1 Geri Claxton, RN Team Leader Brad Gunn, NPThe Rural Program South East LHIN Primary Health Care Forum Thursday October 2, 2016 Geri Geri Claxton, RN Team Leader Brad Gunn, NP

2 Slide 1: Faculty/Presenter Disclosure Name of Presenter(s): Geri Claxton, RN Team Leader Program) Brad Gunn, NP Program) Relationships with Commercial Interests: Grants/Research Support: N/A Speakers Bureau/Honoraria: N/A Consulting Fees: N/A Other: N/A Geri

3 Slide 2: Disclosure of Commercial InterestsThis presentation has received financial support from: N/A This presentation has received in-kind support from: N/A Potential for Conflict of Interest: N/A Geri

4 Overview: Introductions DemographicsThe History of Why What is How does it work? Statistics Collaborative Care Program (CCP) Case study Video Questions. Geri

5 Hospital@Home Partners:

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7 Prince Edward County DemographicsPopulation – 25, 258 (2011 – Stats Can) The SE LHIN projected an increase in percentage of persons >age 65 living in PEC from 22.3% in 2009 to 27.1% in 2016 The provincial average of 13.6% in projected to only 15.6% in 2016 (SELHIN, 2007) National average (>age 65) 14.8% Prince Edward County – mean age 51.6 yrs. Ontario – mean age 40.4 yrs. Geri

8 The History Queen’s conducted background researchReviewed similar projects around the world The hospital: standard venue for treating serious illness, but has risks Evidence: hospital level of care can be done at home & many patients do better Aligns with Ministry of Health looking for alternatives to hospitalization Geri

9 Why H@H? Prince Edward County needs alternative to hospital bedsImprove quality of life (patient and caregivers) Improve access to community resources Improve patient and caregiver confidence in their own ability to manage at home Improve healthcare providers’ satisfaction with the quality of care that they deliver Improve cost effectiveness of healthcare system Geri

10 What is MD “admits” patients to from office, home, ER or hospital Daily, closely supervised care: timely, appropriate, inclusive and collaborative Daily home visit from NP and/or MD in addition to RNs, PSWs, …. together decide on daily care plan Care plan is patient centred Promote healthy behaviours, facilitate patient education and learning Brad

11 How the H@H program works…Admitted for up to 7 days (or more) Daily NP (MD assessment) Daily RN assessment (up to 3/day) Daily PSW visits (up to 3/day) Daily discussion by team (teleconference) Pharmacist (PEFHT pharmacist) Priority access to PEFHT services Referral to community services, eg. Community Care for Seniors Brad

12 Admission Criteria: Elderly, palliative care (for acute symptom management) and complex care patients Otherwise require a hospital admission Facilitate an early discharge from hospital Have local (PEFHT) Family Doctor/PCP Clear primary diagnosis Consent to participate in program (may require changing service providers) Live in Prince Edward County Home environment safe for patient and team Brad

13 The Interdisciplinary Team:Family Doctor Nurse Practitioner Team Leader Community Care Coordinator (South East CCAC) RN(s) PSW(s) Physiotherapist Occupational therapist Pharmacist Others: diabetic educator, clinical nutritionist, Heart Function RN, palliative care coordinator, wound care, mental health services etc Brad

14 STATS: # admissions since 2013 – 245# diverted from hospital admission - 70 Total # of program days – 2132 Average length of stay – 8.6 days Average age 76.7 years # males – 115 # females – 126 Common diagnoses – CHF, COPD, cancer Geri

15 Patients and CaregiversHighly satisfied with experience 89% of patients were completely satisfied with the quality of care received Felt allowed them to be discharged earlier from hospital Perceived prevented long term care/nursing home placement Healthcare Providers Satisfied with their role in patient care and team functioning. Noted that direct access to Primary Care and PEFHT’s team facilitated efficient provision of the most appropriate care Geri

16 Quotes it gave me a lot of confidence to go home with that program. To know that there were people there who were looking after me so that I was not by myself. That was actually for me the nicest thing and the best thing. [Patient] They get a rest. Because some of them that are up in age, we provide a respite care for them as well through the Hospital at Home program so they get the rest they need and they’re looked after as well. And we always ask them how they’re doing …. And I had one Hospital at Home client that didn’t need anything but yet the wife just needed the vent. ... So it’s so much more comfortable for her. [Healthcare Team member] it relieves me of a lot of work. The PSWs came in, they gave him his shower and got him dressed and fed and that sort of thing. They took that responsibility away and … that’s a real big help. [Caregiver] it just takes a lot of the stress and the strain off, and they were keeping an eye on him at the time. It’s the whole mental thing that it it’s just you don’t feel as responsible for everything that’s going on. [Caregiver] Geri The biggest problems ... with managing people at home, on home care, is lack of access to primary care ah support. I was especially attracted to the fact that the Hospital at Home program meant that my clients were going to have access to that primary care support seven days a week, at home. [Healthcare Team member]

17 Collaborative Care ProgramRecent articles from the Ministry of Health indicate that improving coordination of care for seniors in Ontario is a priority. PEFHT aimed to develop sustainable strategies to better serve residents of PEC experiencing complex care needs. NP led Collaborative Care Program (CCP) Brad

18 The Goals of CCP: Increase wellness (as defined by the individual)Improve health literacy Increase confidence of individuals to manage their conditions Decrease poly-pharmacy Indentify/highlight individual health needs and the gaps in meeting those needs To effectively use community resources and programs Better connection with PEFHT resources and programs Brad

19 Case study: Ron S 78 yr. old man with end stage COPD (requiring home oxygen), congestive heart failure, diabetes (requiring insulin) and other chronic conditions Homebound Main caregiver is his elderly, frail wife who has her own multiple health issues Limited financially No immediate family in the area Brad

20 Main health goal – for him to live at home as long as possible Referred to CCP following discharge from the program (he had been admitted for an acute exacerbation of his COPD and refused hospitalization) Through education they learned to recognize and report early signs of destabilization This led to communication with the CCAC to increase services in his home Brad

21 Team work: PEFHT resources involved – COPD nurse, palliative care coordinator, diabetes team and CHF nurse Connected to community resources – Community Care for Seniors (meals on wheels and respite services for his wife) Weekly communication Brad

22 Patient/caregiver experience:Feel that access to care is easier One point of contact is very important Home visits are appreciated Liked talking about their own care goals Brad

23 STATS: 2013 – current fiscal year208 Collaborative care plans to date # patients served – 249 total 2013/2104 – 35 2014/2015 – 87 2015/ # new CCP current year – 30 Geri

24 Fiscal year 2015/2016 # QHC hospital admits pre-CCP – 29# QHC hospital admits post-CCP – 16 Reduction 44.8 % #30 day hospital readmits pre-CCP – 9 # 30 day hospital readmits post-CCP – 0 Reduction 100% #QHC ER visits pre-CCP – 92 #QHC ER visits post-CCP – 48 Reduction 47.8% Geri

25 VIDEO Geri

26 THANK YOU………….! QUESTIONS………….?