January 2018

Improvement Conversation EXTRA team

Nova Scotia Health Authority’s EXTRA team at the August 2017 residency session

When it comes to the well-being of many patients, there’s no place like home.

In recent years, Nova Scotia’s health system has made a concerted effort to send more hospital patients back home, and fewer directly to long-term care (LTC). The philosophy is called Home First. Now, the Valley Regional Hospital in Kentville is exploring if a Home First Transition Team (HFTT) can make a bigger difference in discharge patterns.

“It’s better for people to go home from hospital. That’s where most people want to live, and make longer-term decisions about their future. It also means that a hospital bed becomes available for someone else who needs it,” says Bob Jenkins, Director of Continuing Care, Western Zone, Nova Scotia Health Authority (NSHA).

Jenkins and colleagues in the NSHA and at Valley Regional Hospital are part of the EXTRA cohort. This executive training program from the Canadian Foundation for Healthcare Improvement helps health organizations across the country tackle an existing priority, and build their capacity to make ongoing change happen. EXTRA accelerates health system improvement.

NSHA was created in 2015, when nine district health authorities were reorganized into one. While the NSHA has had success in advancing Home First, the results are not the same everywhere.

Provincially, about 60% of the seniors placed in LTC come from the community and 40% from hospital. The aim is to move that ratio to 65-35. However, at the Valley Regional Hospital the split is more like 50-50, and has been so for about a decade. The hospital, which serves about 80,000 residents of Kings and Annapolis Counties, is now a test site for the HFTT, which started in the fall of 2017.

As Jenkins notes, complex senior patients fall into several broad categories. There are the patients who want to go home, who are able to and who have supports in place. Another cohort has heavy care needs and no adequate supports, and isn’t suitable for home care. Their only option is to wait in hospital for LTC.

The decisions to discharge these patients home or not are relatively straightforward. But there’s a third group of patients in the grey area. Maybe they could go home from hospital, maybe they should go straight to LTC. There’s no easy answer.

In the past, says Jenkins, hospitals tended to keep those patients until a LTC bed opened. However, there are drawbacks to prolonged stays, apart from the added strain on hospital resources.

Patients are at higher risk of hospital-based infections and falls. They may become “deconditioned”, losing some mobility and strength (up to 5% loss per day). Patients can also see a decline in function, not as a result of the original illness but because of hospitalization. Over 25% of elderly patients also develop delirium after hospital admission.

Moreover, when you’re in hospital awaiting LTC you have to take the first bed available within a 100 km of your preferred community. If you go to LTC from the community, you can wait for your facility of choice.

At Valley Regional Hospital, the HFTT starts with the assumption that all patients can go home. The team is working to optimize discharges, with the goal of giving all patients every opportunity to transition back home to their community.

Team meets weekly to review cases

Members of the HFTT are considered “champions” of the Home First philosophy. The co-chairs are the Hospital-Based Continuing Care Coordinator and the Patient Flow Coordinator. Other members represent physicians, nursing, social work, inpatient rehabilitation and care areas, and more.

The patients referred to the HFTT have had all possible discharge options reviewed, and are at risk for LTC placement from hospital. This includes patients who face barriers that may (but not necessarily) affect a discharge home from hospital, like family concerns, caregiver burnout, mobility challenges, supports required in the home/community, etc.

Ideally, cases come to the HFTT as soon as possible once a discharge risk has been identified. That could happen as early as right after admission in emergency. Beginning the process in a timely manner allows the patient, family, and care team to better consider, choose and initiate access to whatever resources may be required.

With referrals in hand, the HFTT meets weekly. Other healthcare staff may be invited to discuss the patient details. The HFTT can recommend a seamless discharge home, possibly with additional support and health services, and has to approve all requests for in-hospital LTC assessments. Committee members or other health care staff involved in the discharge plan will follow up as needed.

”We’re not transitioning the same people to long-term care that we did years ago, and are able to support more of them at home now,” Jenkins says.

Consider one recent patient, late 80s, who had experienced progressive cognitive decline. One child was the primary support. This patient was agitated, paranoid and having hallucinations, with swallowing issues and weight loss. With medication tweaks, adjustments to food texture and encouragement at meal times, all of these issues improved.

Staff discussed the Home First idea with the child, and outlined services that Continuing Care could offer at home. The team created a plan for the patient to have daily support visits. The patient was successfully discharged home.

“We’re not looking to put people at undue risk, but we know there are seniors waiting for LTC who could be supported in their own home once they’re medically stable,” says Jenkins.

Plans to expand the program

In carrying out the project, Jenkins says the EXTRA support has been integral. He and his colleagues have received coaching and education on change management, staff and physician engagement, and how to put clients at the centre of conversations.

Jenkins hopes that by this April the HFTT will have enough indication to know what has been successful and what adjustments are needed. The program could then expand to the Yarmouth Regional Hospital and the South Shore Regional Hospital.

The key performance metrics are increasing the number of discharges home from hospital with home care, reducing the percentage of LTC admissions that come directly from hospital, and reducing the number of people on hospital waiting lists for LTC.

The project is also tracking other measures, like home support client readmissions within 30 days and home support hours. “We want to make sure we’re not causing unintended changes in other parts of the system,” says Jenkins.

In implementing Home First, some challenges include a sense of risk aversion among physicians and hospital staff. They like to err on the side of caution, says Jenkins. He also thinks that ageism may be at play– the attitude of “you’re a senior, you need 24-hour care and we know best what you need.”

Home First and the HFTT affirm the idea that home is often what’s best. When complex senior patients are admitted, physicians, healthcare professionals, patients and families shouldn’t automatically assume that LTC is the only choice.  “Keep all options open,” says Jenkins.