March 29
th
, 2012
Complex Continuing Care &
Rehabilitation
Final Report Executive Summary
South West
LHIN
Table of Contents
0.
Preliminaries
1.
Executive Summary
1.1
Project Overview
1.2
Current State Findings
1.3
Future State
1.4
Expanded Role of the CCAC
& Processes
1.5
Recommendations
1.6
Next Steps
2.
Detailed Recommendations
3.
Data Analysis & Hospital Profiles
4.
CCAC Role & Processes
5.
Secondary Research & Sources
South West
LHIN
0. Preliminaries
Sources
Acknowledgements
Thank You!
The effort of the following individuals was invaluable to the creation of this report
Dr. Keith Sequeira, St. Joseph’s Health Care London – Parkwood
Elaine Burns, Grey Bruce Health Services
Mary Cardinal, Huron Perth Health Alliance
Brenda Lambert, St. Thomas Elgin General Hospital
Donna Ladouceur, Co-Sponsor – South West CCAC
Elaine Gibson, Co-Sponsor – St. Joseph’s Health Care London – Parkwood Hospital
Susan Warner, Project Lead – South West LHIN
Sue McCutcheon, Lead – Access to Care
Mary-Lynn Priestap, Co-Lead–SW CCAC
Sherry Frizzell, Co-Lead–St. Joseph’s Health Care London
Arminda Dumpierrez, OPTIMUS | SBR
Nas Farzan, OPTIMUS | SBR
Wendy Abbas, Woodstock General Hospital
Lana Dunlop, SW CCAC
Dr. Peter Hodes, Physician
Terri Guzyk, McCormick Home
Brian Ashby, SW LHIN
Andria Appeldoorn, Access to Care
Steering Committee Members
Working Group Members
©2012 All rights reserved
Acknowledgements
5
This report could not have been completed without the valuable contribution of
representatives from the following Hospitals:
Thank You!
St. Thomas Elgin General Hospital
Woodstock General Hospital
Stratford General Hospital (HPHA)
St. Marys General Hospital (HPHA)
Seaforth Community Hospital (HPHA)
Clinton Public Hospital (HPHA)
Listowel Memorial Hospital
London Health Sciences Centre
St. Joseph’s Health Care, London – Parkwood
Strathroy General Hospital
Alexandra Hospital
South Huron Hospital
Owen Sound General Hospital (GBHS)
Chesley & District Memorial Hospital (SBGHC)
Tillsonburg Memorial Hospital
Wingham & District Hospital
Woodstock Private Hospital
Four Counties Health Services
1.
Project Overview
2.
Current State Findings
3.
Future State
4.
Expanded Role of the CCAC &
Processes
5.
Recommendations
6.
Next Steps
South West
LHIN
Table of Contents
Executive Summary
Project Overview
Project Rationale
Alternative Level of Care (ALC) pressures have been long recognized as a symptom or
consequence of health systems inadequately aligned with the needs of an aging and
complex population.
Access to Care can reduce the demand for Long Term Care (LTC) and facilitate clients
receiving the right care in the right place at the right time.
The Complex Continuing Care and Rehabilitation initiative is one of three initiatives
from Access to Care in the South West LHIN:
Home First will promote a cultural shift towards proactive discharge planning
with home as the primary discharge destination
Realign Assisted Living/Supportive Housing/Adult Day Programs (AL/SH/ADP)
community capacity and implement the CCAC expanded role to facilitate single
point access to these services
Realign Complex Continuing Care and Rehabilitation bed capacity in hospitals
and implement the CCAC expanded role to facilitate single point access to these
services
ALC
ATC
Project Overview
Greater understanding of current CCC and Rehabilitation bed distribution and
utilization across the South West LHIN
Recommendations that support bed realignment and the CCAC as a single point
of access including common eligibility criteria
Clearer perspective on the current processes on the admission of CCC and
Rehabilitation patients to hospitals
Stakeholder engagement and change management strategy recommendations to
drive success in the implementation phase
Project Mission
Project Success (Outcomes)
Improve Access to Care by ensuring health care delivery in the right place at the
right time
Recommend new processes for the expanded role of the CCAC in coordinating
access to CCC and Rehabilitation beds
Timely access, high and consistent utilization of CCC and Rehabilitation beds,
and increased discharges to the community
Fifteen (15) Interviews Completed at hospitals in South West LHIN that have permanently funded CCC and/or Rehab Beds.
Secondary Research examining current state at other LHINs and Provinces.
Input Types:
• Physician involvement in admissions process
• Perceptions concerning how patients can be discharged sooner
• Staff understanding of major differences between CCC/Rehab and LTC eligible patients
• Presence of repatriation process & eligibility criteria
Qualitative
Inputs
Quantitative
Inputs
ALC Usage of CCC and Rehab Bed Data from Cancer Care Ontario.
One-day Snapshot Data from thirteen (13) hospitals for proxy and weighting purposes where ALC data unavailable.
Input Types:
• # of CCC and Rehab Beds
• Total CCC/Rehab Patient Days
• % ALC Utilization of CCC & Rehab
• Average Length of Stay
• Patient Type
• Referral Source
• Discharge Venue
Project Overview
Current & Future
State Assessment
The following mix of inputs were used to derive the Current and Future State
Data Analysis
& Validation
Current State
Findings
There is a high degree of inconsistency in the approaches and processes across the LHIN
Current State Findings
Employee awareness of primary
challenges
Acknowledgement that collaboration
is needed
What’s Working Well
Lack of formalized definitions
Barriers to discharge
Expertise Gaps
Misplaced Expectations
Current Challenges
Loss of staff
Loss of autonomy
Potential duplication of effort
Concerns implementation
Goal uniformity
Greater creativity in discharge
planning
Seamless integration
Key Success Factors implementation
Current State Findings
Role of the CCAC
The CCAC currently plays a limited role in CCC & Rehab
Significant variability in the role of the CCAC
across the LHIN
Limited involvement in CCC and Rehab
admissions processes
Some involvement in CCC and Rehab discharge
processes
Current State Findings
Region CCC Beds Weighted CCC Utilization Rehab Beds Weighted Rehab Utilization North(Grey & Bruce)
0 - 16 84%
Central
(Huron & Perth)
76 68% 23 90%
South East
(Norfolk & Oxford)
63 43% 22 63%
South West
(Middlesex & Elgin)
45 47% 10 100%
London 82 81% 113 98%
Total 266 62.32% 184 91.89%
Rehabilitation beds, of which there are 184, are significantly better utilized
than CCC beds (266)
CCC & Rehab Beds by Region
Current State Findings
Region Hospital CCC Beds CCC Utilization Rehab Beds Rehab UtilizationNorth Owen Sound 0 - 16 84%
Central Listowel 25 68% 0 - Wingham 12 58% 5 80% St. Marys (HPHA) 5 70% 0 - Stratford (HPHA) 20 74% 14 95% South Huron 4 75% 4 75% Seaforth (HPHA) 10 71% 0 -
South East Woodstock 33 67% 22 63%
Alexandra 14 24% 0 -
Tillsonburg 16 8% 0 -
South West St. Thomas Elgin 45 47% 10 100%
London Parkwood 82 81% 113 98%
Total 266 62.32% 184 91.89%
Current State Findings
There appears to be over capacity in the South that could potentially be
redistributed to the North, which has no beds
Be
d Numb
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Ut
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CCC - Utilization & Beds by Region
0% 20% 40% 60% 80% 100% 0 20 40 60 80 100 London Central SE SW
CCC Bed Weighted Utilization Rate by Region – 2011
Current State Findings
The current utilization rate of Rehab beds in the South West LHIN
is on par with expectations
Rehab - Utilization & Beds by Region
Be
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Ut
ili
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0% 20% 40% 60% 80% 100% 120% 0 20 40 60 80 100 120London Central SE SW North
Rehab Bed Utilization Rates by Region – 2011
Current State Findings
High ALC-LTC use of CCC beds
Compromised access to care
1
Decision making hampered
2
Inconsistent standards & procedures
3
Limited visibility into/knowledge of number of beds and
ongoing bed utilization
Absence of formalized admissions and discharge criteria and
processes resulting in high inconsistencies across the LHIN
Key Takeaways
In the case of CCC, people are in the wrong beds 37%* of the time
Two critical components of the CCC/Rehab Initiative of the Future State
Future State
How many CCC & Rehab beds are needed in the South
West LHIN
Where to realign current beds based on optimal number
Bed Realignment
Expanded role of the CCAC as single point of access and
enhanced system navigator
New admission and discharge processes
Referral Tools & IT enablers
CCAC Expanded Role & Related Processes
Future State
Data as the main driver, perspectives as input
Appropriate utilization of resources
Accounting for a projected significant increase in demand
Geographic consolidation to leverage economies of scale and
caregiver expertise
Improving geographical distribution of resources
Aligning with the South West LHIN’s Blueprint Vision 2022
Considering regional priorities concerning minimizing additional
capital requirements or human resource needs
1
2
3
4
5
6
7
Guiding Principles
The foundations of our approach were the following:
Future State
The following model provided the basis for calculating the future number of beds
Removal of ALC Patient days from Total Patient Days. One-day Snapshot on February 21st to fill in data gaps.
Specific Utilization of CCC & Rehab beds in South West LHIN
1
Factoring in Demographic Shifts & RiskFactors
Adjusting for population growth and health risk factors.
2
Adjusting for Continued ALC Use of CCC & Rehab Beds Adjusting for continued use of beds by ALC Patients.3
Unmet Need Accounts for patients that are newly eligible, and/or now have improved access to resources.4
Overall Utilization Target Utilization Target accounts for variability in bed occupancy.5
System Change Reduction (CCC Only) Anticipated Reduction in demand for CCC beds on basis of improvements.6
Rational for not utilizing Baseline Approach (Population/Bed Ratios)
1.
Cannot deduce appropriate utilization of resources
2.
Absence of comparables renders benchmarking problematic
3.
Baselining assumes homogeneity of populations
Future State
The following were the inputs into the Logic Model
Logic Model Inputs
CCC INPUTS 2013 2016 2021 Pop. Growth 5% 13% 30% Risk Factors 3% 5% 10% ALC Use* 25% 20% 15% System Change* 5% 7% 9% Unmet Need* 3% 1% 1% Utilization* 93% 93% 93% REHAB INPUTS 2013 2016 2021 Pop. Growth 5% 13% 30% Risk Factors 3% 5% 10% ALC Use* 5% 4% 3% Unmet Need* 3% 1% 1% Utilization* 87% 87% 87%
Inputs:
Population Growth
: Ministry of Finance
population projection figures, 2006-2021
Risk Factors
: From South West LHIN
Environment Scan. These encompass
lifestyle factors that may increase the
susceptibility of residents of this LHIN to
future healthcare system usage.
*Targets
set by CCC/Rehab Steering
Committee & Working Group members
based on Provincial targets and LHIN
research and comparators
CCC Bed Realignment Recommendations
Region
CCC Beds
Current
CCC Beds
Future
Rehab Beds
Current
Rehab Beds
Future
North
(Grey & Bruce)
0
10*
16
18
Central
(Huron & Perth)
76
73
23
28
South East
(Norfolk & Oxford)
63
38
22
19
South West
(Elgin & Middlesex)
45
30
10
12
London
(City of London)82
85
113
144
Total
266
236
184
221
By Region
The net impact of the realignment is a 7 bed increase to 457 total beds
CCC Bed Realignment Recommendations
CCC Bed Range*
2013
2016
2021
North - Minimum
37
38
41
North - Maximum
102
104
122
By Region
Bed recommendations in the North are based on forecasted population / bed ratios
In the absence of utilization data the number of CCC beds in the North was benchmarked against the range of population / bed ratios forecasted in the other 4 regions of the LHIN
25% of the goal by 2013 = 10 beds
50% of the goal by 2016 = 20 beds
100% of the goal by 2021 = 41 beds Based on available space and the impact on utilization at other hospitals we recommend
:
*The numbers above are driven by the higher proportion of ageing population in the North compared to the rest of the LHIN
The data shows that we could need 41 beds in the North by 2021.
Future State
Implication
If bed numbers are calculated only on
the basis of verifiable data (population
growth & lifestyle factors), the
number of beds required is
significantly less
Sensitivity Analysis
REHAB BEDS SENSITIVITY ANALYSIS % ALC & UTILIZATION PROJECTIONS
REGION CURRENT 2013 (0%) 2013 (100%) London 113 120 144 Central 23 22 28 South East 22 15 19 South West 10 11 12 North 16 15 18 TOTALS 184 183 221
CCC BEDS SENSITIVITY ANALYSIS
% ALC, SYSTEM CHANGE & UTILIZATION PROJECTIONS
REGION CURRENT 2013 (0%) 2013 (100%) London 82 71 85 Central 76 56 73 South East 63 28 38 South West 45 23 30 North 0 10 10 TOTALS 266 188 236 CCC INPUTS 2013 2016 2021 Pop. Growth 5% 13% 30% Risk Factors 3% 5% 10% ALC Use* 25% 20% 15% System Change* 5% 7% 9% Unmet Need* 3% 1% 1% Utilization* 93% 93% 93%
Logic Model Inputs
CCC Bed Geographic Distribution
Rehab Bed Geographical Distribution
Expanded Role of the
CCAC & Processes
Expanded Role of the CCAC
Guiding Principles
The Future State process must consider the following:
Future state cannot slow patient access to care
Evaluation outcomes related to implementation of process are clear
CCC and Rehab are active points of care, not final discharge destinations
Eligibility criteria will adequately reflect CCC and Rehab populations at each
site and is consistent across the LHIN
Beds are system resources that are to be utilized effectively and efficiently
across the LHIN
Expanded Role of the CCAC
What We Did
Based on the information gathered during the interview process and the newly
expanded role of CCAC, a future state process map was developed
(Appendix –
CCAC Role & Processes )
This future state aligned with the work of Resource Matching and Referral
(RM&R) and was shared with a various stakeholders from across the South West
LHIN and CCAC for feedback during a two-day Kaizen event and one-day
consensus session
Feedback obtained indicated that the interim and final electronic processes and
tools that will be implemented will not exclude the need for clinicians to
communicate from time to time
Expanded Role of the CCAC
Early Adopter
In the new Rehabilitation Unit that opened on March 1, 2012 testing of the
expanded role of the CCAC and related processes is underway
New eligibility criteria and referral for admission documents have been created
and are presently being tested
Referrals for WGH Complex Continuing Care and Rehabilitation services will be
facilitated by the South West CCAC
Determining which patients will be admitted to these beds will be a collaborative
decision between physicians, the clinical team and the CCAC Case Manager
Expanded Role of the CCAC
Future State
The CCAC as a single point of access will have increased responsibilities
for CCC & Rehab determining eligibility for admission
Providing applicants with information
Assess and determine eligibility for admission
Recommending appropriate admissions to CCC & Rehab
beds
Monitoring and managing waiting lists
Recommendations
*Proposed recommendations align with the strategic priorities reflected in South West LHIN Health System Design Blueprint Vision 2022
Recommendations
Overview
Bed transition & removals for increased utilization and geographic consolidationRecommendations are organized into 4 categories
CCC & Rehab Bed Realignment
1
CCAC Role & Processes
2
Governance & Redistribution
3
Stakeholder Engagement & Change Management
4
New roles, processes & tools for improved Access to Care
Governance & accountability mechanisms for implementationRecommendations
Recommendation Urgency
1. Proactively promote stakeholder awareness through communication explaining CCC and Rehab as different specialized programs and what the changes mean for each
stakeholder.
Immediate
2. Develop a detailed change management strategy that drives transformational change through a compelling vision, change team, tools, training and feedback loops.
Short term
3. Develop a comprehensive stakeholder engagement strategy that includes a communications and change management strategy and is overseen by the implementation Management Office (IMO).
Short term
4. Customize stakeholder engagement channels for different stakeholders including
physicians, clinicians, CCAC, LHIN, hospitals, the community and other health care system providers.
Short term
5. Leverage technology as a stakeholder engagement tool through podcasts, websites, intranets, webinars, video and social media depending on the objective.
Short term
6. Update Funding and Accountability agreements including physician incentives. Short term
Recommendations
Recommendation Urgency
1. Develop an Implementation Management Office (IMO) that includes governance, policy, methodology, tools, audits, hospital implementation champions and an ATC implementation Council.
Immediate
2. Develop a detailed systems level implementation plan that includes all three Access to Care initiatives to ensure the most efficient approach in addressing system
stakeholders and capacity.
Immediate
3. Implement a meaningful accountability mechanism that holds stakeholders accountable in implementing the agreed upon future state recommendations.
Short term
4. Develop a patient transition plan for each affected hospital site. Other service
providers across the care continuum will feel the effect, which renders a coordinated strategy crucial.
Short term
5. Develop detailed resource re-distribution plan for hospitals whose CCC/Rehab
programs are being affected. The implementation or dissolution of infrastructure and staffing resources must be coordinated and receive the same priority.
Short term
6. Implement ongoing data reporting and checkpoints so that key decision makers are able to continue to make process, program and bed evaluations and adjustments on an informed and timely basis, based on metrics.
Short term
Recommendations
Recommendation Urgency
1. Implement standardized definitions, criteria and processes governing the provision of CCC and Rehab services across the LHIN. Ensure stakeholder buy-in through training and education.
Immediate
2. Leverage the key role of the CCAC as a system navigator for clinical teams through early involvement in plan of care, family meetings, through adoption of Bullet Rounds, and waitlist management.
Immediate
3. Address the lack of community resources that support discharge, including supportive housing, mental health programs and services for other high-needs groups, through collaborative partnerships to understand system capacity and processes.
Immediate
4. Implement the interim IT integrated infrastructure necessary to roll out CCAC as a single point of access (while waiting for RM&R solution) including
e-notifications, eligibility and referral forms and other tools .
Immediate
5. Address ALC/LTC issues through potential alternatives in care such as restorative care units, convalescent units and/or long term care beds and review the process for accessing LTC beds regularly.
Short term
CCAC Expanded role and Future State Processes
CCAC Role & Process
Recommendations (
for SW LHIN Consideration)
Recommendation Resource Impact* Capacity
1. North - Add 10 beds to Owen Sound in a phased approach. Re-evaluate every six months for a two year period.
Low Required space exists
2. Central – Add 1 bed to Wingham; remove 1 bed from Listowel; remove 2 beds at South Huron and convert 2 to Rehab; and add 1 bed to HPHA. Wingham & Listowel changes due to capacity, South Huron due to lack of critical mass.
Minimal - Moderate
N/A
3. South East – Remove 14 from Alexandra; 16 from Tillsonburg; and add 5 to Woodstock - a new facility equipped with scale, expertise and experience acquired through CCAC Pilot Program.
Minimal N/A
4. South West – Remove 15 beds from St. Thomas Elgin due to low utilization and proximity to Parkwood.
Minimal N/A
5. London – Increase Parkwood by 3 beds due to expected increase in demand.
Low Required space exists
*Resources include all capital & human resource expenses
CCC Bed Realignment
CCC realignment improves use of resources and geographic distribution
Recommendations
(for SW LHIN consideration)
Recommendation Resource Impact* Capacity
1. North - Add 2 beds to Owen Sound due to utilization pressures. Low Required space exists
2. Central – Add 1 bed to Wingham; convert 2 CCC to Rehab beds at South Huron; add 2 bed to HPHA to alleviate capacity issues.
Minimal-Low Required space exists
3. South East – Remove 3 beds from Woodstock due to perceived under utilization.
Minimal N/A
4. South West – Add 2 beds to St. Thomas Elgin due to utilization pressures.
Medium Unknown
5. London – Add 31 total rehab beds (mix to be determined) to address capacity issues and leverage economies of scale in resourcing and clinical expertise.
High Required space exists
Rehab realignment increases resources on the basis of demand
Rehab Bed Realignment
Recommendations
1. Collateral impact on healthcare system of shifting ALC patients out
of CCC
2. Bed realignment may raise strategic questions concerning
sustainability and specialization of specific hospital sites
3. The net financial impact of implementing all Access to Care
initiatives
4. Addressing long term resource gaps through proactive engagement
and collaborative partnerships
5. With increased geographical proximity to underserved
communities achieved, consider cultural engagement strategies
Some of the other critical considerations include:
Other Considerations
System Impact
1
Hospital Impact
2
Financial Impact
3
Resource Strategy
4
Unmet Need
5
Recommendations Summary
Key Takeaways
The net result is a minimum 5% boost in demand between 2011 and 2013
against a minimal increase in bed requirements
A net increase of 7 (1.6%) to 457 total CCC & Rehab beds
CCC beds decreased from 266 to 236
Rehab beds increased from 184 to 221
Bed Realignment Initiative
1
CCAC Expanded Role & Process Improvement
2
Implementation Consideration Requirements
3
CCAC as system navigator and single point of access
Introduction of standardized processes, methodologies &
tools
Strong governance & accountability mechanisms
Use Stakeholder Engagement & Change Management to drive
transformational change
Implementation Approach
(for SW LHIN Consideration)
1. Establish an Implementation Management Office & Governance Structures
2. Develop a detailed ATC system implementation plan that includes all 3 ATC initiatives 3. Develop a detailed Implementation plan including bed transition plan
1. Bed Realignment
1. Implement CCAC Expanded Role on a phased approach after pilot feedback
2. Implement future state processes, tools and technology including interim IT solutions 3. Plan and implement stakeholder education and training for new processes and tools
2. CCAC Role & Processes
1. Develop a robust Communication Strategy
2. Develop a detailed Stakeholder Engagement & Change Management Strategy 3. Update Funding and Accountability Agreements
3. Stakeholder Engagement & Change Management
Implementation Roadmap - for LHIN Consideration
R ea lig nmen t & G ov er na nc e Project Close Project Management, Monitoring, and ControlProject Plan
Establish Implementation
Management Office (IMO)
CCA C R ole & Pr oces s
Implement Stakeholder Engagement & Change Management Plan
Approvals Bed Realignment Implementation
Phased Rollout of Expanded CCAC Role Plan
Implement Future State Processes, Tools & Technology
Developed Detailed Implementation Plan Stakeholder Engagement Strategy Change Management Strategy
Timetable
St ak eho ld er Eng ag emen tDiscussion
“The approach should be to design a system that fits the people,
not to fit the people into a system.”
- Anonymous South West LHIN Hospital CEO
2. Detailed
1.
CCC Beds by Region – Current & Future2.
Rehab Beds by Region – Current & Future3.
Considerations4.
Change Management5.
Stakeholder Engagement6.
Bed Transition Plan7.
Expanded Role of the CCAC8.
Future State Processes9.
IT Enablers10.
Communication11.
Processes12.
Community Resources13.
LHIN Vision AlignmentSouth West
LHIN
Table of Contents
CCC Beds by Region – Current & Future
Region Current 2013 2016 2021
North
(Grey & Bruce) 0 10 20 41
Central
(Huron & Perth) 76 73 74 84
South East
(Norfolk & Oxford) 63 38 39 44
South West
(Middlesex & Elgin) 45 30 31 35
London
(City of London) 82 85 87 98
TOTAL 26 236 245 280
The following are the suggested future state CCC bed numbers on the
basis of the analysis
Rehab Beds by Region – Current & Future
Region Current 2013 2016 2021
North
(Grey & Bruce) 16 18 19 23
Central
(Huron & Perth) 23 28 30 35
South East
(Norfolk & Oxford) 22 19 20 24
South West
(Middlesex & Elgin) 10 12 14 17
London
(City of London) 113 144 155 188
TOTAL 184 221 239 288
Recommendations
The following are the suggested future state Rehabilitation bed numbers
Considerations
Recommendations
Develop a detailed for plan LHIN consideration to execute transformation change in Complex Continuing Care and Rehabilitation across the South West LHIN in a timely and resource efficient manner
The desired future state for Complex Continuing Care and Rehabilitation will only become a reality through a strong implementation plan and process that encompasses all key milestones of the transformation and is driven by a strong project management framework such as a Project Management Office (PMO).
Apart from the best practices in implementation planning and project management in terms of scope, budget, time-line, project charter, detailed work plan etc. we recommend the following:
System Level Implementation should be at an overall Access to Care level , not based on individual initiatives due to the overlap between stakeholders and outcomes and the importance of implementation at a systems perspective.
The roll up of the three Access to Care initiatives will ensure that there are not duplicate or multiple requests / communications for key stakeholders.
Implementation success of the Complex Continuing Care and Rehabilitation is directly tied to the success of the Home First and Assisted Living / Supportive Housing / Adult Day Program to provide additional capacity to address ALC patients who will need to be removed from CCC / Rehab beds in the future state.
Recognizing that these recommendations will result in integration and that the LHIN integration process will need to be executed which may impact timelines, time should be built into the plan
Recommendations
Data Reporting & Check PointsA key component of the implementation should include formal checkpoints to review progress, outcomes and adjust the plan as needed. This includes adjustments to data reporting so that the changes made to the current state can be measured and understood on a timely basis.
Include all the related project metrics from the project charter
Implementation Governance Model
The implementation governance structure should be different from the planning phase due to the different requirements and outcomes including:
Develop a Implementation Management Office (IMO) Framework
Introduce IMO (similar to a PMO structure) needed tools and methodology
Develop IMO governance and policy development
The IMO becomes the owner of an integrated implementation plan that includes the change management and stakeholder engagement components
Institute implementation health checks and audits
Internal implementation Champions at each hospital site level to drive change and communicate with the IMO
Access to Care implementation Committee to review key decisions made up of senior players from the LHIN, CCAC and Hospital Promoting Adherence
Include processes to measure and address adherence issues accountability
Considerations
Change Management
Recommendations
Develop a detailed Change Management Strategy and Plan to drive transformation change in Complex Continuing Care and Rehabilitation across the South West LHIN
Realigning the Complex Continuing Care and Rehabilitation beds requires transformative change due to the large degree of changes related to approach, processes and locations. Change management is about more than just helping people manage the change, a strong change management strategy should include the following key components:
Develop a compelling vision for change
This vision should inspire stakeholders to change their behavior of how they approach Complex Continuing Care
and Rehabilitation and tied back to the Access to Care outcomes and aligned with the LHIN Blueprint Vision 2022
Develop key change messages for different stakeholders
The key messages should clearly outline the reasons for change and specific benefits for each stakeholder group
and the risks of not adopting the change
Change Management Key Success Factors
Rigorous process that outlines the specific steps needed to take the organizations from current state to future state
Driven internally by a skilled lead, working with a small group of change agents to ensure implementation of the
change management process
Recognition that change is a process and not an event
Awareness of where different individuals are on the change journey and flexibility in the process to account for differences
Change Management
Recommendations
Why Change Management Fails Narrow focus on results – change is a process and a journey
“Optional” change – it must be clear that that change is not an option to drive transformational change
Outsourced – key components of change management must be driven internally for sustainability
Lack of focus – change management success depends upon it being a sustained priority and focus Key Components of a Change Management Plan
Identify Change Management Lead and Change Advisory Committee or Board to drive process
Introduce change management concepts and identify risks & barriers to change
Develop change management toolkits and provide change management training
Facilitate change management workshops to help stakeholders address change
Tie change into accountabilities and outcomes
Implement feedback and issue resolution channels for ongoing engagement
Use surveys to gauge stakeholders’ positions pre and post change to also measure the success of the change management program
Provide one on one coaching sessions as needed for key stakeholders
Check with key stakeholders to ensure they understand new processes and roles
Provide opportunities for stakeholders to ‘debrief’ about the transformational change
Plan to manage and address different issues that surface throughout the journey
Facilitate process implementation sessions for new teams to establish the new way forward
Identify other stakeholders affected by the change--strategic partners, advisors, etc.
Stakeholder Engagement
Recommendations
Develop an inclusive, flexible and proactive Stakeholder Engagement Strategy across the South West LHIN at a systems level that includes the three Access to Care Initiatives
System Approach
Integrate the Change Management and Communications strategy as key components of the Stakeholder engagement strategy to ensure the consistency, timing and delivery methods of key messages.
The change management lead, communications lead and stakeholder engagement lead (could be the same person as the communications or change management lead) should work closely together under and be managed by the IMO
Customization & Delivery Channels
Each key stakeholder group should have their own customized engagement strategy including defining the appropriate delivery channels for engagement such as:
Physicians – engagement channels need to be flexible to minimize time requirements for physicians but maximize engagement for implementation - this could include multiple channels such as
podcasts/videos to communicate key engagement components and join existing physician events to drive further engagement
Clinicians – engagement needs to be at a tactical level related to changes in process and tools at a hospital site level as well as overall as a group to ensure consistency and address common questions and concerns that could be funneled into an online forum for example
CCAC – engagement delivery channel can be more formal due to roll out of the new CCAC role such as role clarity sessions including problem solving for expected barriers and how to manage these situations
Stakeholder Engagement
Recommendations
Customization & Delivery Channels ContinuedCommunity – multiple channels to engage key stakeholders in the community could be used to address different local community needs / requirements such as face to face town halls versus online
communication
Assisted Living / Supportive Housing / Adult Day Programs – a critical part of stakeholder engagement for the implementation of the CCC/Rehab future state which overlaps with the work being done in the AL / SH / ADP initiative
Technology
Use technology as a tool to engage stakeholders across geographies and to address busy schedules such as:
Podcasts that stakeholders can access when they have an opportunity to hear important messages in a more dynamic manner than written communications
A dedicated website for stakeholder questions, communication channels and interactive blog posts, forums, etc.
Webinars that can provide a more dynamic environment to communicate key messages
Online video campaigns that involve key stakeholders and can easily be forwarded, commented on etc. by other stakeholders
Bed Transition Plan
Recommendations
Develop a detail Bed Transition Plan to encompass the strategic, financial and tactical requirements and manage all potential risks once bed realignment numbers have been determined
Patient Transition
Some patients who do not fit the future state definitions of CCC and Rehab, and especially at hospital sites where beds will be transitioned out, will need to be assessed to determine the best care environment for them. The best options need to be weighed against where there is system capacity in their community such as supportive
housing. The Home First and AL/SH/ADP initiatives also underway under the Access to Care project charter will support patient transitions. For example.
A patient transition plan for each affected hospital site should be developed by the hospital with support from the CCAC and the LHIN to ensure an appropriate regional / systems perspective
Resource Adjustments
Changes to some programs will be needed as part of the bed realignment, this will have a direct impact on staffing. Depending on the increase / decrease of beds the specific changes will need to be detailed along with financial implications at the hospital level. These adjustments although necessary at a hospital site level will need to be reviewed from a systems perspective to ensure minimal financial impact and the appropriate movement of some resources possible between hospital sites.
Community Resources
In order to successfully implement bed realignment and transition additional community resources will be needed. The specific community resources will need to be consulted to confirm capacity, transition process etc. Updated Accountability Agreements
Expanded Role of the CCAC
Recommendations
Clinical teams must use the expertise of the CCAC Case Manager as a system
navigator to provide individualized assessments and match people with the
appropriate services
Involve CCAC early in care planning
The role of the CCAC Case Manager as a skilled communicator must be leveraged
during family meetings in which discharge plans are discussed and resources and
supports are assessed. They ought to facilitate families and patients in identifying
realistic goals related to discharge
Bullet Rounds/Inter-professional Rounds should be adopted by all organizations
across the South West LHIN
The capabilities of the CCAC Case Manager must be actively leveraged in order to
maximize impact
Future State Processes
Recommendations
Ensure consistency with definition, terminology, eligibility, priority of access to beds and
process:
Physicians, hospital and CCAC staff need to embrace a collaborative approach with this
process
Education must be developed that focuses on the new process, the use of the eligibility
and referral documents as well as the clinical specialties of CCC and Rehab
Right tools and right process need to be understood by everyone involved in the
process to ensure the right people are in the right beds
Regular reviews need to occur to ensure definitions, terminology, eligibility, priority of
access to beds and process are current and ‘workarounds’ are not being created
Interim IT Enablers
Recommendations
There is presently no electronic referral and matching system that meets the needs of this projectWe are aware that the RM&R initiative being developed will meet the needs of the CCC/Rehab initiative with the co leads and sponsors having had the opportunity to assist with the shaping of this work. A 2 day Kaizen event was held in Feb. with CCAC, hospitals and HealthTech, the RM&R consultant firm that is
coordinating this work and in March consensus day event was held that included LHINs 1, 2, 3, 4. However the RM&R system is at least 2 years away.
Because there is no system available, it has been identified that there are IT enablers that will be required to make the single point of access a success and to ensure we meet our guiding principles
To further complicate the decisions that need to be made, there is a partial solution for the CCC part of the project from the CCAC perspective, there will be module available within the CCAC data base which will be available after April 25.
This module will meet some of the needs for the CCC part of the initiative but there is nothing in the foreseeable future for Rehab. CCAC has investigated and will start to use the CHRIS CCC module when it becomes available but as there is both training and business process work that will need to be done, it is not possible to implement the CHRIS CCC immediately.
IT Enablers
Recommendations
There is a need for an interim solution for IT enablers for both CCC and Rehab. KPMG is working on a
solution.
The recommendations below will be necessary for the single point of access to roll out across the
South West LHIN.
Recommendations for IT enablers
:
E-notification of referral, eligibility and referral form that will be housed in the system
Bed board management (matching) tracking tool that identifies services offered by facilities,
ability to access patient information online electronically, and send agreements
Electronic wait list that has the ability to access and update patient information from
Community/ CCAC/Rehab, receive notification, prepare information and discharge client transfer
client to rehab, and send agreements
Communications
Recommendations
Communication/Stakeholder awareness:
CCC and Rehab are different specialized programs – communication must highlight
these differences
Communication must identify that CCC and Rehab are specialized programs that allow
patients/clients to receive appropriate level of care provided by an inter-professional
team who are knowledgeable and skilled regarding the care needs of this population. It
is a client-centred, goal driven program that enables clients to optimize their health
potential before moving to their final discharge destination
Specific communication needs to be targeted at physicians, clinicians and CCAC. There
must be a clear understanding of what these changes mean to the practice of each
individual team member
Specific communication needs to be created for the general public to enhance their
understanding that CCC and Rehab are specialized programs which are not offered in
every hospital. The public needs to know where these programs can be accessed. For
example, what organizations are able to provide these specialized programs?
Communication must identify role clarity and accountability between hospitals, CCAC
and other community health agencies – Who does what, by when in the process-
everyone needs to be aware
Processes
Recommendations Cont’d
Determine the services required to operate CCC and Rehab programs:
Determine best practices in CCC and Rehab programs
Ensure clinical practices align with best practices
Identify standard metrics related to patient/client outcomes
Identify a consistent standard of care for CCC and Rehab programs
Identify clinical competencies related to CCC and Rehab specialties
Ensure the programs take into account the cultural diversity of the community
Scope of Rehab Care varies - the following groups/levels were identified in the
interviews:
Slow progress / low capacity for functional improvement
Slow to moderate progress / low to moderate capacity for functional
improvement
Moderate to rapid progress / moderate to high capacity for functional
improvement
Rapid progress / high capacity for functional improvement
Community Resources
Recommendations Cont’d
Address the lack of community resources that support discharge:
It has been identified that the inconsistency of community resources across the South
West LHIN has posed a challenge to discharge planning
All 3 initiatives need to align during the implementation phases, there must be
thoughtful consideration about the way these initiatives impact each other
Awareness that ALC LTC is impacting the availability of CCC and Rehab beds:
Many patients/clients who are presently occupying CCC and Rehab beds are awaiting
LTC placement. As the Home First and Assisted Living/ Supportive Housing/ Adult Day
Programs (AL/SH/ADP) initiatives are implemented there will be a reduction in the
number of people who are eligible for LTC. There will also be a population deemed ALC
who would have been admitted to CCC or Rehab but now do not fit the new criteria for
CCC & Rehab
In keeping with creating hospital environments that accommodate the physical and
mental health needs of seniors, new alternatives in care must be considered. As beds
are realigned the opportunity exists for hospitals to consider adopting other types of
care: restorative care units and/or convalescent units or long term care beds
LHIN Vision Alignment
The recommendations align with the LHIN’s Vision for an Integrated Health
System of Care:
CCC/Rehab realignment recommendations align with the multi-community
integrated health system of care approach
Service delivery by geographic clustering of moderate volume / complexity
services focused on targeted populations
CCAC expanded role aligns with:
Implications of Recommendations
•
The recommendations proposed will impact the community, CCAC, hospitals,
physicians, clinicians and several different community support service agencies.
•
The realignment of beds poses a concern, particularly for those organizations and
communities that are losing CCC beds, as hospitals contribute to the viability of
the community.
•
Perceptions that the loss of beds will result in loss of staff, people will not have
access to CCC/Rehab services close to home
•
Community support agencies may need to consider an increase in patient numbers
and complexity.
Implications of Recommendations
•
Long Term Care Homes could see an increase in acuity and complexity of patients.
•
The expanded role of CCAC may be perceived as limiting access to CCC/Rehab
beds, duplicating work and prolonging the time it takes to access the beds.
•
With standardized eligibility criteria the potential exists that there will be patients
who may not fit either CCC/Rehab/LTC. This could result in extended stays or ALC
in acute care.
•
There may be a requirement for advanced clinical knowledge and skills be required
for CCC/Rehab and Long Term Care.
Implications of Recommendations
•
Hospitals may be required to care for patients in a way that reduces functional
decline
•
Processes that support pro-active discharge planning between CCAC and hospitals
must take place
•
CCAC to work with hospitals to assess adults and seniors with complex needs
within 48 hours of admission and prior to ALC designation
•
CCAC must understand the discharge options available to effectively assist patients
and their families
•
Engagement of mental health in-patient and out-patient programs must be
encouraged to support CCC/Rehab patients with mental health care needs
Evaluation Considerations
In collaboration, hospitals and CCAC are responsible to:
•
Continually monitor changes in processes and outcomes and take corrective
actions where necessary
o
Monitor accessibility to CCC/Rehab beds (CCC/Rehab appropriate patients
being able to access beds in a timely manner)
o
Monitor patient population accessing CCC/Rehab beds (right people in
the beds)
Detailed Next Steps
ATC CCC/Rehab and AL/SH/ADP Recommendations
Activity Purpose Decision Making Group
1. Review draft recommendations Ensure alignment with Project Sponsors Kelly Gillis, Sandra Coleman
Ensure support from Steering Committee CCC/Rehab Steering Committee CCC/Rehab Steering Committee
Ensure alignment with South West CEO Vision
South West CEO
Receive input from Core Operations Group ATC Core Operations Group 2. Update South West Health System
Leadership Council
Input to the process, implementation plan, stakeholder engagement
South West HSLC 3. Update South West LHIN Board of
Directors
Input from Board regarding alignment to priorities
South West LHIN Board of Directors
4. Update South West CCAC Board of Directors
Input from Board on the change from SW CCAC
South West CCAC Board of Directors
5. Finalize recommendations Receive endorsement of Steering Committee CCC/Rehab Steering Committee 6. Engage stakeholders in
implementation discussion
Receive input on recommendations and implementation
Hospital/CCAC CEO Group including CNE Group 7. Finalize recommendations and high
level implementation plan (including synergy between ATC initiatives)
Endorsement of recommendations/high level implementation plan
ATC Core Operations Group
Endorsement of recommendations/high level implementation plan
South West LHIN Health System Leadership Council
8. Approval of Recommendations and high level implementation plan
Decision required to move system change forward
South West LHIN Board of Directors
3. Data Analysis &
Hospital Profiles
1.
Methodology
2.
1 Day Snapshot
3.
Collected Data Overview
4.
CCC Admits by Hospital,
2008-2010
5.
Rehab Admits by Hospital,
2008-2010
6.
CCC – Utilization & Beds by Hospital
7.
Rehab – Utilization & Beds by Hospital
8.
CCC Bed Realignment Numbers
9.
Rehab Bed Realignment Numbers
10.
Hospital Profiles
11.
Rehabilitation Services
12.
System Change
South West
LHIN
Table of Contents
Seventeen (17) Interviews Completed at all hospitals in South West LHIN that have permanently funded CCC and/or Rehab Beds.
Secondary Research examining current state at other LHINs and Provinces.
Input Types:
• Physician involvement in admissions process
• Perceptions concerning how patients can be discharged sooner
• Staff understanding of major differences between CCC/Rehab and LTC eligible patients
• Presence of repatriation process & eligibility criteria
Qualitative
Inputs
Quantitative
Inputs
ALC Usage of CCC & Rehab Bed Data from Cancer Care Ontario.
One-day Snapshot Data from thirteen (13) hospitals for proxy and weighting purposes where ALC data unavailable.
Input Types:
• # of CCC & Rehab Beds
• Total CCC/Rehab Patient Days
• % ALC Utilization of CCC & Rehab
• Average Length of Stay
• Patient Type
• Referral Source
• Discharge Venue
Methodology
Current & Future
State Assessment
The following mix of inputs were used to derive the Current and Future State
Data Analysis
& Validation
Methodology
The following model provided the basis for calculating the future number of beds
Removal of ALC Patient days from Total Patient Days. One-day Snapshot on February 21st to fill in data gaps.
Specific Utilization of CCC & Rehab beds in South West LHIN
1
Factoring in Demographic Shifts & RiskFactors
Adjusting for population growth and health risk factors.
2
Adjusting for Continued ALC Use of CCC & Rehab Beds Adjusting for continued use of beds by ALC Patients.3
Unmet Need Accounts for patients that are newly eligible, and/or now have improved access to resources.4
Overall Utilization Target Utilization Target accounts for variability in bed occupancy.5
System Change Reduction (CCC Only) Anticipated Reduction in demand for CCC beds on basis of improvements.6
Rationale for not utilizing Baseline Approach (Population/Bed Ratios)
1.
Cannot deduce appropriate utilization of resources
2.
Absence of comparables renders benchmarking problematic
3.
Baselining assumes homogeneity of populations
Methodology
The following were the inputs into the Logic Model
Logic Model Inputs
CCC INPUTS 2013 2016 2021 Pop. Growth 5% 13% 30% Risk Factors 3% 5% 10% ALC Use* 25% 20% 15% System Change* 5% 7% 9% Unmet Need* 3% 1% 1% Utilization* 93% 93% 93% REHAB INPUTS 2013 2016 2021 Pop. Growth 5% 13% 30% Risk Factors 3% 5% 10% ALC Use* 5% 4% 3% Unmet Need* 3% 1% 1% Utilization* 87% 87% 87%
Inputs:
Population Growth
: Ministry of Finance
population projection figures, 2006-2021
Risk Factors
: From South West LHIN
Environment Scan. These encompass
lifestyle factors that may increase the
susceptibility of residents of this LHIN to
future healthcare system usage.
*Targets
set by CCC/Rehab Steering
Committee & Working Group members
based on Provincial targets and LHIN
research and comparators
Methodology
The impact of the projections are significant and cannot be overstated
Implication
If bed numbers are calculated only
on the basis of verifiable data
(population growth & lifestyle
factors), the number of beds required
is significantly less
Sensitivity Analysis
REHAB BEDS SENSITIVITY ANALYSIS % ALC & UTILIZATION PROJECTIONS
REGION CURRENT 2013 (0%) 2013 (100%) London 113 120 144 Central 23 22 28 South East 22 15 19 South West 10 11 12 North 16 15 18 TOTALS 184 183 221
CCC BEDS SENSITIVITY ANALYSIS
% ALC, SYSTEM CHANGE & UTILIZATION PROJECTIONS
REGION CURRENT 2013 (0%) 2013 (100%) London 82 71 85 Central 76 56 73 South East 63 28 38 South West 45 23 30 North 0 10 10 TOTALS 266 188 236 CCC INPUTS 2013 2016 2021 Pop. Growth 5% 13% 30% Risk Factors 3% 5% 10% ALC Use* 25% 20% 15% System Change* 5% 7% 9% Unmet Need* 3% 1% 1% Utilization* 93% 93% 93%
1 Day Snapshot
The Hospitals in the LHIN were asked to conduct a 1-day snapshot on Tuesday,
February 21
st, to provide bed utilization metrics as inputs into the bed realignment
Logic Model. The data served as a proxy for hospitals for which there was no data in
the CCO report
Collected Data Overview
Hospital
CCC
Rehab
ALC Data Snapshot Data
ALC Data Snapshot Data St. Joseph’s Parkwood St. Thomas Elgin Listowel Memorial
--
--
Alexandra (Ingersoll)--
--
Owen Sound (GBHS)--
--
St. Marys Memorial (HPHA)
--
--
Seaforth Community (HPHA)
--
--
Stratford General (HPHA)
Woodstock General
--
Tillsonburg District
--
--
South Huron
--
--
Wingham & District
--
--
CCC Admits by Hospital, 2008-2010
2% 4% 5% 1% 16% 5% 6% 3% 13% 13% 32%CCC Admins by Hospital - 2008-2010
South Huron Listowel Tillsonburg Wingham Stratford Alexandra Seaforth St. Marys Woodstock St. Thomas-Elgin ParkwoodAfter Parkwood, Stratford (Central), St. Thomas Elgin (SW) and Woodstock (SE) took in
the most CCC patients between 2008-2010
2% 2%
11%
14%
12% 60%
General Rehab Admits by Hospital - 2008-2010
South Huron Wingham Stratford Grey Bruce St. Thomas-Elgin Parkwood
Rehab Admits By Hospital, 2008-2010
In addition to accounting for 60% of all General Rehab intakes, Parkwood has the only
Specialized Rehab Beds in the entire LHIN
CCC – Utilization & Beds by Hospital
The weighted utilization rate of CCC beds for the South West LHIN is 62.32%
*.
For comparative purposes, the HNHB LHIN rate is 64.2%
0% 20% 40% 60% 80% 100% 0 20 40 60 80 100
CCC Bed Utilization Rate by Hospital – 2011
CCC Utilization
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Rehab – Utilization & Beds by Hospital
The weighted utilization rate of Rehabilitation beds for the South West LHIN is
91.89%*
0% 20% 40% 60% 80% 100% 120% 0 20 40 60 80 100 120Parkwood Wingham Stratford South Huron Woodstock St. Elgin-Thomas Owen Sound
Rehab Bed Utilization Rates by Hospital – 2011
Rehab Utilization
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Rehab – Utilization & Beds by Hospital
CCC Bed Realignment Numbers
Region Hospital Current Beds Future Beds +/-
North Owen Sound 0 10 +10
Central Listowel 25 24 -1
Wingham 12 13 +1
HPHA 35 36 +1
South Huron 4 0 -4
South East Woodstock 33 38 +5
Alexandra 14 0 -14
Tillsonburg 16 0 -16
South West St. Thomas Elgin 45 30 -15
London Parkwood 82 85 +3
Total 266 236 -30
Realignment facilitates a more equitable access to services
By Hospital/Organization
Rehab Bed Realignment Numbers
Region Hospital Current
Rehab Beds
Future Rehab Beds
+/-
North Owen Sound 16 18 +2
Central Wingham 5 6 +1
HPHA 14 16 +2
South Huron 4 6 +2
South East Woodstock 22 19 -3
South West St. Thomas Elgin 10 12 +2
London Parkwood 113 144 +31
Total 184 221 +37
Virtually all of the increase (37) in Rehab beds is accounted for by a
decrease (30) in CCC beds
St. Joseph’s Health Care,
London — Parkwood Hospital
Hospital Profiles
St. Joseph’s Health Care, London – Parkwood Hospital
STATISTICS & INFORMATION
Current CCC Beds 82
Future (2013) CCC Beds 85 Average Length of Stay (Days) 67.7
Change +3
Utilization Rate (ALC Data) 81% Existing Eligibility Criteria
