Integrated Continuing Care Nov 1, 2011 Home Again program

Home Again Continuing Care program that enables clients deemed ‘Alternate Level of Care’ (‘ALC’) to leave hospital and return home with home support services for up to 60 days, while they make a decision about their long term care. Home support services are enhanced beyond those of the provincial Regular Home Support.

The ‘Home First’ philosophy Home Again is one program guided by the Home First philosophy Goal is to give clients the opportunity to make the decision about their long term care in their home or community. To give people the opportunity to go home whenever possible. In hospital, ‘ALC’ to ‘LTC’ should be considered a last resort. That there should be community alternatives to meet their needs.

Why home is the best option Gives clients time for their health to stabilize BEFORE rushing into an important decision about long term care. Reduces the client’s risk of hospital-acquired illness. Allows client to wait for placement in a LTC facility of choice as opposed to accepting “first available bed.” Makes hospital and nursing home beds available to those who need them most. Cost of the Home Again program is equal to that which client would pay in the Regular Home Care program, which is lower than the ALC rate in hospital.

Home Again process Referral To Hospital Care Coordinator from acute care teams Home Again: ( up to 60 days ) ►Needs assessment ►Coordination of home support services ►Ongoing case management and evaluation Possible client outcomes ►Move to Regular Home Support ►Private/family home support ►No home support required at all ►LTC facility ‘first available bed’ ►Delay nursing home admission

Eligible client: Services: Hospital inpatient, medically stable & deemed ALC Has a home to return to Agrees to complete an application for LTC incl. financial assessment Can be classified for LTC placement Has capacity to direct care/has a Substitute Decision Maker Has Physician support in the community Agrees to participate in the program Intensive case management by a Capital Health Continuing Care Coordinator Home support services: up to 56 hours/week x 7 days/week, for a maximum of 60 days Home support services through established agencies VON Nursing services as required OT & PT community team assessment & follow up

No clients have gone immediately from Home Again to a LTC facility 30 clients in Home Again to date

21 clients completed Home Again 76% reduced to Regular Home Support (16/21 clients) 0.05% required no further Home Support (1/21 clients) 0.05% Deceased (1/21 clients) 0.05% home with private care (1/21 clients) 0.1% returned to hospital to wait for LTC (2/21 clients)

Why Home Again works 1. It minimizes the safety risk of going home thanks to quick response/speed of services. 2. Clients and their families (or informal supports) have access to a collaborative community team - Care Coordinator, OT & PT, rehab assistants, VON, and home support agency workers. 3. Clients get intensive case management. 4. Clients get increased hours of care (up to 56/week) over Regular Home Care support through use of established agencies with varied workers. 5. Clients get enhanced home support to meet their needs without task-specific timelines. 6. Clients are cared for by consistent home support agency workers.

Opportunities & Challenges Phone surveys indicate high degree of client and family satisfaction +ve data used to educate healthcare professionals, gain support from government, and expand program capacity for more clients. Serves as basis for Capital Health’s developing ALC strategy RFP to secure one home care agency. Change the perception amongst hospital teams that going home is riskier. Client and family’s reluctance to complete the Long Term Care application. Explore the idea of HA with client/family at an earlier stage in admission.

Subhead First paragraph Second paragraph of your text Home Again program phases ►6 month trial program ►Evaluate program ►Submit Business Plan Phase 1 Phase 3 Phase 2 ►Submit RFP for 1 Home Support agency ►Develop & deliver program with criteria, standards ►Communications: educate and inform key stakeholders ►Expansion of HA program across Capital district/ Sub Acute ►Community admission to divert emergency room admissions ►Consider Convalescent Care to reduce admissions to LTC