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Presentations and Questions

Day 2: Friday, March 25, 2011

Keynote Speaker -- Integrating Continuing Care: An International Health Reform Challenge

Coffee Table Panel: Addressing Timely Access to Continuing Care Challenge

3 Success Stories on Improving Timely Access to Quality Continuing Care

Closing Remarks

Presentations & Questions – Day 1: Thursday, March 24, 2011 

Keynote Speaker -- Integrating Continuing Care: An International Health Reform Challenge

Dr. Donna Wilson on behalf of Margaret MacAdam

Dr. Wilson began her presentation with the acknowledgement that no organization is static. Healthcare itself has changed enormously over time. The shift to outpatient surgery over the past decade is a case in point. End-of-life care is another area that has changed significantly.

Dr. Wilson shared the results of an end-of-life care research project conducted by herself and Margaret MacAdam.

Traditional thought was that the greatest use of health services occurred in the last six months of life. Their research says this is not the case. Individuals (in particular children and those in their 40s/50s) with chronic diseases use more services continuously over many years.

Their research also documented an enormous shift to dying at home. In Canada, 30 to 40 per cent of deaths currently occur at home, with 10 per cent dying in long-term care facilities.

Dr. Wilson shared some facts that influence a ‘caring for seniors at home’ strategy:

  • 10% of individuals will live to be 100 years old;
  • 50% of individuals will reach 85 years;
  • 1/3 of individuals over the age of 85 have dementia;
  • 2/3 of those individuals over 85 die at home, the rest die at long-term care facilities;
  • 4-5% of people over 65 live in long-term care facilities, the same number are being cared for by family at home; and
  • Family caregivers will reduce dramatically in the future as people have fewer children.

Dr. Wilson stressed the need for integration of vertical and horizontal planning for aging people and services. Evidence is emerging that homecare keeps people out of ERs, hospitals and nursing homes.

She went on to note that many European countries have put in place measures to care for seniors at home. Several provinces have aging or continuing care strategies.

Based on an analysis of successful models of continuing care, Dr. Wilson identified the following common elements:

  • Consistent leadership;
  • Continuity of care as a goal for all staff;
  • Greater emphasis on illness prevention and health promotion;
  • Infrastructure supports; and
  • Sensitivity to the fact that continuing care models which work in urban settings do not necessarily work in rural settings.

The question and answer session that followed brought forward the following discussion points:

  • Decisions regarding end-of-life are a process for families and individuals;
  • England has been a leader in upstream initiatives linking social care, self care and hospital usage;
  • Doctors get trapped in a system of episodic care because of fee-for-service, while a salary model enables continuity of care;
  • Because homecare is not part of the Canada Health Act, standards and the level of service differs across the provinces and territories;
  • Homecare systems deal well with post-acute people from hospitals, but fall short on community services like shopping, cleaning, etc. which are just as important;
  • Victoria State in Australia is very progressive in the area of homecare and should be examined.

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Coffee Table Panel: Addressing Timely Access to Continuing Care Challenge

Donna Dill, Dr. Jeffrey Turnbull, Judith Wahl, & Dr. Donna Wilson

Donna Dill, Judith Wahl, Dr. Jeff Turnbull, and Dr. Donna Wilson offered perspectives on the policies, processes and practices related to long-term care and home care in three provinces: Nova Scotia, Ontario, and Alberta.

Each of the panellists spoke about the need to consider new models of care for continuing care:

Donna Dill and Judy Wahl suggested that supportive housing be given consideration as an alternative to long-term care facilities.

Dr. Turnbull spoke about models of care used in homeless shelters in Ottawa where acute, palliative, and primary care services are available at the shelter. He suggested that this approach has saved $3.5 million costs to health system each year.

Both he and Ms. Dill observed that continuing care facilities, whether retirement homes or long-term care facilities, should be staffed by teams of providers able to provide primary care to residents.

Dr. Turnbull suggested that continuing care is poorly thought through and thus has a built-in reliance on the acute care system.

Ms. Dill introduced the challenges of staffing continuing care. Dr. Turnbull noted that homecare was not being optimized because of workforce capacity shortages.

Dr. Wilson noted that:

  • Aging and geriatrics are not attractive specialties for younger doctors; and
  • Nurses, on the other hand, are seeking specialized certification in gerontology

She also referred to the roles played by informal caregivers and spoke about support and training for informal caregivers.

Ms. Wahl talked about the variations in skills mix depending on patient needs. A conference participant shared the experience of a project where nurse case management and a health behaviourist provided effective continuing care.

All four panellists spoke about the need for patient engagement in designing continuing care programs and strategies.

Ms. Wahl stated that patients need to be active in the decision-making about their continuing care as this improves the quality of both care and the design of physical space.

Dr. Turnbull recommended that health professionals solicit patients’ perspectives and accommodate patient needs on continuing care.

Ms. Dill observed that, unfortunately, the identification of substitute decision-makers has slowed the process of being admitted to long-term care facilities.

She further observed that standardized and needs-based admission criteria are needed for continuing care. She proposed that keeping people in their homes should be the first choice.

Further, Ms. Dill suggested that in some systems, people in hospital have faster access to long-term care facilities than those living at home.

She also spoke of criteria for assessing the appropriateness and stability of the home environment; her view is that consideration has to be given to the patient’s perspective.

Ms. Wahl introduced the issue of affordability. She suggested that policies and programs address options for those seniors who cannot pay for continuing care.

In response to questions, she suggested that co-op housing may be a model for seniors. She also recommended additional investments in public housing.

The creation of waitlists for homecare services has led people to think that in order to access care services, they need to go to long-term care facilities.

Both Dr. Wilson and Ms. Wahl stated that the hospital discharge policies need to be reviewed; many waitlists for long-term care facilities suggest that a patient must take the first available facility whether or not it is close to the patient’s family and regardless of the cultural competence or quality of the facility.

Based on her legal experience, Ms. Wahl suggested that within Ontario, this ‘first available’ obligation is illegal in that it does not recognize a person’s right of choice of living accommodation.

Dr. Turnbull described the current continuing care situation in Canada as “a failure of leadership and structure.”

Questions of the panel addressed infrastructure requirements related to the baby boomers as compared to succeeding generations; it was suggested that the bulge in demand created by baby boomers will require over-building.

The panellists referenced the relative strength of the health of the baby boomer population; the result is that the need for long-term care will be less than that of previous generations.

Participants introduced issues related to the lack of respite care. As well, there were comments about how best to define societal values related to eldercare and its costs.

There was also a brief discussion about the liability in the form of disease exposure and poor quality of care from using hospitals for people that should be in continuing care.

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3 Success Stories on Improving Timely Access to Quality Continuing Care

Liris SmithDr. Peter Nord, & Dr. André Tourigny

Liris Smith

In her presentation, Liris Smith shared the experience with homecare as a key element in regards to access and quality in the Yukon. It is one of the essential components of the integrated health system.

She emphasized that homecare needs to be client-driven and client-directed, taking into account individual needs.

Other important considerations include the need for common language and standards across Canada; responsible data use; and the recognition of the links between homecare and other components of the health system.

For example, homecare effectively shortens hospital length of stay and prevents hospital admissions.

The presentation then focused on the implementation of the Resident Assessment Instrument for Home Care (RAI-HC). The RAI-HC was developed by an international consortium of researchers from 20 countries; it is used by the Canadian Institute for Health Information.

RAI-HC is a standardized, multi-dimensional assessment instrument designed to predict an individual's ability to live independently in the community with support.

With funding support from Canada Health Infoway, the Yukon project provided electronic devices (tablets) with the RAI-HC software to providers.

The project goal was to inform program planning and delivery of care to individual clients. The RAI-HC facilitated real-time sharing of client assessments and the results were integrated into the electronic health care record.

The data produced as a result of the system highlighted interesting facts, such as a smaller percentage of Yukon homecare clients have an informal support network as compared to the rest of the country. Further, data on falls led to the implementation of a fall prevention program.

Dr. Peter Nord

Dr. Nord V.P., C.M.O. and Chief of Staff at Providence Healthcare, presented an Ontario approach to improved flow based on the premise that better quality outcomes result from better flow.

According to his theory of flow, wait times can be reduced by decreasing the flow in and increasing the flow out.

He provided a number of examples in place in Ontario to reduce the flow in as it pertains to ER wait times, including:

  • Avoid re-admissions (e.g., through ‘Virtual Ward’, early discharge planning, chronic disease management, and improved case management);
  • ER diversion and gerontology emergency management nurses;
  • Support for community physicians;
  • Primary care extended hours; and
  • Urgent care centres.

Dr. Nord’s proposed solutions to increasing the flow out include:

  • Initiating ‘Home First’ and ‘Waiting At Home’ strategies;
  • Increasing the capacity of community rehabilitation;
  • Having Community Care Access Centres (CCACs) be accountable for discharge planning;
  • Increasing the availability of supportive housing and assisted living;
  • Implementing an ALC Long Waiters Strategy; and
  • Implementing an ALC within 48 hours strategy.

He then outlined eight strategies in place in Ontario as part of the ER/ALC Strategy, highlighting navigation as a key strategy for which the return on investment is significant.

In the case of the Providence Model, navigation was the bridge to address the gaps between acute care and home. The new approach identified the “essential 13” that all patients need.

Essential13

 

One consistent multidisciplinary team cares for the individual both as an inpatient and outpatient. The community health navigator follows individuals 48 hours post-discharge up to one year.

Data are collected against a number of indicators along the spectrum from acute care to Providence, as an inpatient at Providence and then home. These indicators are the dashboard for quality.

Dr. André Tourigny

D. Tourigny shared the results of the implementation and impact of a coordination-type integrated service delivery system for frail older people titled PRISMA (Program of Research to Integrate the Services for the Maintenance of Autonomy.)

He identified six elements that need to be present to produce positive results for the patient and family:

  1. Coordination between services;
  2. Single point of entry;
  3. Case-management;
  4. Individualized Service Plan;
  5. Unique assessment tool (SMAF) and Case-mix classification system (ISO-SMAF Profiles); and
  6. Information tool (Computerised Clinical Chart).

The research compared this model in three areas to other areas without this model. Costs were neither higher nor lower than the control group but produced better outcomes.

However, the speaker noted that implementation of these integrated networks takes time and it also takes time to see the effects -- four years in fact to see a lower decline in autonomous functionality.

Questions of the panel reinforced some of the key elements including the need to keep in mind the six components of integrated care, the need for streamlining to be shared between front-line staff and administration, as well as the need for better funding for homecare.

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Closing Remarks

Co-chair Bonnie Brossart provided the closing remarks. She noted an abundance of good information and a sense of optimism throughout the 2011 TQ conference.

She thanked the Steering Committee, CMA staffers Brenda Trepanier, Owen Adams and Stephen Vail, the translators, and all those in attendance.

She also advised that the presentations and conference report would be available presently on the CHSRF website in English and French.

In reflecting on concepts and key words that resonated throughout the conference, Ms. Brossart proposed an anagram:

A -- access, abundance, agitation

C -- customer-owner, community, common goals

C -- communication, constancy of purpose, courage, commitment

O -- oneness, orchestra director, openness (or transparency)

R -- relationships - between providers and users and among providers, administrators and policy-makers

D -- determination, direction, data, dignity

Ms. Brossart noted that the 2004 10-Year Plan to Strengthen Health Care (commonly known among health sector stakeholders simply as ‘The Accord’) was winding down.

She reminded participants that the issue of wait times was one of the priorities recognized in that Accord; and therefore the TQ conference series was strongly tied to the Accord.

She proposed that the conversations and ideas which emerged during this conference can and should inform what future accords encapsulate.

Mr. John McGurran of the 2011 TQ Steering Committee thanked the co-chairs for bringing the program to life with wit, humour and grace. He also acknowledged their knowledge and passion.

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