• Marilyn R. El Bestawi, Senior Healthcare Executive (not affiliated with any organization), Toronto, Ontario 

Just in Time Delivery of Quality Results to Influence Decision Making

In Canada, approximately 14% of the population was aged 65 and older in 2009. The proportion of seniors aged 65 years or over will continue to increase. This group will represent between 23% and 25% of the population by 2036 and between 24% and 28% by 2061. By 2036, the number of seniors will be more than double the number observed in 2009 and will vary between 9.9 and 10.9 million persons. By 2061, their number will vary between 11.9 and 15.0 million (1).

In Ontario in 2009 the number of seniors aged 65 and older was 1.8 million or 13.7% of the population. This number is expected to more than double to 23.4% or 4.2 million by 2036 (2). Approximately 75,000 individuals (3) or 4.2%, most of whom are aged 65 and older, reside in Long Term Care (LTC) facilities. Within a six month period in 2005, one quarter of Long Term Care (LTC) residents in Ontario visited an emergency department (ED) at least once. Nearly 25% of initial visits were classified as potentially preventable and 10% as low acuity (4). Studies of the elderly admitted to hospital report 22.9% to 43.9% experience one or more iatrogenic illness with potential for serious or fatal complications (5). Research (3-10) indicates that between 21% and 48.2% of hospital admissions of elderly residents of LTC facilities are potentially preventable. Currently, no tool focused on use by direct care non-regulated staff is available and solutions have concentrated on the use of “experts” and/or additional staff resources.

The Centers for Medicare and Medicaid Services in the United States have estimated that the total costs for potentially avoidable hospitalizations for Medicare-Medicaid enrollees in 2011 were $7-8 billion (11).

During this intervention project, a tool was developed to predict decline in health status of the population of institutionalized elderly and piloted on 50% of the residents in a Toronto LTC facility for a three month period. The goal was to help staff identify and intervene when early signs and symptoms of decline in health status were recognized, which would prevent potentially avoidable ED visits and hospital admissions. The assumption was that if the early identification of decline of health status resulted in actions that prevented further deterioration and resulting transfer to acute care, this would benefit the LTC residents’ quality of life, decrease risk, and may also result in health system savings.

The novel Tool named PREVIEW-ED (Practical Routine Elder Variants Indicate Early Warning for ED) developed for use in the project, focused on the four conditions of pneumonia, urinary tract infection, dehydration and congestive heart failure. According to a Canadian study (12) based on the proportion of the most responsible potentially avoidable hospitalizations, these four conditions comprise 49% of the diagnoses leading to hospitalization of LTC residents. The Tool measures nine indicators, their related signs and symptoms, and severity levels. An aggregate scoring system is used to quantify the change in resident condition and an escalation path to guide staff action is provided. The one page Tool takes between 8-15 seconds per resident to complete by a Personal Support Worker (PSW).

Results of the pilot are promising. For the 66 residents followed in the 3 month pilot, a 57% reduction in transfers from the LTC facility for the four conditions was seen. The reduction continued and improved in the six month post-pilot sustainability period. A model was developed to calculate the potential cost savings if the Tool was implemented on a Toronto Central LHIN (Local Health Integration Network)-wide basis, which includes 6000 LTC beds. The annual LHIN-wide estimated savings are in the order of $500,000. The possible application of the newly developed Tool to other LTC facilities and populations, such as CCC and Community Care are evident as well as potential use in other jurisdictions nationally and internationally.