Urology - Chronic
Kidney Disease (CKD)
Planning Advisory Group
Summary of Meetings
PAG Membership
Rick Badzioch
Dr. Ian Brown
Dr. Euan Carlisle
Jane Cornelius
Terry Dalimonte
Maureen Kitson
Dr. Bill Love
Dr. Frank Scallan
Maureen Shantz
Dr. Bobby Shayegan
PAG Deliverables
Describe the strengths & challenges within the existing health care system
in addressing population health care needs
Identify leading factors that may influence the future demand for health care
Develop a high level, HNHB LHIN wide, ideal services delivery model for
the PAG population
Identify pre-requisites & challenges of implementation of the ideal service
model
Urology & CKD
At the start of the project the PAG concurred that urology and
CKD are distinct services with little overlap and need to be
reviewed separately.
Meeting 1
•
Strengths & challenges within the existing health care system
•
Leading factors that may influence the future demand for health care
Urology - Strengths & Challenges of
Current Health Care System
Strengths
Good distribution of urologists
across the LHIN. Access to
urologists not an issue
HNHB LHIN Urologists – cohesive
group
Readiness of LHIN urologists to
develop quality working group to
review and improve services in
LHIN
Majority of urology related care
available in LHIN, only need to
transfer outside LHIN for special
technology i.e. lithotripsy.
Nurse practitioners in LTCH can
increase capacity by performing
minor care procedures i.e.
changing suprapubic catheters
CCAC – provides continence
referrals
Hamilton – training program for
physician assistants
Less subspecialty among
urologists.
Challenges
Access to interventional urology in Brantford, requires
transfer to Hamilton, often needing an overnight stay
Access & support for new technology i.e. lithotripsy,
robotic
Aging population with limited access to continence
support
Transportation especially with aging population
Agreement & standardization of Nurse Practitioner
practice within LTCH across the LHIN
Centralized model may limit recruitment, impacting
health human resources in smaller sites.
Need to access urologist on urgent basis makes
regionalization of specialty challenging.
Inability to share information across sites (each sites
has meditech and PAC system but cannot share
information online between sites)
Wait time to operative time
Maintain & replace capital equipment
Lack of level 1 evidence for screening in urology. If
evidence supports screening potential for increased
demand.
Increase pressure to teach residents.
CKD - Strengths & Challenges of
Current Health Care System
Strengths
Ready access to specialists
No wait lists (except for transplant)
Immediate access to hemodialysis
(hemo)
Hub & spoke service delivery model
– satellites across the LHIN
CCAC support for home dialysis
Pre-dialysis clinic care > reduce or
delay need for dialysis (medical
preventive care – nephrology
clinics)
Range of hemo dialysis modalities
LTC access for clients on hemo
MOH PD in LTC Initiative
MOH increased support for
transplant services
Challenges
Access to timely surgical, vascular & interventional
radiology support - (for peritoneal dialysis catheter
insertion/replacement, vascular
access/complications, & nephrology tubes)
Access to interventional radiology only in select
areas of LHIN
CCAC staff turnover – has resource implications for
regional centre to retain for home and LTC support
Regional referral role - pressure to accept transfers
from satellites and from other centres for transplant
Access to LTCH for seniors on PD
Costs of different modalities i.e. daily, nocturnal
absorbed by regional centres
LTCH capacity to care for individuals on dialysis i.e.
staffing model
Lack of dedicated funding to support pre-transplant
treatments i.e. plasmapheresis, tissue typing
Management of CKD programs that cross LHIN
boundaries i.e. Halton/Burlington
Maintenance of knowledge/skills at non CKD
centres to facilitate repatriation (critical mass).
Resources/costs associated with supporting dialysis
offsite at other tertiary centres (Hamilton)
Factors Most Likely to Increase or
Decrease Demand – common to both
*Aging population
*
Increase in comorbidities in aging population & starting
earlier in younger population i.e. type 2 diabetes, obesity
*
Social economic profile of the LHIN
* Increase availability of primary care > increase demand
Access to transportation – will increase demand for services
close to home
Medical advancements, both in skill & technology (urology,
transplant, continual renal therapy, cancer treatment options)
Client/family expectations
Competition for limited health human resources
Factors Most Likely to Increase or
Decrease Demand – Service Specific
Urology
Increase demand
None identified
Unknown – evidence supporting cancer
screening
Projected increased oncology demand
Decreased Demand
Increased access to physician assistant
or nurse practitioner may increase result
in increased productivity
CKD
Increased Demand
Increase in individuals with end stage
heart disease
Transplant population – long term use of
anti-rejection medication
Diabetes
Decreased Demand
Increase prevention
Best practice standards for
hypertension, diabetes
Increase client’s knowledge of
health risks and status and success
with self management.
Increase access to nephrology
clinics/care to prevent or delay need
for dialysis
Urology – Components of Ideal Service
Delivery Model
Component Services associated with this component Clinical & non-clinical interdependencies Linkages to community services Health promotion/disea se prevention
Increased education re on prevention of cancer
Increased education on stone prevention
Global media marketing of health
Link to CCO for prevention Link to public Health Primary & Community Care
–Pre & post hospital
Continuity in primary care
Primary care capacity to meet population access requirements in all areas of the LHIN
Standard care paths
Timely access to urologist, other allied health, diagnostic services in the most appropriate place – (does not need to be done at academic centre)
Integrated information system
Coordinated care with community services
Access to funded stoma/catheter therapy training
Early detection, assessment and follow
Access to multidisciplinary team for complex cancer cases \
Role of pre-cancer screening identified
Integrated information system Diagnostic services Outreach multidisciplinary team Interventional radiology Access to specialists
Access to end of life care – identification of what services are needed to provide end of life care
CCAC for follow up care
Community based continence care – keeps people home
Link to rehab services
Link to end of life care
Stoma/catheter support
Urology – Components of Ideal Service
Delivery Model
Component Services associated with this component Clinical & non- clinical
interdependencies
Linkages to community services
Acute Care – Hub and Spoke Model Tertiary care Community hospitals Community Clinics
Hub (everything plus)
Complex cancer services
Multidisciplinary team
Interventional radiology
Timely access to tertiary care beds
Access to evidence based technology
Community Hospitals
Most oncology cases, the majority of stones cases, most male and female voiding dysfunction, most infectious diseases, most erectile dysfunction, much of pediatrics, most andrology, basic infertility
Access to urology services at multisite hospitals
Access to interventional radiology
Clinics
Simple basic surgical procedures
Primary & Specialist care services
Early urological screening & diagnostics
Monitoring and follow up
Outreach team
Integrated
information system
Cross site urology work group to monitor quality of care and outcomes Interventional radiology Supportive specialists i.e. cardiology Education across sites Videoconferencing/w eb based education CCAC & community care Continence, catheter and stoma care & support
CKD – Components of Ideal Service
Delivery Model
Component Services associated with this component Clinical & non-clinical interdependencies Linkages to community services Health promotion/ disease prevention
Strong, integrated primary prevention system to prevent diabetes, high blood pressures & obesity
Increased coordination & integration of all diabetes education programs
Link to Public Health/Min Health Promotion, CDPM,
Diabetes strategy
Heart and stroke strategy to reduce cardiac and HTN events
Municipalities – planning
Other ministries i.e. education CDPM CHCs Primary & Community Care - Pre and post acute
Education provided by mixture of health care professionals. Flexible models
Best practice guidelines for screening
Early detection of high risk population.
Continuity in primary care for assessment, monitoring & follow up
Staffing model standards/regulations for community & LTC (Default mech)
CCAC maintain home PD & hemo.
Access to rehab/LTCH/end of life/basket of services for dialysis clients
Pre-emptive transplant care
Established ongoing communication system between regional centre/LTC/Community sector
Designated number LTCHs adequately resourced to care for the CKD population
Integrated information system
Access to other specialists, endocrine, cardiac etc
Ongoing education for community and LTC
Public health/primary care vaccinations for hepatitis
Ongoing education to maintain expertise - across health professionals and EMS
Role of community support for brittle diabetics
Diabetes education programs
CCAC for home dialysis support
Access to rehab, LTC
Link to rehab services
Link to end of life care
Accessible transportation
Partnership with kidney foundation
CKD – Components of Ideal Service Delivery
Model
Compone nt
Services associated with this component interdependencies Linkages to community Acute Care – Hub & Spoke Model Regional centres Satellites IHF Defined by MOH CKD model Hub/Regional Centre
Tertiary centre: Transplant & dialysis to other tertiary centres
Vascular & interventional resources for vascular access. Access to interventional radiology services at the regional centre or
formalized linkages to access service in a timely manner
Timely body access – Dedicated OR time for Vascular & PD
Primary level 2 & 3 dialysis
Pre & Post dialysis clinics, nephrology clinics
Home dialysis & training
Access to surgeons – all hemo patients surgeon consult
Nephrology clinics referral based on GFR
Express protocol for admission to regional centre established (with repatriation agreements)
Optimize ambulatory services and supports to reduce inpatient stays
Dedicated resources for plasmapheresis
Maximize transplant program along the transplant continuum
Home dialysis targets appropriate for the demographic and geographical area
Satellites
Level 1 – 2 dialysis
Post dialysis and nephrology clinics
Predialysis clinics based on critical need (mobile clinics)
Selective home dialysis training.
Integrated
information system
Services for vascular access – link to vascular PAG
Interventional radiology Urology re PD insertion Access to resources/specialists to treat peripheral vascular disease Combine treatment clinics (diabetes, nephrology, stroke/HTN) Videoconferencing/ web based conferencing CCAC – community support Access to rehab, LTC End of life care education and support Link to Critical Care Lead to identify dialysis needs at LHIN critical care units. Diabetes clinics
CKD – Components of Ideal Service Delivery
Model
Component Services associated with this component interdependencies Linkages to community – Hub and Spoke Model Regional centres Satellites IHF Defined by MOH CKD model
IHF - Level 1 dialysis
Reevaluate the necessity of IHF through expansion of home dialysis
Regional CKD Centre
Meeting 2
•
Incorporate PAG colleagues feedback
•
Diagram of PAG ideal service delivery Model
•
Describe PAG Ideal Model using LHIN Criteria
•
Describe prerequisites, enables and challenges to the implementation
of the ideal service model
Heath
Promotion
•Cancer prevention education •Stone prevention •Global media marketing of health Primary Care•Assessment and early detection
• Consistency in referrals (care paths & regular knowledge sessions)
•Follow up care & monitoring
•Coordinated & integrated with community providers care (including palliative)
Community Care
•Coordinated by CCAC
•Continence care
•Pre and post acute care education/support for stoma and catheter care
•Pallative care (hospice/outreach)
•Pain Clinics
Primary & Community
Pre & Post Acute Care
Integrated & Coordinated Care Across the Continuum
Urology Ideal Service Delivery Model
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Complex Cancer &other urology cases Multidisciplinary outreach
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, Most oncology, stone, voiding
infertility, erectile dysfunction pediatric and basic fertility,
andrology cases.
Medical oncology & multi-disciplinary cancer care (oncology, palliative car etc. )
C
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C
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Simple basic surgical proceduresAssessment, monitor, follow up
Diagnosis, Access to Primary Care & Urologist Outreach team
Heath
Promotion
Strong, integrated primary prevention system to prevent diabetes, high blood pressures & obesity Increased coordination & integration of all diabetes education programs/clinics, nephrology and cardiac/stroke/ HTN clinics Primary Care Education provided by mixture of health care professionals.Best practice guidelines for screening
Early detection of high risk population.
Continuity in primary care for assessment, monitoring & follow up
Pre-emptive transplants
Community Care
•Staffing
standards/regulations for community & LTCH (Default mech)
•CCAC maintain home PD & hemo.
•Access to
rehab/LTCH/Pallative care for dialysis clients
Primary & Community
Pre & Post Acute Care
Integrated & Coordinated Across the Continuum
Satellites
A,B, C Level 1 & 2
Dialysis Post dialysis and Nephrology clinics Outreach Pre-dialysis
clinics
CKD Regional Centre Defined by MOH CKD Model
Body access – Vascular and PD Dedicated OR time for PD
Interventional radiology Dialysis level 2 & 3 Pre & Post dialysis clinics,
nephrology clinics
Home dialysis including training
Tertiary Regional Centre Role
Renal Transplant services Dialysis services to other tertiary centres
IHF?
Home
LTCH
Supporting tertiary Specialties i.e. Cardiac, neuroPAG Ideal Model -LHIN Criteria
Domain
Criteria
Assessment
Strategic Fit
Aligns with LHIN
priorities for
health
improvement,
health care needs
and system
transformation
Promotes patient flow and integration across the
continuum of care
Builds on existing infrastructure & optimizes use of
health human resources
Responds to health care needs of population i.e.
close to home
Population
Health
Heath Status –
clinical outcomes
Prevalence
Health Promotion
and disease
prevention
Strong emphasis on integrated prevention across the
continuum of care (screening – case finding in early
stages)
Supports quality outcomes
The hub and spoke model can quickly respond to
variances in prevalence and incident.
PAG Ideal Model -LHIN Criteria
Domain
Criteria
Assessment
System
Values
Client Focused
Promotes prevention, early detection, close to home and
in the home
Focused on patient safety
Partnership &
Community
Engagement
Hub and spoke model depends on partnerships between
hospitals, community and primary care
Greater integration with community which will build
confidence between teams
Innovation
LHIN model promotes integration ideas and centres,
which is innovative
Does not considered IHF model for urology (stand alone
centres i.e. Alberta)
Integration of knowledge
Equity
Equity of services through hub/spoke model
Access to advanced technology limited i.e. lithotripsy
Efficiency
Integrated information system needed, to reduce
duplications of tests i.e. labs, xray (model has potential to
gain efficiencies)
PAG Ideal Model -LHIN Criteria
Domain
Criteria
Assessment
System
Performance
Access
Quality
Sustainability
Integration
Model
improves access
promotes quality
is feasible. sustainable and does not require
substantial new investments
optimizes health care professionals and supports
training
promotes and depends on integration across the
continuum.
Ideal Service Model - Prerequisites,
Enables & Challenges to Implementation
Category
Prerequisite
Enables
Challenges
Policy/legislation
Changes in
legislation/policy re staffing
models LTCH- community
CCO guidelines for urology
Policy change re use of
creatine vs GFR for
nephrology clinics
PD policy in
LTCH
Funding policy for CKD
Funding policy for CKD in
LTCH
Resources
Existing
infrastructure,
formal hub and
spoke model for
CKD
LTCH – PD Dialysis
resources for dietician
Transportation
Lack of integrated
information system –
communication with regional
centre
Transplant resources
Preemptive transplant
resources
Ideal Service Model - Prerequisites,
Enables & Challenges to Implementation
Category
Prerequisite
Enables
Challenges
Community
readiness
Availability of resources
(funds & HR) in
community
Standard medical
directive/orders for
nursing
Community support
LHIN based
interactive IT
Transportation
Lack of supportive
housing/assisted living
Home
maintenance/adaption
Services
eHealth – transfer of
information
Partnerships/
linkages
Enhanced
communication process
between acute, LTC and
community
Urology – cohesive
collaborative group
CKD model