Links among hospitals, community care and nurses help resolve ALC woes
Community care managers are able to start the placement process before patients are admitted to hospital.
From Canadian Healthcare Technology, September 2011 issue
By Andy Shaw
Toronto – Once you fought your way through the fog of presenters’ PowerPoints, three-syllable words and unexplained acronyms at the annual conference of the Ontario Association of Community Care Access Centres (OACCAC), phew, in Toronto, one thing did come clear. Forging firmer, faster links between acute, community, and home care providers in Ontario has become a serious, collaborative business.
In the province’s 14 Community Care Access Centres (CCACs), government-funded groups of hospital clinicians and department heads, community care nurses, case managers, long-term care providers, and technology vendors, even patients, are working together – putting into place new ways to keep the chronically ill and elderly out of overcrowded, high-cost hospital rooms. By one means or another, the working groups’ common aim is to provide better and less costly care for such patients – either in their homes or in places where they feel at home.
To that end, the issue these work groups are all grappling with is ALC, short for “alternate level of care”. The acronym refers to patients who end up in hospital but remain there at great expense to the taxpayer because they have no home in which to be cared for, or they are unable to find a place in community facilities such as a nursing home.
To the rescue come the likes of OACCAC conference presenter Jean Kish, a 20-year nursing science veteran who leads one of these groups in the Central East CCAC, which stretches from Scarborough east along the Lake Ontario shoreline and up to Haliburton.
“We are implementing a known model of care called Home First, says Kish. “I know it sounds like a project, but it isn’t; Home First is a tried and true philosophy.”
A philosophy that Kish and her cohorts firmly believe will profoundly change Ontario health-care for the better. “Our primary objective for Home First is to systematically pull our clients back into the community as soon as possible,” says Kish, “place them appropriately, ensure they have the services and care they need, and do all that in What’s unsafe about unduly long hospital stays, Kish further explains, is that patients tend to “de-condition” or become less fit and more unhealthy, leaving themselves susceptible to bed sores or skin ulcers and also to hospital-spawned infections.
Often a chronically ill or elderly patient’s stay is lengthened because he or she has difficulty deciding about or knowing where they can go after discharge.
“Of course, we can’t prevent people from going to the hospital, but the Home First initiative aims to get the CCAC involved at an earlier stage in the patient’s progress through the hospital,” says Kish. “We try to engage with the patient within 24-48 hours, then start addressing right away any barriers to discharge they may have.”
In some cases, Kish’s team and their partners – aided by the CCAC’s sophisticated alerting technology – have rushed a case manager to the emergency department and been able to pull and successfully place a patient in home or community care before being admitted to hospital.
The chief technology enabler of that swift work has been in the hands of David Merkley, the CCAC’s senior manager of decision support and a whiz at data management.
“The data on our CCAC information system has to be as close to real time as possible so that our case managers can identify, locate and engage the patient,” explains Merkley. “So our network reaches into our 13 hospitals as well as to our seven branch offices in our CCAC. We get alerted anytime one of our clients shows up in an emergency department. We know right away and can usually send a case manager out immediately.”
But of course not all patients going to the ED have come under community or home care programs before and will not therefore be known to the CCAC. However, they may well still need its alternate level of care (ALC) services.
“So we have developed a ‘fingerprint’, if you will, for patients who are likely to go ALC at the end of their [hospital] stay, so that we can be also alerted when they show up,” says Merkley. “The fingerprint is: somebody who is 75 or older with at least two or more risks, including a history or evidence of cognitive impairment, difficulty walking, a recent history of falls, has visited the ED within the last 30 days, lives alone, or has no available care giver.”
All the hospital IT departments in the East Central CCAC have co-operated with Merkley and his staff and now issue their alerts electronically. Merkley is quick to admit that the system is not perfect and some patients who end up requiring ALC are not automatically made known to the CCAC.
“But even when that happens, we want to know about it and we follow up to see what happened,” says Merkley, “We ask ourselves: Was this a preventable case that we just missed? Or was it a legitimate ALC that we could have done nothing about anyway?”
Merkley adds that their answers to those questions and other data have been made meaningful to both hospital and the Central-East CCAC alike, thanks in part to the OACCAC’s own CHRIS (Client Health Related Information Network) that connects all 14 CCACs.
“We had recently switched to CHRIS and a lot of the SQL (database) script writing and data extraction expertise needed for that went into helping our hospitals with pulling data out of their subsystems and getting the data to us,” says Merkley. “We helped them transform that data, consolidate it into little batches, and put them in a common data format before they end up into our repository. Once the information is in there, we can radiate the data back to a wide geography, including the hospitals.”
Sounds simple but it is not light work.
“We receive batches of data four times an hour, 24 hours a day from our 13 hospital sites,” Merkley points out. “So that’s 150,000 batches a month or 1.8 million a year. That’s the kind of data processing it takes to sustain something like Home First.”
But Central East CCAC is not resting on those data management laurels.
“We use all the alerts coming into us to measure our success. We focus mainly on ALC numbers because avoiding ALC designations is what this all about,” says Merkley. “We look at what percentage of hospital beds are occupied by people who shouldn’t be in those beds.”
In effect, and in a truly integrated way, the Central East CCAC is managing acute lengths of stay in its hospitals guided by its Home First philosophy. So they pay particular attention to who comes out of hospital too soon and then has to go back in.
“We are monitoring the re-admission rates. It’s one of our process indicators,” says Merkley. “Indeed, we have a set of 40 indicators that we share with each hospital. So they can track them and see how much the ALC they are providing is decreasing.”
Central East CCAC finished the rollout of its Home First-guided data tracking system just a few weeks before the late June OACCAC meeting in Toronto. There, Jean Kish reported that this enhanced service had already seen 14,000 patients through to discharge.
“Some of our hospitals have already reported that they have empty beds for the first time in six or seven years,” says Kish. “We also believe, most importantly, that we provide a better experience for the patient because they are involved by our case manager in the decision-making process of what’s going to happen to them on discharge almost from the moment they enter the hospital.”
But Central East CCAC is not alone in bringing technology-assisted innovation to better integrated hospital, community, and home care.
The North Simcoe Muskoka CCAC, covering cottage country north of Toronto and the burgeoning city of Barrie, has focused on getting the best out of the “automated provider reports” that pour into the CCAC on the health of its clients from the visiting nurse partner organizations and long-term care providers.
“To get automated provider reports you may have to consider buying new hardware, especially if you are using any point-of-care technology,” Susan Gains of Procura told the OACCAC meeting in a session meant to acquaint attendees with the practicalities. “And you have to make sure you understand all the OACCAC rules and testing you must do to interface with the CHRIS network before your automated provider reports can go live.”
Victoria, BC-based Procura is a vendor partner for North Simcoe Muskoka and specializes in home and community care software. It’s been adopted widely by recognized agencies in the sector such as We Care Home Health Services, the non-profit St. Elizabeth Health Care, and Bayshore Home Health, all of which are service provider partners with North Simcoe Muskoka.
For these community and home care agencies Procura provides software to handle their back office administration, as well as a range of mobile software products which enable connection with agency caregivers via their smartphones and tablets.
“Automated provider reports can contain things like a patient’s change in health status, care plan change requests, other updates on the patient, and of course their discharge,” explains Gains. “The report can be filled in at the point of care by the caregiver and then, when the ‘COMPLETED’ button on their phone or tablet is touched, it is automatically sent by the CHRIS system to the CCAC. It is also filed via Procura in the patient’s electronic medical record, all at the same time.”
