CCAC Stroke Community Model

Transcription

Waterloo Wellington CCAC
Community Stroke Program
Stroke Collaborative 2014
October 27, 2014
Maria Fage, OT Reg. (Ont.)
Manager, Client Services
Map of
Waterloo
Wellington
LHIN
Waterloo Wellington Community Care Access Centre
2
Background
Integration of Stroke Services Across the Continuum
(April 1, 2014)
Waterloo
Wellington
Stroke
Steering
Committee
LHIN Integration Order (August, 2013)
Reports
Hospital reorganization
Stroke
Implementation
Task Force
CCAC to
deliver bestpractice
stroke care
“Improving Access to Quality Stroke Care in
Waterloo-Wellington” (2011);
“Transitioning to a System of Rehabilitative Care in
Waterloo-Wellington” (2012)
Access
Outcomes
System
efficiencies
3
Waterloo Wellington Stroke Steering
Committee & Implementation Task Force
4
CCAC Community Stroke Program is One
Component of the Waterloo Wellington
Integrated Stroke Care System
5
Program Components & Timelines
Phase 1: November 2013
Phase 2: April 1, 2014
•
Designated Stroke Care Coordinators:
Hospital & Community
•
First home visit by therapist within 48
hours of hospital discharge
•
Link to Primary Care
Discharge Link Meeting (Rehabilitation
& Acute Sites)
•
•
Consolidated Service Provider – “Stroke •
Team”
•
Use of Rehabilitation Assistants
•
24 hour on-call access
•
Transition to Next Phase of
Clinical Rehab Pathway as per best practice
guidelines; including rehab assistants
Phase
1
Rehabilitation
•
Evaluation
Phase 3: Fall 2015
•
Phase
2
Incorporate Nursing & PSW into Stroke
Team
Phase 3
6
Consolidated Service Provider “Community Stroke Team”
• Care Coordinators
• Dedicated
• Additional training and
knowledge of stroke
system and resources
Stroke Care
Coordinator
• Stroke Team
• Dedicated
• Education and skill
requirements:
PT
•
•
•
•
Neuro/stroke
rehabilitation
Knowledge of stroke
best practices
SCATM
Best practice
assessment tools
OT
(Lead
Therapist)
SW
Rehab
Assistants
SLP
RD
7
WWCCAC Stroke Pathway
Pre-Discharge
•Discharge
Planning
•Discharge
Link Meeting
Weeks 1-2
•Assessment &
Goal Setting
•Care
Coordinator
Assessment
Weeks 3-4
•Case
Conference
•Treatment
Weeks 5-8
•Treatment
•CSS linkages
Weeks 9-12
•Transition &
Discharge
•Case
Conference
•Care
Coordinator
Reassessment
•CSS linages
•
Based on the clinical stroke pathway developed by NSM CCAC and adopted by
the OACCAC. Based on Canadian Stroke Best Practice Guidelines, and
validated by the OSN.
•
Defines expected outcomes and interventions of the Care Coordinator and
Therapists; OT typically the lead therapist and attends Discharge Link.
•
Available visits to provide an intensity of therapy (OT, PT, SLP, SW, Nut,
Rehab Assistants) that is in keeping with best practice (45 min-3hour visits; 35x/week)
•
Patient’s progress determines how he/she move through the pathway.
•
Patient transitioned to the next phase of rehabilitation upon completion of the
pathway.
8
Waterloo-Wellington Banding Model:
-
Used to Guide Patient Flow & Eligibility
Band 1
Assessment
and Triage;
TIA
Band 2
Short Stay Rehab
High Intensity and
Short Duration
Band 3
Moderate
Intensity/Duration
Band 4
Low Intensity/Long
Duration
Band 5
Severe Strokes
Palliative
Little or No
Improvement
Outpatient
or
Community
Program
CCAC Stroke
Program
Eligibility for WW CCAC Stroke Program:
• Band 2, 3, or 4
• Need for multi-disciplinary stroke
rehabilitation
• Willing to participate
• Rehabilitation needs are best met in the
home
• Patient lives greater than 30 minutes from
an outpatient program
9
Acute & Rehab vs CCAC Stroke Volumes
60
50
49
47
45
44
Average:
45.4
42
Number of Patients
40
Total Acute+Rehab
30
WWCCAC
20
Average:
14.2
20
15
15
10
11
10
0
April
May
June
July
August
Month
10
Number of Stroke Pathways Started & Completed
1 Apr - 17 Aug 2014
63
70
60
50
40
28
27
30
20
10
0
Total # of Pathways
Pathway Completed: goal met
Client Still Active on Pathway
11
Therapy Utilization as a Percentage of Patient
Pathways
1 Apr - 17 Aug 2014
120%
97%
100%
86%
80%
59%
60%
44%
40%
16%
20%
0%
Visit OT
Visit PT
Visit SW
Visit SLP
Visit RD
12
Time per Visit by Therapy Discipline
1 Apr - 17 Aug 2014
100
90
80
70
60
50
40
30
20
10
0
Visit OT
Visit PT
Visit SW
Visit SLP
Visit RD
Average time per visit (mins)
58
58
63
57
61
Min. time per visit (mins)
15
30
50
30
60
Max time per visit (mins)
95
90
90
75
75
13
Patient & Caregiver
perspective on
impact of program:
- Patient
Experience Survey
Magnitude of
Functional Change:
System Impact:
- Hospital readmission rates
- RAI-HC
- In-patient
rehabilitation
length of stay
- Barthel Index
- RNLI
Program
Evaluation
14
Brant Haldimand Norfolk
Community Stroke Rehabilitation Pilot Model
Metrics Update
September 2014
Lori Schiappa
Manager, Client Services
Partners
17
Development of HNHB- CSR Brant
Haldimand Norfolk Pilot Model
• Integration of the Community Stroke Rehab Model
into the care path of the Integrated Stroke Unit
(ISU)
• Identification of patient’s rehabilitation needs in
the hospital stay, within 24-72 hours
• Strong link with District and/or Regional Stroke
Centre’s ISU
18
• Strong link with primary care physician
• Post discharge interdisciplinary meetings monthly
• Transferability of model (is the model able to be
spread across the HNHB based on the pilot results)
• Standardized reporting requirements
• Consistency of Service Provider Stroke Team (80%
of care is to be provided by a consistent
OT/PT/SLP in the community)
• Stroke Team Members Expertise (e.g. FIM, MoCA
(OT), Neuro Motor Rehab, Supportive conversation
for Adults with Aphasia)
• Dedicated Care Coordination
20
• Time to first visit within 72 hours following
hospital discharge for provider and the Care
Coordinator
• Care pathway into streams (mild, moderate,
severe) based on best practice standards: 2-3
outpatient or community based allied health
professional visits/week (per required discipline)
for 8-12 weeks and incorporates milestones and
opportunities for reassessment
Eligibility
• Persons post stroke will be triaged into two CSR program
• Outpatient clinic based therapy
• Outreach home based therapy (CCAC)
• Eligibility for in home therapy will be based on the following
criteria:
• Live beyond a 30 minute drive of a specialized clinic based
OP stroke rehab program (BCHS)
• Do not have the tolerance to travel 30 minutes to an OP
program and participate in therapy
22
Care Coordination - Value for the
Patient
• Dedicated Community Care Coordination
• Assessment in patients home within 72 hours of CCAC admission
• Additional training for Care Coordinator (Hemispheres training, Aphasia)
• Standardized assessment tool (interRAI-CA, RAI-HC)
• Link patients to community programs (Health Care Connect to find a
physician)
• Referral to other agencies (Adult Day Program, supportive groups in
community, other rehab in the community)
• Connection with service providers (post discharge meeting monthly,
updates)
• Care Coordinator housed in office to address urgent patient calls
• Assistance with transitioning to alternate levels of care (RHs, LTCHs)
• Coordinates post discharge stroke team meetings monthly
23
Community Stroke Rehabilitation Pilot
Model
Metric Results from December 2013-June 2014
(Data Source: HNHB CCAC CHRIS)
24
Model
Stream &
Services
# Patients
Visits
Avg.
Visits per
Person
7
19
103
3.5
9.5
17.2
PT Visits
Mild
Moderate
Severe
2
2
6
OT Visits
Mild
Moderate
Severe
3
2
6
18
20
113
6.0
10.0
18.8
51
43
66
17.0
43.0
13.2
Average visits per person were highest in the
Severe stream for PT and OT. Average visits
per person for SLP were higher in the Mild
stream and highest in the Moderate stream
SLP Visits
Mild
Moderate
Severe
3
1
5
25
Model
Services
# Patients
# Patients Received PT Services
10
Total PT Visits
129
Average PT Visits per Person
12.90
# Patients Received OT Services
11
Total OT Visits
151
Average OT Visits per Person
13.73
# Patients Received SLP Services
9
Total SLP Visits
Average SLP Visits per Person
The number of
visits and average
visits per person
were highest for
SLP, followed by
OT and lastly PT
160
17.77
26
Community Stroke Rehabilitation
Pilot Model
Goal Met
Stream
Yes
No
80% Consistency
in Service Delivery
# Patients
Patient Discharged
to a Community
Program
Yes
No
Yes
No
Mild
3
3
0
3
0
3
0
Moderate
2
2
0
1
1
2
0
Severe
6
3
3
6
0
6
0
Total
11
72% (8 out of 11)
patients met their
program goals; 3
patients went to
hospital
10 out of 11 of
patients had
80% consistency
in service
delivery
All patients were
discharged to a
community program
Model
DRS (Depression Rating Scale)
# At
# At 3
Admission Months
DRS 0
7
8
DRS 1
1
3
DRS 2
1
0
DRS 3
1
0
DRS 4
1
0
From admission to 3
months – DRS Score
remained the same for
6 patients; improved for
4 patients; worsened
for 1 patient
28
Model
RNLI (Reintegration to Normal Living # Patients Avg. RNL1 # Patients Avg. RNL1
Initial
Discharge
Index) Score
Mild
79
55
3
98
Moderate
3
2
1
72
Severe
4
52
2
68
Used to evaluate degree to which a patient
is able to return to normal life. Higher scores
represent better perceived integration (up to
a max of 100)
Scores From Initial to
Discharge
Mild – Increased by 24%
Moderate – Increased by 31%
Severe – Increased by 31%
29
Model
FIM (Functional Independence measure) Scores
Number Avg. FIM Number of Avg. FIM
of
at Admit Patients
at
Patients
Discharge
Mild
3
114
3
124
Moderate
2
80
2
104
Severe
6
70
6
83
Measures level of disability and indicates how
much assistance is required to carry out
activities of daily living. Higher scores represent
increased independence (up to a max of 126)
Scores From Admit to
Discharge
Mild - Increased by 9%
Moderate – Increased by 30%
Severe – Increased by 19%
30
Model
All 11 of the patients received a
Inter-RAI CA on admission, a RAI-HC within 72 hours and
at 3 months, from a CCAC Care Coordinator
100% of patients
had a RAI-HC
completed at
admission and at 3
months
31
Model
Background
Patients were called at the 3 month mark to determine their level of satisfaction with how the team has
been supporting them post hospitalization.
6 of the 12 patients (March- June) agreed to provide feedback. (Non- participants included, language
barrier, unavailable, did not want to participate)
Patients or Caregivers were approached (4 caregivers, 2 patients)
Preliminary Results
Overall, how satisfied were you with the help you or your loved one received from the team?
•
100% of respondents indicated they were Satisfied or Very Satisfied.
The team members and I decided together what would help me.
•
•
•
33% strongly agreed they felt included in deciding together what would help them
50% neither agreed or disagreed:
Comments: “The plan was outlined for us”.
17% strongly disagreed
Comments: “The amount of service in the beginning was overwhelming”
My therapy program was explained to me in a way that I could understand.
•
•
83% either strongly agreed or agreed
17% strongly disagreed
The team helped me adjust to my life after stroke.
•
•
83% either strongly agreed or agreed
17% disagreed
Comment “I am not sure we will ever adjust”
Would you recommend this team to another family member of friend needing this type or assistance?
•
•
83% Yes
17% Maybe
Model
Survey Comment
“We were not expecting all of the care that we
received from the CCAC. Myself and my sister are
very busy and appreciative of all the support for my
mom”
Model
In summary, this CSR model provides seamless transition through a
standardized care path that details the patient’s journey from ER to
community. The model facilitates collaboration between Hospital and
community supporting patients to work on their Rehab goals in a home
setting.
Thank you!
34
David Ure, OT Reg. (Ont.), CPA, CMA
Development of the model
In response to the request for proposal issued by the Ministry of Health and Long-Term
Care in September 2001, the Southwestern Ontario Region submitted a pilot project
titled:
“A Regional Stroke Rehabilitation System:
From Vision to Reality”
This Outreach Service was effective in meeting the needs of service
providers in the region and the clients/families they serve.
• This is demonstrated by the demand for the service, high levels of satisfaction by
the requesters and the improvement in knowledge self-rating by the participants.
Pilot report submitted to the MOH December 2004
Permanent funding received for 2009 launch
Designed to offer rehabilitation in the community for stroke survivors
with on-going rehabilitation needs
Mandate
1.
2.
3.
Provide rehabilitation in the most appropriate setting (home and community)
Offer secondary prevention, system navigation and community re-integration
Provide caregiver support
Key elements of the model Stakeholders
Key elements of the model – Access
Grey Bruce
Huron Perth
Thames Valley
Southwest
Local
Health
Integration
Network
Key elements of the model – Multidisciplinary
Teams
• Nurse
• Physiotherapist
• Occupational Therapist
• Speech Language Pathologist
• Social Worker
• Therapeutic Recreation Specialist
• Rehabilitation Therapist
Key elements of the model
•
•
•
•
Specialized team
Treatment setting home & community
Service delivered to remote communities
Transition from long term care to
community living
• Community reintegration/linking
with community services
• 6 month follow-ups after discharge
Development and implementation
Key Success Factors:
Ease of referral
Comprehensive data base
Outcome measures on intake, discharge and 6 month follow-up (FIM, PHQ2/9, Bakas,
RNLI)
Self-Management focus
Communication:
• Weekly Rounds, cell phones, Wi-Fi
Development and implementation
Number of Clients Referred
Annual Referral Volume
700
600
500
400
300
200
100
0
2009
2010
2011
2012
Year
2013
2014
Metrics
Referrals per month:
50
Days – referral to first contact:
1-20
Days – contact to first visit:
2-15
Days – Average length of service:
53
Days – Max Ave. Length of service:
84*
Average visits per client:
41
Average intake FIM - 2013:
100
Minimum intake FIM - 2013:
26
Evaluation and Outcomes – System
Impact
Parkwood Hospital - Inpatient Rehabilitation Program
Year of implementation:
32% decrease in alternate level of care days
18% decrease in average length of stay
44.9% decrease in days waiting for admission to inpatient rehabilitation
Evaluation and Outcomes
Evaluating the Effectiveness of Southwestern Ontario’s Community Stroke
Rehabilitation Teams
Gains on the FIM and the physical, communication and social participation domains of Stroke Impact Scale
Fewer signs of anxiety and depression
Required less caregiver assistance
Caregivers (informal, unpaid) experienced improvements in well-being over the course of the program
Patient and caregiver gains were maintained at 6 month follow-up
Allen et al. Evaluating the effectiveness of Southwestern Ontario’s
Community Stroke Rehabilitation teams. Stroke 2013; 44:e213 and
Canadian Journal of Neurological Sciences (in press)
Projecting the Impact of Southwestern Ontario’s Community Stroke
Rehabilitation Teams: An Economic Analysis
Based on the analysis, it is suggested that the community stroke rehabilitation team
model is a cost-effective way to provide community rehabilitation services.
Allen et al. Assessing the impact of Southwestern Ontario’s
Community Stroke Rehabilitation Teams:
An economic analysis. World Congress of Neuro-Rehabilitation,
Istanbul Turkey, April 2014.
A Comparison of Rural versus Urban Stroke Survivors Treated with a Homebased, Specialized Stroke Rehabilitation Program
When provided with access to a home-based, specialized stroke rehabilitation program,
rural dwelling stroke survivors make and maintain functional gains comparable to their
urban-living counterparts.
Allen et al. A comparison of rural versus urban stroke
survivors treated with a home-based specialized stroke
rehabilitation program. Stroke 2013; 44:e192.
Community Stroke Rehabilitation
Alliance
An alliance of community-based stroke rehabilitation programs:
Support and learn from each other (various stages of development)
Compare and contrast existing models
Distribution list for questions/contacts
Forum for addressing issues

CCAC Stroke Community Model

Transcription

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