Patient Flow – Long Term Care Barriers & Opportunities

Lori Lamont, Executive Director PCH Program

Long Term Care Association of Manitoba

October 8, 2008

What you will learn?

• Long Term Care continuum • Client/resident profiles• Barriers and opportunities• Using Resident data to inform

change

Long Term Care Strategy

• 2006 – Manitoba Health approval of the WRHA Long Term Care Strategy and Provincial announcement regarding the Aging in Place Policy

• Long Term Care Strategy is a 5 Year Business Plan that:

Creates affordable community living with support options

Improves quality of PCH environments (reduce multi-bedded spaces)

Supports the Aging in Place policy

The Case for Change

• Too many multi-bedded spaces personal care home spaces (about 30 % of Winnipeg’s PCH capacity) Causes multiple moves for seniors Family / Resident preferences Infection control issues Patient Safety: Resident to Resident aggression issues

• Need to increase the range of options About 30 % of individuals paneled in Hospital and 50%

paneled in community are level 2s – there may be other options for some of these individuals

Manitoba has the highest rate of institutionalization (people age 75+ in 24 nursing home facilities ) and the most comprehensive Home Care Program in Canada

Supply and Demand

Winnipeg Population Projections, Ages 75 to 84 and 85+

0

1000020000

3000040000

50000

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

2013

2014

2015

2016

2017

2018

2019

2020

2021

2022

2023

2024

2025

2026

Year

Thou

sand

s of

Peo

ple

75 to 84

85+

WRHA Projected Population Aged 75 and Older

30000

35000

40000

45000

50000

55000

60000

1998 2000 2005 2010 2015 2020 2025

1.2

% o

f Pop

. >75

Adm

itted

to N

ursin

g H

ome

WRHA Projected Population Aged 85 and Older

10000

11000

12000

13000

14000

15000

16000

1998 2000 2005 2010 2015 2020 20254.

3 %

of P

op. >

85

Adm

itted

to N

ursin

g H

ome

Enhanced Supportive Living Continuum

Support Services to Seniors

Home Care

Independent Living

Supports to Seniors in

Group Living

Expanded Supportive

HousingSpecialized

SupportsPersonal

Care Home

Supports for Seniors in Group Living

• Enhanced support services provided to individuals living in existing community congregate settings.

• Services will depend on identified needs • Target population: Seniors who do

not require 24 hour support and supervision.

• Cost: Resident is responsible for rent

Supportive Housing

• Housing with supports based on eligibility criteria

• Target Population: Individuals who require 24 hour support and supervision and additional supports in order to live in a group, congregate setting

• Cost: Resident is responsible for rent and service package and WRHA funds care component (per diem funding) and professional home care services

Specialized Supports

• Provision of enhanced specialized supports in specifically designated locations or through funding of individualized service plans.

• Target Population: Individuals with complex health and personal care needs requiring special supports to live in the community.

• Cost: Resident pays for rent and service package. WRHA funds the care component.

Personal Care Homes

Who are we and what is our future?

Who are we?

Beacon Hill Lodge Bethania Mennonite PCH

Calvary Place Charleswood Care Centre

Concordia Place Convalescent Home Deer Lodge Centre Donwood Manor

Fred Douglas Lodge Foyer Valade Golden Door Geriatric Centre

Golden Links Lodge

Golden West Centennial Lodge

Heritage Lodge Holy Family Home Kildonan PCH

Lions Manor Personal Care Centre

Luther Home Maples PCH Meadowood Manor

Middlechurch Home Misercordia Health Centre

Oakview Place Park Manor

Parkview Place Pembina Place Poseidon Care Centre River East

Riverview Health Centre River Park Gardens St. Amant Centre St. Joseph’s Residence

St. Norbert Saul & Claribel Simkin Centre

Taché Centre Tuxedo Villa

Vista Park Lodge West Park Manor

Regional Program Team

• Executive Director• Pharmacy Manager• 2 Clinical Nurse Specialist• Program Educator• Infection Prevention and Control Manager• RAI Coordinator• Safety Coordinator (shared with DLC)

Regional Services

• Speech Language Pathology• Respiratory Therapy• Clinical Nutrition• Quality Improvement• Community Therapy Services

Who do we work with – System Partners

• Geriatric Mental Health • Acute Care – Emergency Program• Palliative Care• Home Care – Access and IV Therapy• Community groups

PCH Services PCH Standards & Regulations

•24 hour nursing•Personal care•Physician services•Medication•Basic supplies•Recreation•Limited rehab service•Accommodation services

•Gov’t Regulation• 26 Standards •Reviewed q2years•Licensed annually•PPCO•Critical Incidents•Complaints•Unscheduled reviews

Who lives in PCH

Male = 27.9%Female = 72.1

0

5

10

15

20

25

30

35

Age

<75

75 to 84

85 to 89

>90

Diagnosis

0

5

10

15

20

25

30

35

40

45

50

DementiaHypertensionArthritisCardiacCVADiabetesCHFHypothyroid

0%

20%

40%

60%

80%

100%

6 (Total dependence) 0.5 0.1 0.0 13.2

5 1.3 0.5 0.2 17.8

4 2.7 2.0 0.8 8.2

3 6.5 4.9 8.5 26.9

2 15.1 15.9 12.8 18.3

1 8.2 7.3 13.5 6.2

0 (Independent) 65.6 69.4 64.3 9.5

PrivateDwelling

AssistedLiving

SupportiveHousing

PCHResident

Physical Functioning: ADL Self-Performance Hierarchy Scale

Centre on Aging Study

0.0

20.0

40.0

60.0

80.0

100.0

5 (Incontinent) 4.8 4.1 5.3 34.3 1.9 1.1 2.5 25.8

4 11.0 12.9 12.5 19.0 2.6 2.4 4.3 10.5

3 9.1 10.2 8.0 9.0 2.7 3.0 2.7 7.6

2 11.3 13.1 16.3 12.2 5.3 5.4 5.5 13.7

1 2.2 2.2 0.5 0.0 1.5 1.0 0.5 0.0

0 (Continent) 61.4 57.3 57.5 25.5 85.9 87.1 84.6 42.5

PrivateDwelling

AssistedLiving

SupportiveHousing

PCHResident

PrivateDwelling

AssistedLiving

SupportiveHousing

PCHResident

Bladder Bowel

Continence

Centre on Aging Study

0%

20%

40%

60%

80%

100%

6 (very severe impairment) 0.5 0.1 0.0 12.0

5 3.2 1.3 7.3 15.9

4 1.2 0.6 2.5 5.3

3 18.9 21.7 47.7 28.5

2 11.5 14.1 18.9 11.8

1 14.8 18.2 11.6 14.0

0 (intact) 49.9 44.0 12.0 12.5

PrivateDwelling

AssistedLiving

SupportiveHousing

PCH

Cognition: Cognitive Performance Scale

Centre on Aging Study

Dementia

• 12.5 % are cognitively intact• 25.8 % have mild cognitive

impairment• 33.8 % are moderately impaired• 27.9 % are severely impaired

0

5

10

15

20

25

30

%

Private Dwelling 2.28 2.13 0.42 0.94 4.52

Assisted Living 2.62 1.18 0.25 3.65 3.63

Supportive Housing 7.48 3.32 1.33 0.63 8.47

PCH 15.44 14.22 8.84 13.33 24.9

Wandering Verbal AbusePhysical Abuse

Socially Inappropriate

Resists Care

Behaviours by Care Setting

Centre on Aging Study

% of residents

65.8

23.9

10.2

0.0

10.0

20.0

30.0

40.0

50.0

60.0

70.0

0 1 to 3 4+

Aggressive Behaviour Scale Score

Aggressive Behaviour Scale – PCH Residents

Centre on Aging Study

Challenging Behaviours

34% of Residents have some aggressive behaviors in PCH

• What to do when this aggression creates high risk to other residents and staff?

Case Example - Lori

• 45 year old woman with acquired brain injury

• Physically, verbally and sexually aggressive behaviours

• PCH to PCH to Behavior Treatment Unit to St. Amant

• Took over 5 years to find the right spot

Case Example - Joe

• 72 year old with mild dementia, history of ETOH, and anti-social behavior

• Unpredictable physical aggression toward staff and other residents

• Trips to ER following aggressive incidents• Geriatric psychiatry, Service Coordination involved• 24 hour security guard for nearly 2 years• Possible transfer to Selkirk Mental Health Centre• Died suddenly at PCH

Challenges to flow – Hospital Use

Overnight Hospital Admissions in Last 90 Days

None = 92.81

= 6.6

2+ = 0.6

ER Visits in the Last 90 Days

5.5% of residents

Long Waiting Lists

• 107 people waiting in hospitals• 294 people waiting at home

• No significant change in wait list for past 18 months

Wait List Management

• Wait list based on panel date – fair and equitable process?

• How to match residents with behaviours to sites that may have capacity to manage?

• How to balance case-mix within PCH with system needs?

Private Dwelling Supported Living

RAI-HC Indicator

Live Alone

With Spouse

With Others

Assisted Living

Supportive Housing

Age Age 75+ Age 75+

Gender Female

Education < Grade 8

< High school

High school

ADL Decline

Any Any Any Any

Bladder Incontinence

Any Any Any Any

IADL Great difficulty

Great difficulty

Cognition Any decline

Any decline Any decline Any decline

Behaviour Problem present

Problem present

Problem present

Caregiver Distress

Any present

Any present

Any present

MAPLe Mild score +

Mild score +

Moderate + High +

Factors Associated with Move to PCH

Centre on Aging Study

System Initiatives

• Move of Long Term Care Access Centre to PCH Program

• Use of RAI-HC measures in panel• Why are “independent” people in

PCH• Address Care Giver Burden in

community

PCH New Initiatives

• Nurse Practitioner in PCH• Early results show decreased

acute care and ER use• Reduced medication use

• PIECES Education• Education and a tool kit for front-

line professionals to assess and manage challenging behaviours

Staffing

• Manitoba Health increased staffing to 3.6 hours per resident day

• Standardize staff model and mix across all sites

• Highest staffing levels in the country• Implemented over next 3 years• Increases coming to Allied Health

staffing

Long Term Care Strategy

• Ensure people are placed in most appropriate alternative

• Create more private PCH accommodation

• Specialized options for some complex cases

Questions