MH LHIN Community Investments Foundation For Change Dale Clement, ALC Strategy Lead, MH LHIN
Community Investments CCAC Programs • • Wait At Home • Stay At Home • Geriatric System Navigators Adult Day Programs • Supports for Daily Living • • Mobile • Hub & Spoke Transitional Services • • Restore Program Outreach Programs • • Regional Geriatric Mental Health Outreach • Peel Halton ABI Services • Nurse Practitioners in LTC
Wait At Home – Targeted Base Funding CCAC Enhanced service package – up to 56 hours / week • PSW Available for a 60 day period • Designed to facilitate hospital discharge with • appropriate supports while planning and waiting for transition to LTC / SDL / ADS etc All applications completed at home • Stronger operational linkages with CCAC Community • Case Managers and CSA agencies to facilitate smooth transitions
Stay At Home – Targeted Base Funding CCAC 106 spots created for seniors with high MAPLe scores, • currently on 60 hrs PSW services waiting for LTC in the community Clients receive the new service maximum of 90 hours • PSW services / month Program helps to keep clients out of hospital, enabling • them to wait safely for LTC at home Many clients have found this level of service sufficient • to delay / defer need for LTC Clients are waitlisted for program – 106 spots are fully • utilized at all times
Geriatric System Navigation (GSN) – AAH Funds Any person 75+ treated and released from an ED in • MH LHIN is automatically referred to MH CCAC GSN team for contact, assessment and linkage to appropriate community resources Decreases risk and inappropriate utilization of ED • Process for referral is a scheduled report every 24 • hours from each hospital information system which is faxed to CCAC
Geriatric System Navigation (GSN): (Nov 1, 2008 to June27, 2009) Referrals to GSN Team Information & Referral by GSN Total Referrals 2728 Laboratory services 50% Total from LTC 195 Meals on Wheels 80% Known to CCAC 654 Lifeline / Connect care 15% Total Contacted by GSNs 1879 Housekeeping 90% Admitted to CCAC (All 11 Home Maintenance (outside) – 98% snow shoveling largely left ED before seen) 100% had family doctor Adult Day Program Info 70% Transportation (for family doctor 90% & clinic appointments, groceries) GSN reviewed alternatives to ED use with all contacts
Adult Day Program Expansion – AAH Funding Programs expanded to offer greater community • services Performance measures include requirement to offer • services for a higher needs client and take patients with higher RAI – HC MAPLe score Specialized programs identified to meet a greater need • i.e.: Alzheimer’s and Bathing Programs New programs required to locate in areas within LHIN • where seniors live
Supports for Daily Living (SDL) – AAH Funding Service model which separates Supportive Housing and • Care Delivery Model supports an average 1.5 hours PSW services / • day delivered throughout the 24 hour period to meet clients more frequent needs Services are available to clients at scheduled times or • as needed, anytime of the day within a 24 hour period, 365 days a year Services are designed for clients with overnight needs • or more frequent visitation than those services offered through the CCAC.
Supports for Daily Living (SDL) – AAH Funding Supports for Daily Living provides non-medical • services that include: • personal support /attendant care (prescheduled tasks) • homemaking services • safety and reassurance checks (via phone or in person) & 24 hour urgent response The delivery model is through two methods – mobile • services (in client’s own home in community clusters) & hub and spoke (Extends in 2km radius from existing supportive housing site to community)
Restore Program: A “Sub-Acute” Transitional Service Specialized LTC unit for acute patients who require • additional time (~4-8 weeks) and reactivation to enable them to go home • Higher acuity than typical LTC resident Reduces ALC days in acute care and avoids • premature institutionalization in LTC Similar to Convalescent Care model •
Restore Program: Performance Results Over First Year 4935 acute-care days made available = 13.5 acute care beds Restore Program Restore Program # of Clients % of Clients Admissions from Discharges to Trillium 100 Home 80% Credit Valley 29 LTC 6% Halton Healthcare 8 Hospital 10% Others 10 Deceased 4% MH LHIN 147 Target length of stay = 35-42 days • Average length of stay = 44 days Source: Mississauga Lifecare, March 2008 - March 2009
Outreach Services – AAH Funding Psychogeriatric outreach teams and PHABIS work with • hospitals, CCAC and LTC to support transitions to LTC for hard to serve patients Work directly with LTC staff to ensure successful • transition plans developed and implemented PHABIS is funded to provide on-site care in LTC (up to • 8 hrs / day) and offers Adult Day Services to LTC residents with ABI Both providers help with behaviour escalation • management to support LTC staff and avoid unnecessary transitions to acute care
Outreach Services – ED & MOHLTC Funding LTC Nurse Practioners now provide coverage to all • 27 LTC homes in MH LHIN Nurse Practitioners focus on: • • Building clinical capacity within LTC homes • Supporting on-site care to avoid inappropriate transfers to acute care • Assisting with timely repatriation of residents from Acute Care
Impact LTC Waitlists • Hard to Serve Patients • Number of ALC Individuals in Acute Care •
LTC Waitlist Impact 450 Avg. 215 400 350 Avg. 176 300 250 200 150 100 50 0 Jan. Feb. Mar. Apr. May. Jun. Jul. Aug. Sep. Oct. Nov. Dec. Jan. Feb. Mar. Apr. May 08 08 08 08 08 08 08 08 08 08 08 08 09 09 09 09 09 3 Clients 3 w/ Transfer
Hard to Serve Patients who require post-hospital care: A new approach • Addresses the needs of people with complex medical issues, behavioral problems and/or mental health challenges who are in hospitals • Extensive engagement with providers on “Day 1” LTC-eligible • Acute care, CCAC, ABI services, Psychogeriatric outreach, Nurse Practitioners and LTC • Process requires referral to each provider organization and data sharing requirements • Currently manual: eReferral will streamline • Ongoing monitoring of patient group
Hard to Serve performance results: Number of patients > 60 acute-care ALC days reduced by 76% over a 2-month period # Hard to # Hard to Hospital Serve Patients Serve Patients % Impact @ Jan 26/09 @ March 27/09 THC 43 14 -67% HHS 19 2 -89% CVH 6 0 -100% MH LHIN 68 16 -76% Aug 3, 2009 – 15 Hard to Serve Patients - not all the same patients as in March / 09
MH LHIN Reduction in Alternate Level of Care (ALC) – Individuals Waiting in Acute Care 250 MH LHIN ALC Data 227 225 220 206 202 200 187 155 152 150 141 136 133 122 121 112 100 93 77 73 73 64 55 50 0 Sept-08 Oct-08 Nov-08 Dec-08 Jan-09 Feb-09 Mar-09 Apr-09 May-09 Jun-09 18 Total ALC Total ALC - LTC
Thank You Presentations will be posted at the link below following the video conference An area for questions is also available in the link http://www.mississaugahaltonlhin.on.ca/Form.aspx?ekfrm=4658
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