Patient Flow Pressures
Presentation to
Board of Directors
Hamilton Niagara Haldimand Brant Local Health Integration Network
December 11, 2013
Patient Flow (in this context)
• Refers to the movement of individuals from the community to acute inpatient hospital care and from acute to post-acute care or home.
• In the hospital setting, patient flow becomes an issue when it is impeded as a result of:
• A high number of individuals waiting in hospital for an alternate level of care (ALC) setting (e.g.
rehabilitation, long-term care (LTC), or home with community supports);
• Individuals experiencing long waits to access an ALC setting, or
• A combination of both.
Joan ALC Rehab
John ALC LTC
Mabel ALC Home with Support
F
ul
l W
ai
t H
er
e
Patient Flow ACTION Plan
• Between 2009 and 2012 a three year Patient Flow Action Plan was developed and implemented to achieve sustainable improvements in ALC.
• The ACTION plan developed under the leadership of the HNHB ALC Steering
Committee (ALC-SC) incorporated bundled and targeted initiatives.
• Central to these initiatives was an overall philosophy that individuals preferred to return home following a hospital admission (Home First philosophy).
• LHIN invested in the HNHB Community Care Access Centre (CCAC) allowing them to support individuals requiring higher
levels of care to return home from hospital.
0.0% 5.0% 10.0% 15.0% 20.0% 25.0%
HNHB LHIN Acute ALC Rate (Internally Monitored)
Source: Weekly Hospital ALC Trigger Report
Patient Flow – Reversing Trend
• April 2013 marked the start of an increasing trend in number of individuals waiting in hospital for an ALC. • From April 1, 2013 to November 10, 2013 the number of individuals waiting in hospital increased from 409 – 535*.
• The ALC rate increased from 12.9% in March 2013 to 15.9% in October (draft). 0.0% 5.0% 10.0% 15.0% 20.0% 25.0%
HNHB LHIN Acute ALC Rate (Internally Monitored)
Source: Weekly Hospital ALC Trigger Report
LHIN Analysis
•
LHIN Emergency Department (ED) admission rates
•
Population admitted through the ED – Comparison of
April 1 – June 30, 2012 (Q1) with April 1 – June 30, 2013 (Q1)
•
ALC destinations and hospital specific ALC pressures
•
Population discharged home with CCAC
•
LHIN Long-Term Care Home (LTCH) capacity
Key Findings – Admission Rates
• The HNHB LHIN reported the 3rd highest admission rate for
the population 75 years and older of all Ontario LHINs between April 1 – June 30, 2013
• Between April 1 – June 30, 2013*:
• 17,157 people were
admitted to LHIN hospitals through the ED, 870 more patients over the number admitted during the same interval in 2012.
• Hamilton hospitals
accounted for 72% of the increased admissions.
Population Admitted through the ED
102,110 380,953 733,410Fiscal Year 2012-13
From Registration/Triag e to Physician Initial Assessment From Physician Initial Assessment to Decision to admit 24,704 96,986 200,682Q1 2013-14
From Registration/Triage to Physician Initial Assessment From Physician Initial Assessment to Decision to admit From Decision to Admit to left EDSource: HNHB LHIN IDS.
• In 2012-13 people admitted though HNHB LHIN EDs spent over 1.2 million hours in
the ED, the majority of their time was spent
waiting for a bed.
• A review of data for April 1 – June 20, 2013 shows a similar trend.
• Comparing Q1 2012-13 to 2013-14 (April 1 – June 30)*:
• The age group demonstrating the greatest growth for ED admissions, were 64 years and older, with the
exception of Hamilton Health Sciences Corporation – Juravinski site.
• There was a 14% increase in the
number of admissions through the ED for the population 75 years and older on CCAC services.
7
ALC Destinations and Hospital Specific ALC
Pressures (
in October 2013
)
Five destinations with the highest
number of people waiting:
•
LTC (173)
•
Home with CCAC (89)
•
Complex Care (63)
•
Supervised or Assisted Living (36)
•
Rehabilitation (36)
Five destinations that have the
most ALC days:
•
LTC (18,796 days)
•
Supervised Assisted Living (8,526 days)
•
Home with CCAC (1,569 days)
•
Complex Care (765 days)
•
Rehabilitation (290 days)
Patient Flow Pressures -Combination Volumes and Days
A LC Ra te # of P e opl e W a it ing for a n A LC9 148 181 88 112 418 403 483 404 535 0 100 200 300 400 500 600 N u m b e r o f P a ti e n ts
HNHB Hospitals Active ALC Patient Numbers by Designation Total April 1 2012 - November 10 2013 Weekly (Sunday)
Long Term Care Supportive Assisted Living
Complex Continue Care
Rehab
Home with CCAC Total
Source: HNHB CCAC Active ALC Count Nov 10, 2013 Email Nov 14 2013
August 4 2013 17,018 10,461 18,796 8,526 28,972 23,470 33,832 0 5,000 10,000 15,000 20,000 25,000 30,000 35,000 40,000 A L C Da y s
HNHB LHIN Hospital ALC Days – All Bed Types Complex Continuing Care
Bed
Home - with CCAC Services
Long Term Care Bed (LTC)
Rehabilitation Bed
Supervised or Assisted Living
All ALC Discharge Destinations Source: WTS ALC Accessed November 2013
Population Discharged Home with CCAC
• Between April – August 2013 - 65% increase in the number of individuals discharged with home support greater than eight over the same period in 2012 (263 vs. 434).
• Of the 434 discharged home, 239 received level of care greater than 16 hours per day.
• Comparison of Q1 2013-14 with Q1 2012-13
three LHIN hospitals showed a reduction of 4,322 ALC days across all populations, of which 3,819 could be attributed to the population 75 years and older. At a LHIN level (all LHIN hospitals) there was a decrease of 3,224 ALC days*.
• The high number of people receiving more than eight hours of care when compared to other LHINs made the HNHB CCAC look inefficient and resulted in a funding reduction under the Health System Funding Reform methodology.
0 10 20 30 40 50 60 70 80 90 100 # o f R ef er ral s
CCAC Admissions from Hospital for > 8 hours
service
Source: HNHB CCAC October 2013
LHIN Long-Term Care Home (LTCH)
Capacity
• The HNHB LHIN has 86 LTCHs for a total of 10,477 beds (includes interim and short stay beds).
• The HNHB LHIN has the 5th highest rate of LTCH beds per 1,000 population 75 years
and older.
• In August 2013, the average length of stay (turnover rate) was 3.0 years, a reduction from 3.6 years reported in 2008*.
• HNHB LHIN, on average, has less than 30 idle LTCH beds per month, an idle bed refers to a vacant bed and there is no one on the wait list.
• As of September 2013, the HNHB CCAC LTCH long stay wait list reported:
• 1,822 individuals waiting in an HNHB LTCH bed for their admission into the LTCH of their choice.
• 2,463 discrete individuals on the wait list for admission to a LTCH bed within the HNHB LHIN. The location that these individuals are waiting is listed below
• Community - 1,575 • Hospital - 273
• Outside HNHB LHIN - 615
Source:* MOHLTC Health Data Branch, Health System Information & Investment Division LTCH Report August. 2013 ** HNHB CCAC November 2013
HNHB CCAC–Placement Waitlist Numbers by Waiting Location
LTCH Wait Lists and Individual’s Choice
• Individuals waiting to access a LTCH can be on up to five LTCH wait lists.
• For an example one person could be on five LTCH wait lists.
• Adding the number of people waiting by each
LTCH does not equal the number of people waiting for admission to a LTCH.
• An individual’s choice of LTCH can influence their wait time.
• In September 2013, Hamilton LTCHs reported wait lists ranging from ten to 526 people waiting. The LTCH reporting 526 people on the wait list was reported to admit on average five people per month from April – August 2013. Individuals waiting for this LTCH could wait years.
LTCH Examples # of People on LTCH List LTCH A 428 LTCH B 469 LTCH C 526 LTCH D 10 LTCH E 363 Total People Waiting for LTCH 1,796 13
HNHB LHIN LTCH Capacity by LHIN Area
LHIN Area Number of LTCHs
Number of Beds
Percent of LTCHs Beds that are “C”
Beds per 1,000 Population > 75 years Hamilton 28 3,931 28% (1,093) 97.6 Niagara 31 3,611 36% (1,332) 90.7* Burlington 0 1,218 18% (225) 84.2** Brant 8 890 44% (393) 90.4 Haldimand – Norfolk 9 797 45% (360) 104.8*** HNHB LHIN 86 10,391 33% (3,403) 90.0
Ontario Not available 77,641 Not available 83.9
Source: Ministry of Health and Long-Term Care. Health Data Branch, Health System Information Management and investment Division (HISMI). Long-Term Care Home System Report as of August 31, 2013.
Note: 1. *Excludes 96 LTCH beds recently approved in Niagara to built
2. **Excludes 64 that will move from Hamilton to Burlington in September 2014
3. ***Does not include LTC beds and population in Norfolk outside of the geographic area of the HNHB LHIN
Key Considerations
•
To support patient flow, the HNHB CCAC has supported the discharge
of an increasing number of people by providing higher levels of support.
•
This approach (above) has been successful in assisting hospitals to
maintain flow. However, due to the increasing volumes, it may not be
financially sustainable.
•
Hospitals are seeing higher volumes of patients being admitted through
ED. The LHIN’s review has shown insight into the population but further
analysis is required.
•
The impact of any service changes, especially in Hamilton would be a
concern to the LHIN.
LHIN Actions to Address Patient Flow Pressures
• Ongoing discussions between the LHIN and Ministry of Health and Long-Term Care to reconcile impact of Health System Funding Reform (HSFR) on CCAC’s funding.
• CCAC and LHIN hospitals developing plans to reduce the number of individuals discharged on more than eight hours of care without negatively impacting the community.
• Short and medium strategies in addition to those listed in the LHIN’s Patient Flow Action Plan have been identified:
• Explore opportunity to increase capacity by opening hospital beds until March 31, 2014
• Understand the impact of opening additional beds on the HSFR on hospitals and CCAC
• Gain a better understanding of the service increase seen by CCAC
• Work with LHIN providers to optimize existing capacity within the system i.e. Assess Restore
• Engage stakeholders in Hamilton and Burlington to identify opportunities within the community.
