1. Samir K. Sinha MD, DPhil, FRCPC Director of Geriatrics Mount Sinai and the University Health Network Hospitals Virtual Ward Rounds 15 February 2011 A Practical and Evidence-Based Approach to Reduce Potentially Avoidable Hospitalizations of Nursing Home Residents

2. None related to the contents of this presentation. Disclosures

3. Presentation Objectives Demonstrate how current paradigms for providing acute care for nursing home residents are problematic. Introduce three evidence-based care models that deliver better patient and system outcomes. Identify some practical tools that can help you transform the care you deliver.

4. Does this sound familiar? Margaret is 86F NH resident. She has a host of chronic medical problems and a moderate degree of dementia. Her nurse becomes concerned one afternoon that she is more confused, and is not eating or drinking as usual. She is found to have a spreading erythematous area on her right foot. The nurse consults with the off-site doctor over the phone on how best to proceed and…

5. Why Our Current System fails Residents

6. Our Current System 1. Limited LTC options & resources push ‘911’ calls for transfer to ED

7. Our Current System 2. Travel to hospital causes Resident Anxiety and can be an Inefficient use of EMS resources.

8. Our Current System 3. Long ED Waits create added health risks and increase a resident’s chance of admission.

9. Our Current System 4. The potential risks of Hospital Stays should not be underestimated.

10. Our Current System 5. Discharge Planning can be particularly Complex.

11. Our Current System 6. The return home requires Resources and can again produce added Anxiety.

12. Our Current System 7. Potential Gaps in Communication around care needs can complicate transitions and thus…

13. Our Current Reality Hospitalization of nursing home residents can cause discomfort for residents, morbidity due to iatrogenic events, and excess healthcare costs. At least 25% of hospital visits/admissions are for ambulatory-care sensitive diagnoses. (Grabowski et al, 2007; Walker et al, 2009; Gruneir, In Press) Reducing potentially avoidable hospitalizations presents a significant opportunity to improve care and reduce healthcare costs.

14. Finding better Approaches

15. What Defines Better Care? 1. On-Site or Phone Assessments and Care provided within Nursing Homes.

16. What Defines Better Care? 2. ED Transfers averted or facilitated when required

17. What Defines Better Care? 3. Enhanced Caregiver Capacity, Knowledge and Interprofessional Communication

18. The Mobile Long-Term Care Emergency Nursing Program Toronto Investigators: Annabelle Bandurchin, MHSc, Project Manager Mary Jane McNally, RN, MN, Director of Nursing, TWH Mary Ferguson-Paré, RN, PhD, Chief Nursing Executive, UHN Samir K. Sinha, MD, DPhil, FRCPC, Director of Geriatrics MSH/UHN

19. Program Objective To determine whether a Mobile Emergency Nursing Program in Toronto, Canada could reduce avoidable transfers of NH residents to Acute Care Hospitals.

20. Program Structure 3 RNs (2.5 FTE) and 1 NP (1.0 FTE), based out of the ED of an urban teaching hospital. Available for consultation 09:00 – 21:00 Daily. Medical Supervision provided by NH Physicians. 17 Partnering NHs (3313 Residents) joined pilot between October 1, 2008 to October 1, 2009. 500K Pilot Grant - Nursing Secretariat, Ontario.

21. Program Structure PREVENTION Proactive Rounds to build NH Staff Capacity AVOIDANCE NH Staff contact Mobile RNs for telephone mediated assessment and coaching and/or on-site visit to help manage acute conditions. RAPID ED ENGAGEMENT Enables rapid transfer, intervention and discharge. FOLLOW-UP Active Consults and Discharges within 48Hrs.

22. Program Structure PREVENTION Proactive Rounds to build NH Staff Capacity AVOIDANCE NH Staff contact Mobile RNs for telephone mediated assessment and coaching and/or on-site visit to help manage acute conditions. RAPID ED ENGAGEMENT Enables rapid transfer, intervention and discharge. FOLLOW-UP Active Consults and Discharges within 48Hrs.

23. Pilot Program Outcomes 497 required acute care (or 911) 388 averted ED & received acute care at NH 109 sent to the ED 78% success rate October 1, 2008 to October 1, 2009 35% decrease in ‘Non-Urgent’, ‘Less Urgent’, and ‘Urgent’ unscheduled Ambulance Transfers. 617 Consultations 120 did not require acute care

24. 5 Most Common Consultation Requests* HYDRATION CONCERNS PAIN MANAGEMENT DYSPNEA INFECTION ENTERAL FEEDING TUBE PROBLEMS * 70% of total requests

25. Conclusions/Implications This i s a cost-effective model that delivers acute care in NHs and prevents ED visits. It is unique in its focus on peer-to-peer consultation and cross-sector partnerships. It has been effective at building the capacity and morale of Nursing Home RNs. This model has now been expanded to cover all NHs in Central Toronto and funded by the Toronto Central LHIN.

26. Lessons Learned

27. Much of what has been proven to work really comes down to applied common sense. The Mobile LTC Emergency Nursing Model demonstrates how a needs-based resourcing service delivery model can still deliver significant benefits. The success of each of this model requires individuals to champion implementations and sustain momentum.

28. Questions? Samir K. Sinha MD, DPhil, FRCPC Director of Geriatrics Mount Sinai and the University Health Network Hospitals 416-586-4800 x7859 ssinha@mtsinai.on.ca