Short Stay Convalescent Care Program and RAI-HC Assessment Evaluation Demonstrating improved patient outcomes and care transitions June 10, 2014 OACCAC – Achieving Excellence Together Jennifer Scott, Director, Patient Services - Placement Services Debbie Taciuk, Supervisor, Patient Services Central CCAC – Outstanding care – every person, every day Agenda • Short Stay Convalescent Care (SSCC) Overview • Resident Assessment Instrument – Home Care (RAI-HC) Analysis: • Data Overview • Demographics • Outcome Measures • Client Assessment Protocols (CAPs) • SSCC Outcomes & Transitions • Summary • Appendices 2 Short Stay Convalescent Care Program Overview • CCAC/Long-Term Care Home (LTCH) partnership • Provided within LTCHs funded by MOHLTC • 690 beds in Ontario • 105 beds in Central LHIN • Requires access to 24-hour care, and rehabilitation goal(s) • Medical, therapy and support services • Patient and family education • Maximum 90 days length of stay • Based on attaining rehabilitation goal(s) • Discharge to community setting 3 Ms. C’s experience • 77 years old • Fractured knee post-fall • SSCC improved pain, independence with ADLs and most IADLs Hospital Referral Day 7 • RAI Admit Day 7 • Rehab Goals SSCC Admit Day 12 CCAC assesses & determines eligibility • Rehab Goals met • RAI Discharge Day 44 Discharge Home Day 49 CCAC reassesses & coordinates CCAC & Community Service (s) to support transition home 4 Ms. C: RAI Data Comparison RAI Outputs ADL (0-6) ADL Long (0-28) Pain (0-3) CHESS (0-5) MAPLe DRS (0-14) CAPs RAI Admit 4 18 3 1 Moderate3 2 7 RAI Discharge 0 2 2 0 Mild 0 4 Medication Review RAI Admit (4) RAI Discharge (4) Tylenol PRN at least two/day Tylenol at Bedtime Zopiclone (Imovane) PRN taken daily (sleep) Calcium daily Coversyl daily (blood pressure) Centrum Vitamin daily Fragmin daily Vitamin D daily 5 Data Overview • Includes 1681 Central CCAC patients with a SSCC Referral Start and End date between January 2007 and February 2014 • All patients had a RAI-HC completed upon starting the SSCC referral (RAI Admit) • All patients had a RAI-HC completed prior to SSCC referral discharge (RAI Discharge) • Average Length of Stay: 64 days 6 Demographics/Living Arrangement • 74% women and 26% men • Average age: 81 years 40% 35% 30% 25% 39% 20% live alone 31% live with spouse and/or family 10% 5% 0% Spouse/Life Partner With Family 20% With Spouse and Family 20% 15% Alone Other Arrangement 13% 13% Non‐Private Residence 6% 7% Not Available 3% Note: Not Available Living Arrangement information part of initial referral assessments to CCAC only 7 Demographics: Marital Status • 54% Widowed • 30% Married 54% 60% 50% 30% 40% 30% 20% 10% 6% 1% 2% 7% Divorced Married Other Separated Single Widowed 0% 8 RAI-HC Outputs Compared: Admission vs Discharge • Changes in Health, End Stage Disease and Signs and Symptoms (CHESS) • Pain • ADL Hierarchy (ADL) • ADL Long (includes all ADLs) • Method for Assigning Priority Levels (MAPLe) • Client Assessment Protocols (CAPs) • Depression Rating Scale (DRS) 9 CHESS Comparison between RAI Admit and RAI Discharge 60% 51% 51% 68% improved on RAI Discharge 50% 40% 31% 29% 30% Discharge 20% 10% Admit 13% 13% 5% 4% 1% 1% 0% 0% 0% 0 1 2 3 4 5 CHESS scale is a predictor of risk of adverse outcomes such as mortality, hospitalization, pain and caregiver stress, as well as medical complexity. 10 Pain Scale Comparison between RAI Admit and RAI Discharge 58% 60% 50% 40% 30% 20% 0= No Pain 29% 18% 50% 1/3= Less than Daily Pain 8% 10% 2/3 = Daily Pain (mild OR moderate) 3/3=Daily Severe Pain Admit Discharge 16% 12% 9% 0% 0 1 2 3 Frequency and intensity of reported pain improves 35% on RAI Discharge More % improvement possible, as score of 2 varies in pain intensity 11 ADL Comparison between RAI Admit and RAI Discharge 60% 50% 40% 51 % require limited to weight-bearing assistance on RAI Admit vs 14% on RAI Discharge 30% 20% Admit Discharge 10% 0% 0 1 2 3 4 5 6 Admit 7.50% 11.24% 30.46% 18.62% 25.64% 6.48% 0.06% Discharge 56.34% 15.29% 14.40% 7.38% 4.52% 1.61% 0.48% ADL hierarchy includes personal hygiene, locomotion, toileting and eating ADL = 1-2 = Light Physical Care Needs ADL = 3-4 = Medium Physical Care Needs ADL = 5-6 = Heavy Physical Care Needs 12 ADL Long Comparison between RAI Admit and RAI Discharge 70% 69% 87% improved on RAI Discharge 60% 50% 40% 27% 30% 20% 10% 10% 17% 14% 28% 5‐8 Discharge 16% 8% 5% 0% 0‐4 Admit 9‐12 13‐16 3% 2%1% 0%1% 17‐20 21‐24 25‐28 ADL Long includes all ADLs within RAI-HC • 90% scored 5-24 on RAI Admit vs 32 % on RAI Discharge 13 MAPLe comparison between RAI Admit and RAI Discharge 80% 70% 60% 50% 40% 30% 20% 10% 0% 73% 97% Moderate to High on Admit 62% Moderate to High on Discharge 41% 16% 18% 0% 1% Low Mild Admit 24% 21% Discharge 2% 4% Moderate High Very High A shift to the left indicates decreased risk for LTC placement and reduced resource allocation in home care services. 14 RAI Discharge Score Improvements vs. No Change 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Depression Rating Scale Improvements No Change CHESS 68% 23% Pain 35% 53% Maple 43% 40% DRS 43% 40% ADL 75% 17% ADL long 87% 5% CHESS, ADL, and ADL Long score prove to be areas with the most significant improvements in score on the RAI Discharge. 15 Top Triggered CAPs at Admit vs. Discharge 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 97% 63% 82% 79% 71% Admit Discharge 57% 48% 48% 38% 36% 23% 15% 19% 17% 6% 7% 16 RAI-HC Rehabilitation Admit Criteria: Criteria Based on Data Review: Description RAI Scale Medically CHESS Stable ADL Needs ADL Hierarchy Ms. C meets criteria Admit Score Check 0-2 2-4 ADL Long 5-20 MAPLe ModerateHigh 0-2 triggered ADL/IADL Needs/ Cognition IntactMild Impairment CPS Motivation & Potential ADL Rehab CAP 17 SSCC Outcome by LTCHs January 2011- January 2014 80 72.9 72.4 70.4 64.9 64.7 70 Overall 85% go home or to other destination 60 % Discharged Home 50 % Discharged to Hospital 40 % Discharged to LTCH 30 14.2 20 10 20.4 22.2 18.3 5.1 % Discharged to Other Destinations 0 Hawthorne Place Maple Health Centre Newmarket Health Centre Senior's Health Centre Unionvilla Other destinations include: • Rehabilitation • Respite/Return to Retirement Home18 • Supportive Housing/Assisted Living Care Transitions after SSCC • 66% of patients did NOT receive Central CCAC home care and/or LTC services • 34% of patients received Central CCAC home care and/or LTC services 19 Summary • Patients experienced functional improvements and transitioned back to community setting • Significant improvements on RAI Discharge: • ADL Hierarchy, ADL Long, CHESS Scale and MAPLe • Falls and ADL Rehab Potential CAPs • The number of CAPs triggered decreased after completing SSCC program • Review areas for greater improvement • Pain, Falls, Urinary Status, Psychotropic Medications, Depression • Validate falls coding with assessors 20 Data Limitations • Falls Coding • Need to ensure NOT over coded if last RAI-HC assessment completed within last 90 days • Discharge Destination not consistently captured over time of program • Length of Stay used the referral dates in CHRIS admission to discharge date • Required both Client Health and Related Information System (CHRIS) and RAI records to be included in data review for consistency • Implemented CHRIS in 2009, RAI in 2003 21 Questions • Josian Petgrave, Decision Support [email protected] • Jennifer Scott, Director, Placement Services [email protected] • Debbie Taciuk, Supervisor, Placement Services [email protected] • Jennifer Wright, Senior Manager, Patient Services Projects [email protected] 22 Appendix A: Primary Language/ Use of Interpreter 2% 3% 11% English Italian 1600 1400 Chinese Russian 1200 1000 75% No 800 Yes 600 400 200 0 Needs an Interpreter 23 Appendix B : MAPLe MAPLe Level Service Direction Need to Review: 1. LOW Generally I&R light homemaking 2. MILD Likely to need personal care & homemaking 3. MODERATE Require a range of services – almost none appropriate for I&R only NOTE: Convalescent Care – usually Moderate 4. HIGH May require intensive in-home services and # of patients appropriate for LTC 1. Poor Stamina 2. Prior Self Rated Health 3. Hospitalization 4. Emergency Visits 5. Caregiver Status 6. Hours of Informal Care 7. Hours of Formal Care 8. Family Preferences 9. Patient Preferences 10. CHESS Score – Medical Complexity 11. 24 hr supervision 12. Mental Health 5. VERY HIGH Highest # appropriate for LTC or remain in home with intensive services 24 Appendix C: MAPLe: Moderate-3 Patient Characteristics: Moderate - Sublevel 3 Present • Cognition Performance Scale (CPS) = 2 or less • ADL Hierarchy score = 1 or greater Absent • No behaviour problems • No falls problems • No for few meals • No swallowing problems 25 Appendix D: MAPLe level: ModerateSublevel 3 80% 60% 64% 36% Yes 40% No 20% 0% MAPLe Moderate-3 means the patient has ADL deficit(s) (ADL>1) and is cognitively intact (CPS<2) • Possible predictive criteria for SSCC program 26 Appendix E: Diagnosis (Based on sample of 267 patients in 2011) Top 8: 1. HTN 2. Arthritis 3. Other Fracture 4. Osteoporosis 5. Diabetes 6. Hip Fracture 7. CAD 8. Emphysema/COPD /Asthma Average Number of Diagnoses per patient: 4 80% 70% 60% 50% 40% 30% 20% 10% 0% Admit Discharge 27 Appendix F: % Falls Admit vs Discharge 66 70 60 50 50 40 30 Admit Discharge 30 22 13 20 10 8 5 2 4 2 0 0 1 2 3 4+ 28 Appendix G: Number of Falls 800 765 747 700 600 500 400 300 200 100 0 Fewer falls No change 177 More falls Falls Frequency After Discharge 29 Appendix H: SSCC Outcome Overall by LTCHs Review based on data captured to date: January 2011-2014 69.4 80.0 60.0 40.0 20.0 0.0 15.6 7.5 7.5 % % % % Discharged Discharged Discharged Discharged Home to Other to Hospital to LTCH Destinations Discharge Destination 30
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