Short Stay Convalescent Care Program and RAI-HC

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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