2010/11
27 IP Rehab–Hip Fracture Median Admission FIM by LHIN Data Source: CIHI NRS, 2010/11
28 Results of Orthopaedic Stakeholder Engagement – ALC Rehab Symposium on Orthopaedic Care
29 Stakeholder Engagement Sessions Two Symposiums:Physician Stakeholder Session – April 24thRaise awareness amongst physicians of provincial effortsDiscuss impact of provincial initiatives on care planningProvide an opportunity for physicians to render their input to how to implement the proposed changesAdministrative Stakeholder Session – April 25thRaise awareness of provincial effortsProvide an opportunity to hear about other LHIN-based effortsDiscuss potential impact of MOHLTC funding reformProvide an opportunity for input on how to implement the proposed changes
30 RecommendationsSeries of recommendations arising out of stakeholder engagement sessions and steering committee deliberationsKey Areas:System right-sizingStandardized Care PlansPatient FlowLocation of OP RehabCommunicationFunding Reform
31 System Right-sizing Primary, Unilateral Hip & Knee Replacements In accordance with Ontario Bone & Joint Network best-practice guidelines and MOHLTC/Orthopedic Scorecard performance targets for orthopaedic care, the acute care system will reduce its reliance on inpatient rehabilitation for TJR patients, and move towards a 90% (+ 9) rate for discharge home (with appropriate supports)Therapy for the 90% discharged home will include a combination of in-home CCAC services, hospital, community based outpatient services (details on patient care guidelines to follow)In addition, a target ALOS of 4.4 days will be implemented for this patient populationHip FracturesChanges in management of TJRs will provide earlier access to inpatient rehabilitation for Hip Fracture patientsIncreased use of inpatient rehabilitation for Hip Fracture patients, in accordance with best practice guidelines and standardized care pathways (to be developed)These changes combined should create additional IP Rehab capacity for stroke patients (CLHIN Phase Two report on Stroke to be released in Fall 2012)A Rehab Capacity and Sizing Working Group will be established to consider the implications for the siting of MSK and Stroke services within the Central LHIN.
32 Standardized Care Pathway Need to develop standardized care pathways that can be used consistently across all CLHIN Hospitals in management of TJRs and Hip FracturesLack of existing documentation in current system is creating variation in care management of these patientsNeed to build on existing best practice guidelines and care pathways developed in other LHINs i.e. TC LHIN toolkitPathway should include guidelines for home-based and/or hospital-based/other OP physiotherapyStandardization of processes is required and clear targets need to be established throughout episode of care. For example, what should we expect with regards to patient outcomes at day 1, day 2, etc…Messaging needs to be multi-lingualStandardized pathways for TKR should include post-surgical guidelines for flexion and extension. For example,If flexion does not reach 90 degrees within 4 weeks post surgery surgeons should be notifiedflexion of degrees at the end of the therapyfull extension of the knee prior to being discharged from therapy
33 Standardized Care Pathway (cont.) Care pathways need to delineate clear decision-making criteria for pathway algorithmsFor example, factors such as patient age, weight-bearing status, cognitive impairment, and other co-morbidities need to be factored into creation of pathway algorithmsStandardized way of triaging patients based on early and timely access to rehabShould involve other members of clinical team in application of discharge criteriaCreation of implementation plan to ensure pathway adoption and necessary allocation/re-allocation of resources, where necessaryResources may need to be re-allocated both within organizations and system-wide to meet pathway care requirementsAugmentation of OP physiotherapy/rehab will be required to ensure timely access to post-acute careImpact on rehab skill mix also needs to be considered as more TJRs are referred to OP settings
34 Patient FlowNeed to improve timeliness of rehab referrals and response timesALC Rehab survey results showed that significant variation exists in wait times by facility (for both wait 1 and wait 2)70% of Patients are referred to an IP Rehab facility within 3 days of being designated as ALC80% of Patients had referral response times of 2 days or lessWeekend resources may need to be augmented to ensure timely referrals and improve overall patient flow effectively to establish 7 day a week business processesRelatively efficient in overall management of ALC days for wait one and wait two (majority are short stay discharges)Findings suggest that while rehab does account for substantial number of ALC cases, they are not the long stay ALC patientsStrong support for ensuring adherence to GTA Rehab Network protocols on referral to sub-acute systemDifferent standards are being applied on acceptance of referrals; even under RMR sub-acute facilities are asking for additional informationInconsistencies and lack of standardization in application processSome facilities have noted that it takes anywhere between min per patient to issue out referral
35 Patient Flow (cont.)CCAC requirements for “medically stable” patient needs to be re-visitedMessaging that patient has to be identified as ALC before CCAC RAI-HC assessment can be undertaken is not correctCCAC requirements state patient must be “medically stable” before assessments can be doneHowever, this does not facilitate efficient patient flow because patients often end up waiting (post ALC designation) for assessment to be completedNeed to investigate feasibility of implementing parallel processes so that assessments can be undertaken earlier in acute care episode to allow for effective discharge planningRMR electronic referral must include TCLHIN rehab facilities and CLHIN acute hospital based rehabilitation unitsCurrent system doesn’t necessarily ensure timely and transparent access to patients awaiting placement in IP RehabHospitals with designated rehab beds/units often give preferential access to their patientsEnabling electronic referral to any rehab bed within the CLHIN system would create a level-playing field and ensure access to the “right bed at the right time”At a minimum, standardized response times should be set for responses to referral requests and compliance to response time targets should be monitored
36 Location of OP RehabLocation of OP Rehab should leverage existing capacity and ensure equitable access across Central LHINTCLHIN report recommends using hospital based OP physio clinics to maximize cost –efficiency and facilitate standardized approach to rehab careHowever, CLHIN geography is different; key principle needs to be geographical equityCLHIN may not be able to locate OP rehab exclusively at Hospital sites due to rural geography, but also need to consider issues of critical mass in more rural areas; need to strike a balance between patient travel times and critical mass and possibly leverage home-based physio in more rural areas of CLHINIs it a possible for CCAC to have congregate care type clinics in more rural settings? can LHIN contract services from private clinics?Parking discounts at hospital-based settings is a fundamental requirement to equitable accessInvestigate access to care in evenings and weekends; clinic access should not just be Monday to Friday, but also on weekends and evenings – want to encourage people to get back to workOptimize LTC facilities for those patients who came from LTC
37 Location of OP Rehab (cont.) Irrespective of OP Rehab setting, there needs to be standardized outcome measures collected at standardized times and LT follow- up is encouragedNeed to ensure that appropriate communication processes are set up with surgeonConsider creation of accredited OP rehab care providers/facilities which are appropriately trained on care pathway and required physiotherapy regimenFacility/providers should not be paid until outcome measures are achievedStrengthen relationship outside of traditional rehab model –relationship to active facilities i.e. fitness centres? Community centres?
38 CommunicationConsistent strategy and messaging required to manage patient expectations regarding access to IP rehab post-surgeryno legislative requirement for patient to identify 3 choices for placement in IP rehab – only applies to LTC home placementNeed for consistent patient education strategy and information pamphlets and/or letters identifying OP rehab options and locations of OP physiotherapy clinics (within and outside of the hospital settingNeed for strong relationship between care provider and surgeons post- dischargeConsider establishment of clinic days where OP physio care providers and surgeon meet to discuss patient progress and treatment plansStrong recommendation for IT communication enablers between CCAC, Surgeon’s offices, and hospital
39 Funding ReformNeed for further clarity on MOHLTC Funding Reform and impact of newly proposed Quality Based Procedure funding on the delivery of orthopaedic care in Central LHINGeneral belief that new funding model will create less variation and more standardized pathways and perhaps even Increase qualityFocus on outcomes will become paramountConcern regarding double dipping (private funding under insurance plans for some patients vs. MOH public funding; Private funding options should be exhausted first prior to use of public fundsImpact of new funding model on hospitals and physicians not clearly understoodWill new funding model lead to creation of centres of excellence in certain procedures?What impact will funding model have on use of Ortho implants? Hospitals may want to consider developing tighter protocols for when certain high-cost implants are usedHospital Decision Support, Health Records and IT resources will be key to measuring hospital performance in new era of fundingWill we be re-distributing OR time depending on physician efficiency? Re-allocation of blocks due to funding mechanism, volume, quality, etc…?
40 Next Steps…Communicate and obtain feedback on draft Phase One report to CLHIN system leadership and symposium attendeesFinalize Phase One reportEstablish necessary working groups (revise workplan, as necessary) and focus on Implementation of recommendationsCapacity & Sizing Working GroupPathway & Flow Working GroupProceed into Phase Two review of Stroke services within CLHIN