1. Patient Flow – Long Term Care Barriers & Opportunities Lori Lamont, Executive Director PCH Program Long Term Care Association of Manitoba October 8, 2008

2. What you will learn? Long Term Care continuum Client/resident profiles Barriers and opportunities Using Resident data to inform change

3. Long Term Care Strategy 2006 – Manitoba Health approval of the WRHA Long Term Care Strategy and Provincial announcement regarding the Aging in Place Policy Long Term Care Strategy is a 5 Year Business Plan that: Creates affordable community living with support options Improves quality of PCH environments (reduce multi- bedded spaces) Supports the Aging in Place policy

4. The Case for Change Too many multi-bedded spaces personal care home spaces (about 30 % of Winnipeg’s PCH capacity) Causes multiple moves for seniors Family / Resident preferences Infection control issues Patient Safety: Resident to Resident aggression issues Need to increase the range of options About 30 % of individuals paneled in Hospital and 50% paneled in community are level 2s – there may be other options for some of these individuals Manitoba has the highest rate of institutionalization (people age 75+ in 24 nursing home facilities ) and the most comprehensive Home Care Program in Canada

5. Supply and Demand

6. WRHA Projected Population Aged 75 and Older 1.2 % of Pop. >75 Admitted to Nursing Home

7. WRHA Projected Population Aged 85 and Older 4.3 % of Pop. >85 Admitted to Nursing Home

8. Enhanced Supportive Living Continuum Support Services to Seniors Home Care Independent Living Supports to Seniors in Group Living Expanded Supportive Housing Specialized Supports Personal Care Home

9. Supports for Seniors in Group Living Enhanced support services provided to individuals living in existing community congregate settings. Services will depend on identified needs Target population: Seniors who do not require 24 hour support and supervision. Cost: Resident is responsible for rent

10. Supportive Housing Housing with supports based on eligibility criteria Target Population: Individuals who require 24 hour support and supervision and additional supports in order to live in a group, congregate setting Cost: Resident is responsible for rent and service package and WRHA funds care component (per diem funding) and professional home care services

11. Specialized Supports Provision of enhanced specialized supports in specifically designated locations or through funding of individualized service plans. Target Population: Individuals with complex health and personal care needs requiring special supports to live in the community. Cost: Resident pays for rent and service package. WRHA funds the care component.

12. Personal Care Homes Who are we and what is our future?

13. Who are we? Beacon Hill LodgeBethania Mennonite PCHCalvary PlaceCharleswood Care Centre Concordia PlaceConvalescent HomeDeer Lodge CentreDonwood Manor Fred Douglas LodgeFoyer ValadeGolden Door Geriatric CentreGolden Links Lodge Golden West Centennial LodgeHeritage LodgeHoly Family HomeKildonan PCH Lions Manor Personal Care Centre Luther HomeMaples PCHMeadowood Manor Middlechurch HomeMisercordia Health Centre Oakview PlacePark Manor Parkview PlacePembina PlacePoseidon Care CentreRiver East Riverview Health CentreRiver Park GardensSt. Amant CentreSt. Joseph’s Residence St. NorbertSaul & Claribel Simkin Centre Taché CentreTuxedo Villa Vista Park LodgeWest Park Manor

14. Regional Program Team Executive Director Pharmacy Manager 2 Clinical Nurse Specialist Program Educator Infection Prevention and Control Manager RAI Coordinator Safety Coordinator (shared with DLC)

15. Regional Services Speech Language Pathology Respiratory Therapy Clinical Nutrition Quality Improvement Community Therapy Services

16. Who do we work with – System Partners Geriatric Mental Health Acute Care – Emergency Program Palliative Care Home Care – Access and IV Therapy Community groups

17. PCH Services PCH Standards & Regulations 24 hour nursing Personal care Physician services Medication Basic supplies Recreation Limited rehab service Accommodation services Gov’t Regulation 26 Standards Reviewed q2years Licensed annually PPCO Critical Incidents Complaints Unscheduled reviews

18. Who lives in PCH Male = 27.9% Female = 72.1

19. Diagnosis

20. Physical Functioning: ADL Self-Performance Hierarchy Scale Centre on Aging Study

21. Continence Centre on Aging Study

22. Cognition: Cognitive Performance Scale Centre on Aging Study

23. Dementia 12.5 % are cognitively intact 25.8 % have mild cognitive impairment 33.8 % are moderately impaired 27.9 % are severely impaired

24. Behaviours by Care Setting Centre on Aging Study

25. Aggressive Behaviour Scale – PCH Residents Centre on Aging Study

26. Challenging Behaviours 34% of Residents have some aggressive behaviors in PCH What to do when this aggression creates high risk to other residents and staff?

27. Case Example - Lori 45 year old woman with acquired brain injury Physically, verbally and sexually aggressive behaviours PCH to PCH to Behavior Treatment Unit to St. Amant Took over 5 years to find the right spot

28. Case Example - Joe 72 year old with mild dementia, history of ETOH, and anti-social behavior Unpredictable physical aggression toward staff and other residents Trips to ER following aggressive incidents Geriatric psychiatry, Service Coordination involved 24 hour security guard for nearly 2 years Possible transfer to Selkirk Mental Health Centre Died suddenly at PCH

29. Challenges to flow – Hospital Use Overnight Hospital Admissions in Last 90 Days None = 92.8 1 = 6.6 2+ = 0.6 ER Visits in the Last 90 Days 5.5% of residents

30. Long Waiting Lists 107 people waiting in hospitals 294 people waiting at home No significant change in wait list for past 18 months

31. Wait List Management Wait list based on panel date – fair and equitable process? How to match residents with behaviours to sites that may have capacity to manage? How to balance case-mix within PCH with system needs?

32. Private DwellingSupported Living RAI-HC Indicator Live AloneWith Spouse With OthersAssisted Living Supportive Housing Age Age 75+ Gender Female Education < Grade 8< High schoolHigh school ADL Decline Any Bladder Incontinence Any IADL Great difficulty Cognition Any decline Behaviour Problem present Caregiver Distress Any present MAPLe Mild score + Moderate +High + Factors Associated with Move to PCH Centre on Aging Study

33. System Initiatives Move of Long Term Care Access Centre to PCH Program Use of RAI-HC measures in panel Why are “independent” people in PCH Address Care Giver Burden in community

34. PCH New Initiatives Nurse Practitioner in PCH Early results show decreased acute care and ER use Reduced medication use PIECES Education Education and a tool kit for front-line professionals to assess and manage challenging behaviours

35. Staffing Manitoba Health increased staffing to 3.6 hours per resident day Standardize staff model and mix across all sites Highest staffing levels in the country Implemented over next 3 years Increases coming to Allied Health staffing

36. Long Term Care Strategy Ensure people are placed in most appropriate alternative Create more private PCH accommodation Specialized options for some complex cases

37. Questions