Need for Specialized Geriatric Services in the Central East LHIN - Central East Regional Specialized Geriatric Services

 
Need for Specialized Geriatric Services in the Central East LHIN - Central East Regional Specialized Geriatric Services
October 2013

   Central East Regional Specialized Geriatric Services

         Need for Specialized Geriatric Services
               in the Central East LHIN

                                Prepared by:

                     This report contains copyrighted material
Need for Specialized Geriatric Services in the Central East LHIN - Central East Regional Specialized Geriatric Services
What We Found
Purpose of the Study
                                            There are many developed and evolving specialized geriatric programs in the Central East
The Regional Specialized Geriatric          LHIN. The Regional Specialized Geriatric Services entity is positioned to improve the
Services (RSGS) entity was formed to        planning and coordination of these programs. The number of seniors in the LHIN is
improve the organization, coordination      projected to double over the next 20 years, but this does not imply that existing services
and governance of specialized geriatric     can or should be increased proportional to senior population growth. Service location and
services for frail seniors in the Central   configuration will need to change, as some communities are growing faster than others.
East LHIN. In 2013, the RSGS                Seniors' preferences and constrained health care budgets will increase the need for
Governance Authority commissioned           community based delivery of senior care. Specialized geriatric service (SGS) can support
Preyra Solutions Group (PSG) to:            the shift from institutional to community settings.
   assess the current and future           Since almost 90% of CE LHIN seniors live in the community, focusing mainly on institution
    specialized geriatric service needs     based services would under serve the population. There is potential for SGS resources to
    of the CE LHIN population               expand in many settings outside long term care homes and hospitals, including seniors'
   assess the capacity of specialized      own homes, in retirement homes or Assisted Living in Supportive Housing. Early access to
    geriatric services in the CE LHIN       these interventions in the community is critical for delaying or avoiding frail seniors' need
   examine the gaps between needs          for institutional care.
    and capacity for different sectors
    that provide specialized geriatric      Hospital days, ED visits and LTC days could be reduced with earlier access to geriatric
    services                                services in the community. RSGS can support the CE LHIN in its specific aim to substantially
   suggest services, subpopulations,       reduce long term care bed days. Expanding SGS services could be extremely cost effective.
    and activities that should be           Without adjusting for case mix and inflation and if capacity were unconstrained, we
    priorized for system improvement        project LTC home expenses in the LHIN would grow by $365 million over the next 20
   identify system reconfigurations        years. Community based SGS interventions could delay and reduce the need for long term
    and resource redistributions to         care days. For example, we estimate that if all LTC homes achieved at least the 50th
    achieve an integrated system of         percentile average length of stay, roughly one million LTC home bed days would be
    specialized geriatric services.         available without increases in capacity. Our analysis also finds that residents in some
                                            homes are less frail than others, creating an opportunity for residents that would
To conduct its assessment PSG worked        otherwise be in long term care to remain in the community.
with an RSGS Steering Committee,
which included clinicians and managers      There are many health risks that SGS can be expected to reduce. These risks are
from specialized programs in the CE         measurable and are important indicators of system efficiency, patient experience and SGS
LHIN. PSG conducted extensive               effectiveness. We found substantial variation in seniors’ risk of health service utilization
analysis using population,                  across the LHIN. These variations include Potentially Avoidable Hospital Use and low
administrative, and survey data.            acuity visits from the LTC to the ED.
Methods included linked episodic,
                                            Case finding is an important tactic to ensure that SGS resources are best used. To
single episodic, and population based
                                            demonstrate, we created a segment of high users that could be targeted for specialized
analysis. To understand demand, we
                                            services. We identified 4,900 high acute use seniors in the CE LHIN. These seniors had high
estimated the risk of health decline. To
                                            rates of Potentially Avoidable Hospitalizations and their health deteriorated from low to
understand service need, we matched
                                            high levels of frailty in the years before their hospitalization and institutionalization.
different kinds of senior health risks to
RSGS interventions that could reduce        Specialized geriatric services in both institutions and the community will need to increase
that risk. Where possible, statistics       in the future as the population ages. How this is done will affect the whole health care
from other specialized programs and         system. There is no single best way to organize specialized geriatric services, although
the literature were used for                there are essential components: services should be provided to those seniors that would
comparisons.                                benefit most; coordinated specialized geriatric services should be available in the
Victoria Van Hemert generously
                                            community with the goal to reduce specific health risks such as injuries, muscle
provided extensive comments on an
                                            weakening, infections and exacerbation of chronic conditions; and service should be
earlier draft. The report does not
                                            continuously evaluated for quality, access and effectiveness.
necessarily represent the views or
actions of the Central East LHIN or the                                                                                               2
RSGS Governance Authority.
Need for Specialized Geriatric Services in the Central East LHIN - Central East Regional Specialized Geriatric Services
Table of Contents
Background......................................................................................... 4
Scope and Methods ........................................................................... 5
Seniors in The Central East LHIN ................................................ 6
I. The Needs of Frail Seniors in the CE LHIN .......................... 10
      Frail Seniors ............................................................................. 10
      Health Risks that RSGS Can Reduce ................................. 13
      Priority Populations for RSGS............................................. 19
II. Meeting the Needs of Frail Seniors in the CE LHIN ......... 27
      What RSGS Resources are Available? ................................ 27
      What Are the Service Gaps? .................................................. 36
      Findings and Suggestions ..................................................... 47
Appendices ........................................................................................ 51
      Appendix A ............................................................................... 51
      Appendix B ............................................................................... 52
      Appendix C ............................................................................... 59
      Appendix D ............................................................................... 60

                                                                                                    3
Need for Specialized Geriatric Services in the Central East LHIN - Central East Regional Specialized Geriatric Services
Background               In May 2011 the Central East LHIN identified the opportunity to create the Regional
                         Specialized Geriatric Services entity (RSGS): Regional, for close-to-home care that
                         meets community needs; Specialized, because skilled interprofessional teams provide
                         the care; Geriatric because seniors, especially those older than 75 years, are the
                         focus; and Services, which are a portfolio of available interventions that combine to
                         improve frail senior health. RSGS became operational in July 2012.

                         These basic qualitative ideas about RSGS motivate our policy questions: Who are the
                         frail seniors? What specific services do the CE LHIN frail senior population need? How
                         much of each service should be provided? Where should services be provided? What
                         outcome improvements can be expected by program expansion and redesign?

                         That these questions are unanswered reflects the Central East LHIN's current
                         patchwork of specialized geriatric services across community and institutional
                         settings.

                         Specialized Geriatric Services
                         SGS uses expert, inter-professional teams to provide eldercare. These teams include
                         physicians trained in geriatric medicine and geriatric psychiatry. Services include
15% of CE LHIN           geriatric emergency management, geriatric rehabilitation, geriatric day hospital,
residents are seniors,   geriatric outreach, geriatric specialty clinics, inpatient geriatric consultation, inpatient
yet consume almost       geriatric assessment and treatment, acute care of the elderly units, urgent-emergency
                         care clinics, community and long term care psychogeriatrics, and nurse led outreach
half of the LHIN's
                         to long-term care.
health care resources
                         Frail seniors and their families experience SGS as services in varied settings by
                         interprofessional teams.

                         Within SGS programs, service availability and delivery modes differ by CE LHIN
                         community. Specialized geriatric programs in the LHIN have evolved to reflect
                         differences in the resources, values, effort and vision of community focused teams.

                         RSGS allows frail senior programs to be distinct yet benefit from the coordinated care
                         and planning that is possible under a single entity.

                                                                                                                   4
Need for Specialized Geriatric Services in the Central East LHIN - Central East Regional Specialized Geriatric Services
Scope and                             This study assesses the need for specialized geriatric services in the CE LHIN. The
                                      frailest seniors are found in hospital and long term care yet most frail seniors are in
Methods                               the community; specialized services for all these seniors are in scope for this study.
                                      Our first objective was to infer unmet SGS need from differences in frail senior
                                      resource use and outcomes between Central East and other LHINs and among Central
                                      East clusters. Our second objective was to describe current CE LHIN SGS capacity,
                                      organization, expansion and reconfiguration options to meet future need.
                                      Beginning a study of this kind, it is difficult to predict which information is most
                                      important. We undertook extensive analysis which was reviewed by an RSGS Steering
                                      Committee in order to select priority areas. This report describes the topics and
                                      results that are immediately important for RSGS planning. Further details about the
                                      Committee and the analysis are in the appendices.
                                      To do our work, we organized multiyear clinical and financial administrative data from
                                      hospitals, long term care homes, the Community Care Access Centre and Community
                                      Health Centres. We obtained additional statistical and financial information about
                                      specialized geriatric services in the LHIN directly from the programs, and surveyed
                                      managers when we needed more detailed information and statistics.1 We used
                                      Census data and Ministry of Finance population estimates and projections to compare
                                      and report results by geographic cluster within the LHIN. Our person based analysis
                                      was both single and multiple encounter, akin to the approach used in risk adjustment
                                      systems such as the Health Based Allocation Model (HBAM). We devised population
                                      segmentation approaches to better match frail seniors to specialized services, and to
                                      help RSGS prioritize interventions. In most cases, we compared Central East
                                      measures with other LHINs and the province. Where possible, we used information
                                      about better practice2 gleaned from our literature review.
                                      There are several important limitations to our analysis. First, program statistics were
                                      not always comparable across clusters or across LHINs. This is because many of the
                                      programs were historically developed independently of each other, with their own
                                      service definitions and reporting requirements. Second, programs in the LHIN did not
                                      have similarly defined counterparts in the other jurisdictions, limiting our ability to
                                      benchmark; as with the Ontario comparisons, this reflects the evolution and
                                      customized nature of specialized geriatric programs. Third, there is little client level
                                      morbidity data for ambulatory and community-based services, which limits refined
                                      estimation of community specific need and program case mix.

1
 Data from program managers was collected between April and June 2013.
2
 We refer to improvements in service access and delivery as "better practice". "Best practice" would incorrectly suggest that there is
consensus about an ideal state.
                                                                                                                                    5
Despite these limitations, there are numerous strengths to the analysis. We combine
                                          survey with financial and clinical administrative data, and apply leading analytic
                                          methods to describe the current system and ways it can be improved. It is the first
                                          inter-sectoral analysis of health service use, need, capacity, specific to frail seniors in
                                          the CE LHIN, and its findings can substantially inform RSGS strategy.

Seniors in The                            15% of the Central East LHIN's 1.6 million residents are seniors, yet consume almost
                                          half of the LHIN's health care resources.3 Over the next 20 years, the LHIN's senior
Central East                              population is forecast to double, substantially increasing total health care need.4
LHIN
                                          The Central East LHIN covers 17,000 square kilometers of mostly rural geography.
                                          Only 11% of residents live in rural regions while 80% of residents are concentrated in
                                          Scarborough and Durham.

                                          Meeting the SGS needs of frail seniors will require different approaches for rural and
                                          dense urban areas. Exhibits 1 and 2 show the location of the LHIN's nine acute
                                          hospitals, 68 Long Term Care Homes, 39 Community Support Services, 17 Assisted
                                          Living Services in Supportive Housing, seven Community Health Centres and other
                                          services5 with overlays for rural geography and demographic growth. As Exhibit 1
                                          shows, most services are concentrated in urban areas, with service clusters around
                                          populated rural areas.

                                          The location of services will likely need to change in the future. As Exhibit 2 shows,
                                          local services will need to grow faster in some communities than others because of
                                          differential population growth; for example, 20 year senior population growth
                                          forecasts range from 60% in Scarborough to 170% in Durham.

3
  Ministry of Finance. “Ontario’s Long Term Report on the Economy.” Web. 5 July 2013.
.
4
  Statistics Canada, Ministry of Finanace Population Projections.
5
  Central East LHIN. “Developing Ontario’s Seniors Care Strategy: A Central East LHIN Perspective.” Central East LHIN.
.
                                                                                                                                    6
Exhibit 1         Health Care Providers and Rural Regions in the Central East LHIN

Different approaches
are required for rural
and urban areas

                                 Source: FSA Rural Geograph, MOH Health Indicator Tool

                                                                                                              7
Exhibit 2         Health Care Providers and 20 Year Forecast Growth in the Senior
                                          Population in the Central East LHIN

Specialized geriatric
services will need to
grow faster in some
clusters

                                Source: MOF Population Projections, MOH Health Indicator Tool

                        Where Do Seniors in the Central East LHIN Access Services?

                        Most specialized geriatric services are best received close to home, so a LHIN cluster`s
                        resources should be strongly linked to its total senior residents. However, for
                        specialized geriatric services that should be co-located in hospitals, resources should
                        flow to where seniors receive care, which might not be at a hospital in their cluster. In
                        Exhibits 3 and 4 below, we show the extent to which seniors receive hospital inpatient
                        and emergency department care within their own cluster.

                                                                                                               8
Exhibit 3           Where Central East 75+ Seniors Receive Services, Inpatient
                                                           Discharges 2011/2012

                                                                                Hospital Location
                                                                 North East     Durham      Scarborough     Out of         Total
CE seniors do not                       Patient Residence
                                                                  Cluster       Cluster        Cluster      LHIN        Discharges
always receive care in                  North East Cluster          86%         2%            0.4%          11%           8,574
their home cluster                      Durham Cluster              2%          74%            6%           17%           8,875
                                        Scarborough
                                                                    0.1%        1%            76%           23%           9,950
                                        Cluster
                                        Central East LHIN           27%         25%           30%           18%          27,399
                                        Source: DAD, 2011/12

                                       Exhibit 4           Where Central East 75+ Seniors Receive Services, ED Visits
                                                           2011/2012

Total services located                                                             Hospital Location
within a cluster need                                              North East     Durham      Scarborough      Out of     Total ED
                                        Patient Residence
not always be                                                       Cluster       Cluster        Cluster       LHIN        Visits

proportional to the                     North East Cluster           95%             1%             0.1%        4%         26,857
                                        Durham Cluster                2%             85%             3%         11%        26,036
number of seniors                       Scarborough Cluster          0.5%            1%             82%         17%        25,041
living in the cluster                   Central East LHIN            34%             29%            27%         10%        77,934
                                        Source: NACRS, 2011/12

                                       Overall 18% of the total 27,399 inpatient discharges for Central East residents aged
                                       75+ were from hospitals outside the LHIN. Scarborough residents were more likely
                                       than North East residents to receive inpatient care from hospitals outside the LHIN.
                                       Although Durham and Scarborough residents are approximately equally likely to leave
                                       their cluster for care (26% vs. 24% respectively), in Durham, 8% of the outflow is to
                                       other clusters within the LHIN (compared to Scarborough at just over 1%).

                                       The North East is almost completely self sufficient for senior ED care (at 95%),
                                       compared with the amount of ED care for Durham and Scarborough seniors that is
                                       provided outside the LHIN (11% and 17% respectively). This patient flow suggests that
                                       total services located within a cluster need not always be proportional to the number
                                       seniors living in the cluster; hospital based geriatric service planning will need to
                                       incorporate both subLHIN6 population growth and market share.

6
    Sub-LHINs are geographic units within LHINs and are synonymous with clusters in the CE LHIN
                                                                                                                                    9
I. The Needs of Frail Seniors in the Central East LHIN

Frail Seniors                              Frailty and Health Risk
                                           There is no all-purpose definition of frailty, nor is there consensus on definitions
                                           within specific settings.7 8 9 In practice, the term frailty is imprecise and potentially
                                           confusing.

                                           Briefly put, frail seniors are at risk for worsening health; frail seniors are less able than
                                           others to recover after a health stressor event. Examples of their health risks include:
                                           need for institutional care; falling; delirium; post surgical complications; functional
Frail seniors are less                     dependence and death. Specialized geriatric health maintenance, health restorative
able than others to                        and preventative interventions each reduce health risk.
recover after a health                     Conceptually, we use the terms frailty and health risk interchangeably, but for
stressor event                             analysis, we specify the type of senior health risk to be managed. Referring to frailty
                                           without identifying the specific nature of the risk is operationally incomplete.

                                           As RSGS develops and implements its strategy, it should be aware of the types of
                                           health risks that can be reduced through specialized interventions, and should
                                           understand how clinicians, planners and researchers measure frailty in populations.
                                           Exhibit 5 shows a sample of approaches. These differ in method, the data used and
                                           the extent to which they are calculable across different settings in Ontario.

                                           Exhibit 5              Sample Frailty Indexes
                                                                                                                     Ontario Data
                                                  Measure              Developer              Data Used
                                                                                                                   Currently Available
There is no single                              CSHA Clinical
                                                                     Rockwood et al.      Clinical Assessment           Some Sites
                                                Frailty Scale
definition of frailty                          Edmonton Frail
                                                                      Rolfson et al.      Clinical Assessment           Some Sites
that is appropriate for                            Scale
                                              Rockwood Frailty                             Comprehensive
all RSGS purposes                                  Index
                                                                     Rockwood et al.
                                                                                         Geriatric Assessment
                                                                                                                        Some Sites

                                              Adjusted Clinical       Johns Hopkins                               Hospital IP DS and ED/
                                                                                            Administrative
                                                  Groups                University                                         OHIP
                                                                                                                   Assessed Home Care,
                                               MAPLe/CHESS              InterRAI            RAI Assessment
                                                                                                                       All LTC, CCC
                                                                                                                  Hospital IP DS and ED/
                                              High Risk Seniors           PSG               Administrative
                                                                                                                           OHIP

7
  Fried, L.P., C.M. Tangen, M.A. McBurnie, J. Walston, A.B. Newman, C. Hirsch, J. Gottdiener, T. Seeman, R. Tracy, W.J. Kop, G. Burke and the
Cardiovascular Health Study Collaborative Research Group. "Frailty in older adults: evidence for a phenotype." The Journal of Gerontology. 56.3
(2001): M146-56. Web. 3 July 2013.
8
  Rockwood, Kenneth , and Arnold Mitnitski. "Frailty in relation to the accumulation of deficits." The Journal of Gerontology 62.7 (2006): 722-727.
Web. 3 July 2013.
9
  Meloche, James. "LHINs, Primary Health Care and Health System Design: Integrating Systems and People to Achieve Better Outcomes for our
Community." Central East LHIN. Web. 5 July 2013. .
                                                                                                                                                  10
Several research studies conclude that, in care settings where different instruments
                                             can be compared, frailty measures are highly correlated.10 When frailty measures
                                             use different data elements, such as comorbidity and functional status, results can
                                             differ, but then the measures can be used together to better describe population
                                             frailty.

                                             Choice of instrument matters at the individual level but, since results are often similar
                                             at the regional level, RSGS can choose one approach to estimate frailty for regions
                                             within the LHIN. For example, using Rockwood's application of the CSHA Clinical
                                             Frailty Scale to Canadian data, we can estimate and forecast frailty prevalence in the
                                             population 65 years and older in the Central East LHIN11, as shown in Exhibit 6 for the
                                             FY 2012/2013.

                                             Exhibit 6           CSHA Clinical Frailty Scale Estimated Number of Seniors by Level of
                                                                 Fitness in the CE LHIN

                                                                     North East              Durham           Scarborough             Central
                                                                      Cluster                Cluster             Cluster             East LHIN
                                              Relatively Fit            15,467               19,344               20,615               55,426
                                              Less Fit                  18,724               23,177               24,901               66,802
                                              Least Fit                 15,431               18,881               20,456               54,768
                                              Frail                     15,126               18,164               19,923               53,214
                                              Total                     64,748               79,566               85,895              230,209
                                              Source: Rockwood Frailty Scale, MOF Population Projections

                                             Frailty is a continuous measure, but Rockwood et al. created four groups for analysis.
                                             These groups vary by health risk: for example, the four year mortality rate in the age
                                             70+ Frail group is 36% compared to 20% in the Least Fit group. Planners should
                                             certainly focus on the 53,214 people in the Frail group but are also likely to focus on
                                             the 54,768 seniors at risk that are in the Least Fit group. Later in this report, we use a
                                             broad definition of frailty, which results in slightly different target population
                                             estimates, but here we use the Rockwood groups to illustrate aspects of population
                                             based change. Exhibit 6 shows that the forecasted prevalence varies by both relative
                                             fitness and geography. Exhibit 7 shows that the Frail population is expected to
                                             increase by 25% over ten years, while the Relatively Fit senior population is expected
                                             to increase by 10%. Exhibit 8 shows that the Frail population forecast varies by sub-
                                             LHIN with Durham North/Central expected to increase by 40% and Scarborough by
                                             12%.

10
   Armstrong, Joshua J., Paul Stolee, John P. Hirdes, and Jeff W. Poss. "Examining three frailty conceptualizations in their ability to predict negative
outcomes for home-care clients." Oxford Journals: Age and Ageing 39.6 (2010): 755-758.
11
   Rockwood, K., X. Song, C. MacKnight, H. Bergman, D.B. Hogan, I. McDowell, and A. Mitnitski. "A global clinical measure of fitness and frailty in
elderly people." Canadian Medical Association Journal 173.5 (2005): 489-95.
                                                                                                                                                      11
Exhibit 7            Ten Year Forecast Change in Central East Senior Population by
                                               Relative Fitness
The number of frail
seniors in the CE
LHIN is expected to
increase by 25% over
the next ten years and
this varies by cluster:
40% in Durham and
12% in Scarborough

                          Source: Rockwood Frailty Scale, MOF Population Projections

                          Exhibit 8            Ten Year Forecast Change in Central East Frail Population by Cluster

                          Source: Rockwood Frailty Scale, MOF Population Projections

                                                                                                                12
Health Risks that                           The previous section reviewed frailty measures and demonstrated their use for
                                            population based frailty estimation. Although frailty measures use different data in
SGS Can Reduce                              different ways, they are typically validated based on how well they predict nursing
                                            home admission and mortality12. However, there are other health risks that RSGS
                                            expects its services to reduce, such as hospital-acquired functional decline and
                                            delirium.13 These risks are measurable and are important indicators of system
                                            efficiency, patient experience and SGS effectiveness.

                                            Since risk indicates need for specialized services, measuring risk is a prerequisite to
                                            service gap estimation. Exhibit 9 illustrates how matching risk to service provision can
                                            improve outcomes.

                                            The use of health services over three years for three hypothetical seniors is shown,
                                            beginning at age 75. One senior is healthy, visits primary care once per year and costs
                                            the system $231 over the three years. The other two seniors, with paths in red and
                                            blue, are clinically similar at baseline, but differ in their access to geriatric services.
                                            Both seniors had an incident hospitalization at age 75 with acute costs per day of
                                            $1,250. Unlike the senior in red, the senior in blue has timely access to Long Term
                                            Care, which is enhanced by specialized care shown as LTC+, which costs $200, instead
                                            of $150, per day.

12
   Rockwood, K., X. Song, C. MacKnight, H. Bergman, D.B. Hogan, I. McDowell, and A. Mitnitski. "A global clinical measure of fitness and frailty in
elderly people." Canadian Medical Association Journal 173.5 (2005): 489-95.
13
   Raymond, Glenna and van Hemert, Victoria. “Development of a Regionalized Specialized Geriatric Service in the Central East Region." Central
East LHIN. .
                                                                                                                                                      13
Exhibit 9   Frailty, SGS and Health Service Use: An Illustration

                               The senior in red became an ALC patient at a cost of $600 per day as they waited for
                               LTC placement. During that time, they developed a pressure ulcer. After admission to
                               a LTC home, the pressure ulcer became infected and they were admitted to the
                               emergency department and discharged back to the home with undetected delirium.
                               They fell, which resulted in a minor laceration and were again sent to the emergency
                               department. The delirium was still undetected and the senior fell again, fracturing
                               their hip. They were admitted to hospital, treated surgically and discharged to the
                               long term care home where they were immobile for an extended period of time. They
                               developed blood clots in their legs, resulting in a pulmonary embolism, and were
                               admitted to hospital, where they died.
                               The senior in blue received timely access to long term care, which avoided the
                               pressure ulcer. In the two years following discharge, they were sent to the emergency
                               department twice. Other emergency department visits were avoided through use of
                               nurse practitioners and protocols in the long term care home to reduce avoidable
                               hospital visits. Exhibit 10 summarizes the outcomes for these seniors.

                                                                                                                 14
Exhibit 10           Outcome Comparison with and without Enhanced Services

                                                                                              Senior with                 Senior without
                                                                                           Enhanced Services             Enhanced Services
                                            Emergency Visits                                         2                            4
                                            Inpatient Visits                                         1                            3
                                            Total Hospital Cost                                  $10,400                      $118,950
                                            Total Hospital and LTC Cost                         $194,970                      $230,040
                                            Health Status after Three Years              Alive, Moderately Frail                Dead

                                          Although this example is simple, the trajectories described are not uncommon among
                                          seniors admitted to hospital. The example suggests how access to specialized services
                                          for frail seniors may improve cost, quality of life, survival outcomes, and the use of
                                          hospital capacity.
                                          Seniors face many health risks, and Exhibit 11 summarizes our literature review of
                                          risks that specialized geriatric services can reduce.
                                          For example, Nurse Practitioners Supporting Teams Averting Transfers (NPSTAT),
                                          Interventions to Reduce Acute Care Transfers (INTERACT), and Acute Care for the
                                          Elderly (ACE), are three SGS interventions shown to reduce senior health risks. Under
                                          NPSTAT, nurse practitioners provide outreach services to LTC homes and reported
                                          reductions in ED transfers of more than 50%.14 INTERACT is a set of tools and
                                          protocols to support LTC home staff. The Centre for Medicare and Medicaid Services
                                          in the US (CMS) pilot studies report that INTERACT reduces Potentially Avoidable
                                          hospital admissions by as much as 50%.15 ACE is an interprofessional model of in-
                                          hospital care that includes physicians, geriatricians and allied health teams. ACE has
                                          been shown to significantly reduce both hospital length of stay, readmissions and
                                          complications.16

14
   Lori Brown. “MH-LHIN’s Nurse Practitioner LTC Rapid Response Team.” Mississauga Halton LHIN.
.
15
   Ouslander, JG., G. Lamb. R. Tappen, L. Herndon, S. Diaz, BA. Roos, DC. Grabowski, and A. Bonner. “Interventions to reduce hospitalizations from
nursing homes: evaluation of the INTERACT II collaborative quality improvement project.” Journal of the American Geriatrics Society.
16
   NSW Dept. of Health. “Acute Care for the Elderly (ACE).” 2006. 
                                                                                                                                               15
Exhibit 11       Examples of SGS Interventions to Reduce Senior Risk
                                                                                         Intervention
        Risks That SGS can Reduce                      Intervention Examples                                    Reference
                                                                                           Settings
ED Visits from LTC                              NPSTAT, INTERACT                     LTC Home           Ouslander et al. (2011),
                                                                                                        Intrator et al. (2004)
ED Visits from Community                        Community Outreach                   Community          Prior et al. (2012)

Hospital Days                                   Interprofessional Geriatric          Acute Inpatient    Hogan et al. (2007),
                                                Consultation Teams                                      Jayadevappa et al. (2006)

Hospital Admissions                             Geriatric Emergency Management,      ED/LTC Home        Sinha et al. (2010),
                                                INTERACT                                                Ouslander et al. (2011)
Complications in Hospital                       Acute Care of the Elderly (ACE),     Hospital           Harari et al. (2007),
                                                Comprehensive Geriatric                                 Vidan (2005)
                                                Assessment (CGA),
                                                Interprofessional Interventions
Admissions to LTC, LTC Days                     GEM, Preventative Home Visits        ED, CCAC           Phibbs et al. (2006),
                                                                                                        Jones (2012),
                                                                                                         Kleinpell et al. (2008)
Avoidable Hospitalizations
      Injury in Community Including Falls       Fall Clinic, Screening, Single and   Outpatient,        Tinetti et al. (1997),
                                                Multifactorial Prevention            Physician Office   Tareef Al-Aama (2011)
                       Adverse Drug Events      Geriatric Nursing Protocol           LTC Home           Zwicker et al. (2012)
                     Urinary Tract Infections   NPSTAT, INTERACT                     LTC Home           Ouslander et al. (2011),
                                                                                                        Intrator et al. (2004)
                           Heart Failure        Geriatric Consultation Teams         Hospital           Buist et al. (2002)
          Dehydration and Gastroenteritis       NPSTAT, INTERACT                     LTC Home           Ouslander et al. (2011),
                                                                                                        Intrator et al. (2004)
   Chronic Obstructive Pulmonary Disease        Home Care by Outreach Nursing        Home               Smith et al. (2008)

                Septicemia or Severe Sepsis     NPSTAT, Interprofessional            LTC Home           Saltvedt et al. (2002)
                                                Interventions
      Minor Procedures in the Emergency         NPSTAT, INTERACT,                    LTC Home,          Ouslander et al. (2011),
                             Department         Preventative Home Visits             Home               Prior et al. (2012)

                                       Guided by our literature review, we selected categories of service use shown to be
Central East LHIN                      sensitive to SGS. To find the best opportunities for RSGS, we compare the rates for
has higher rates of ED                 seniors age 75+ for each of these categories in the CE LHIN and its clusters to the rest
visits and Potentially                 of the Province. Exhibit 12 shows the results of our comparison. RSGS will make the
                                       biggest reductions in risk of avoidable health service use by targeting services where
Avoidable ED visits
                                       rates are high compared to those seen in other regions. We compare the CE LHIN's
from LTC than rest of                  rates of services use against two reference rates: 1) the 25th percentile, and 2) the
the Province                           median. 25% of subLHINs have rates at or below the 25th percentile while half of
                                       subLHINs have rates at or below the median. The 25th percentile is a more ambitious
                                       target than the median, but it is a reasonable reference since it is observed in 25% of
                                       subLHINs. All rates are standardized to control for differences in demographics.
                                       Further description of our methods can be found in Appendix A.

                                                                                                                                   16
Exhibit 12            Variation in Service Use for Seniors Age 75+ in the Central East LHIN

                                                              Amount of     CE LHIN Variation from            Cluster Level Variation from
                                                              Service Use       Reference Rate                   CE LHIN Average Rate
                 Risks that SGS Can Reduce
                                                              for CE LHIN     25th                   NorthEast       Durham          Scarborough
                                                              Seniors 75+                Median
                                                                            Percentile                Cluster        Cluster            Cluster
 ED Visits from LTC                                             19,016        39%          19%         -17%            -14%              25%
 ED Visits from Community                                      201,265        15%           1%         23%              4%               -21%
 ED Visits per Senior from LTC                                   1.6          11%           7%         -5%              -2%                  4%
 ED Visits per Senior from Community                             1.9           8%           4%          7%              4%               -11%
 Hospital Days                                                 832,438        11%           0%         14%              -4%              -7%
 Hospital Admissions                                            78,791         3%          -8%          8%              -1%              -6%
 Repeated Hospital Admissions per Senior IP User                 1.4           3%           1%          3%              1%               -3%
 Admissions to LTC                                              11,964        20%           6%         -7%              -1%                  6%
 Average Length of Stay in LTC                                   612           3%          -5%          5%              5%               -7%
 Post-Procedural Complication                                   4,189          0%          -12%        -3%              7%               -3%
 Post-Admit Comorbidity                                         2,553          1%          -10%        -10%            14%               -4%
 Avoidable ED Visits
                       Injury in Community Including Falls      30,586        15%           1%         15%              7%               -17%
                                   Urinary Tract Infections     8,525         12%          -4%         43%             -11%              -24%
                                             Heart Failure      5,844         15%           0%         -8%              2%                   4%
                   Chronic Obstructive Pulmonary Disease        6,428         29%           7%         42%              4%               -35%
                          Dehydration and Gastroenteritis       3,074         21%           9%         12%              4%               -12%
                              Septicemia or Severe Sepsis        989          29%           9%         -24%             -7%              25%
                                       Adverse Drug Event        167          21%          -17%        63%              -9%              -41%
                                                     Other      16,077        17%           1%         21%              3%               -19%
                          All Avoidable ED Visits from LTC      7,817         36%          18%         -15%             -6%              17%
         Visits from LTC for Minor Px (Suture, Catheter)        1,328         45%          26%         -5%              -5%                  8%
                                    All Avoidable ED Visits     71,690        15%           1%         20%              3%               -17%
 Avoidable Inpatient Hospitalizations
                                             Heart Failure      4,228          8%          -5%         -10%             0%                   7%
                       Injury in Community Including Falls      5,913          9%          -11%        23%              4%               -21%
        Urinary Tract Infections Including Pyelonephritis       2,207          9%          -7%         -13%            -15%              23%
                   Chronic Obstructive Pulmonary Disease        4,099         19%          -6%         27%              2%               -22%
                              Septicemia or Severe Sepsis       1,156         19%          -7%          7%             21%               -23%
                          Dehydration and Gastroenteritis        588          13%          -14%         3%              3%               -5%
                                       Adverse Drug Event         37          28%          -17%        10%             -24%              12%
                                                     Other      3,704          0%          -11%         8%              -8%                  0%
                 All Avoidable IP Hospitalizations from LTC     2,911         24%           2%         -16%            -14%              23%
                          All Avoidable IP Hospitalizations     21,932         2%          -10%        10%              0%               -7%
 Source: DAD, NACRS, RAI-LTC, RAI-HC; FY 2009/10 – 2011/12

                                                                                                                                                  17
How to interpret the information in Exhibit 12:

                         Between 2009/10 and 2011/12, there were 19,016 ED visits by residents of LTC
                         homes to CE LHIN hospitals. Controlling for differences in population
                         demographics, CE LHIN had 39% more visits than expected at the rate seen in 25%
                         of subLHINs and 19% more visits compared to the median subLHIN rate.

                         These findings imply that there are opportunities for SGS to reduce the risk of ED
                         visits from LTC in the CE LHIN.

                         How does the rate vary across Central East clusters? Northeast and Durham
                         clusters were 17% and 14% below the CE LHIN average, while the Scarborough
                         cluster was 25% above.

                         These findings imply that the most opportunity to reduce ED visits among LTC
                         residents is in the Scarborough cluster.

                        Below we list other examples of service use where there may be important
Delaying admission to
                        opportunities for RSGS to reduce risk.
LTC is potentially a
leading goal of         ED visits from LTC and Potentially Avoidable ED visits from LTC are high throughout
                        the Central East LHIN compared to the Province. Other categories of service use are
specialized geriatric
                        generally similar to the Province, but they vary substantially among clusters within
services                the LHIN. For example, although the number of hospital days in the CE LHIN is at the
                        median, the North East cluster is 14% higher than the CE LHIN average while the
                        Scarborough cluster is 7% lower.

                        ED visits per senior in the CE LHIN are higher than the Provincial median, both for
                        seniors from LTC and for seniors from the community. There is substantial variation,
                        however, among clusters within the CE LHIN. In the Scarborough cluster, ED visits per
                        senior from LTC are 4% above the CE LHIN average, while visits per senior from the
                        community are 11% below. In the North East and Durham cluster, visits per senior
                        from LTC are 5% and 2% below the CE LHIN average, while visits per senior from the
                        community are 7% and 4% above. These findings imply that, in Scarborough, there is
                        opportunity to reduce ED visits per senior from LTC, while in the North East and
                        Durham, there is opportunity to reduce ED visits per senior from the community.

                        The rate of post-admit comorbidities for seniors in the Central East is below the
                        Provincial median, but again there is substantial variation among the Central East
                        LHIN clusters. While post-admit comorbidities in Scarborough and the North East
                        clusters are below the CE LHIN average, Durham cluster is 14% above. This suggests
                        that there is opportunity to reduce post-admit comorbidities for seniors in the
                        Durham cluster.

                        Potentially Avoidable Hospital use refers to inpatient and ED encounters that have
                        been demonstrated in the literature to be preventable using community and LTC
                                                                                                              18
based interventions. The literature suggests that differences in the availability of
                                            specialized geriatric services across subLHINs is manifested as differences in
                                            potentially avoidable hospital use and LTC use.

                                            The rates of Potentially Avoidable Hospital use differ substantially by cluster. For
                                            example, in the North East cluster, the rates of COPD inpatient admissions and ED
Average stay in LTC                         visits among seniors are 27% and 42% higher than the CE LHIN average rate, while in
                                            the Scarborough cluster, the rates are 22% and 35% below, respectively. For
varies by cluster. SGS
                                            Septicemia or Severe Sepsis, there are also differences between clusters in rates of
could delay the need                        ED versus inpatient use. In the Scarborough cluster, the rate ED visits for Septicemia
for LTC.                                    or Severe Sepsis is 25% above the CE LHIN average, while the rate of IP admissions is
                                            23% below.

                                            Delaying admission to LTC is potentially a leading goal of specialized geriatric services.
                                            Since SGS reduces risk of worsening health, use of SGS services outside LTC could
                                            result in shorter LTC stays by delaying LTC admission. In the Central East LHIN, the
                                            average LTC resident stay is 612 days. This is similar to the provincial 25th percentile,
                                            so the CE LHIN rate is not currently high; but delaying LTC admission will be an
                                            important CE LHIN strategy as population aging puts additional demand on this
                                            resource.

Priority                                    The previous section described the types and amount of health risk that RSGS could
                                            reduce. The most cost effective RSGS tactic will be to target seniors who would
Populations for                             benefit most from specialized geriatric services.17 For focused analysis, the RSGS
RSGS                                        Steering Committee reviewed population segments that would benefit from
                                            specialized geriatric services. Excluded were people younger than 75 years old,
                                            receiving palliative care or with malignancy.18 95% of seniors aged 75+ remained in
                                            our focal population: the RSGS priority population. We describe this subset of the
                                            Central East senior population as the frail seniors, understanding that the degree of
                                            frailty within this population varies widely.19

                                            Exhibit 13 shows the proportions of these frail seniors living in residential care and in
                                            the community.

17
   Winograd, C.H. "Targeting strategies: an overview of criteria and outcomes." Journal of the American Geriatrics Society 39 (1991): 25S-35S.
18
   The Committee also suggested excluding people with single conditions that we already part of other provincial initiatives such as Stroke, COPD
and Heart Failure. The prevalence of these seniors were so low that they were included in the target population for completeness.
19
   This working definition of frailty is similar to that used by the Institute for Clinical Evaluative Sciences in Health System Use by Frail Ontario
Seniors, 2011. Bronskill et al.
                                                                                                                                                    19
Exhibit 13          RSGS Priority Population by location, residence site and care type
Knowing the specific                           2010/11

settings where the frail                                                                                         Community seniors**

senior population can        Setting                       Location        %        Residence         %         Care Type        %
                             CCC                            1,177        1.2%         1,177         1.2%
be reached is                LTC Home                       8,131        8.4%         8,131         8.4%
important for RSGS           Community                      87,265      90.4%
program design                 ALSH                                                   1,371         1.4%
                               Retirement Home**                                      2,250         2.3%
                               Home in the community                                 83,644         86.6%
                                 Primary Care
                                                                                                                 54,797         65.5%†
                             Teams
                                 Solo-practice Primary Care Physicians                                           25,787         30.8%†
                                   Unattached to PCP                                                              3,060         3.7%*
                                   Home Care                                                                     15,617         17.9%‡
                             Total                          96,573       100%         6,573         100%
                             Excluded§                      4,983
                             Total pop. 75+                101,556

                             * Proportion of seniors 65+ in Ontario unattached to a family physician, as reported in the Primary Care
                             Access Survey (PCAS), 2007-08 {Hay, 2010}.
                             ** Proportion of seniors in retirement homes and receiving different types of primary care are estimations.
                             † Proportions reported by Rosser (Rosser et al. 2011), subtracted the proportion of unattached.
                             ‡ The proportion of total target seniors receiving home care services was 16.2%.
                             § Exclusion criteria were senior receiving palliative care and with malignancies.
                             Source: DAD, NACRS, OMHRS databases, CCRS, RAI-LTC, RAI-HC, NRRS, Statistics Canada, ALSH statistical
                             data; fiscal year 2010/11.

                           Specialized geriatric services for frail seniors living in the community can be provided
                           in hospitals, in physician offices or through CCAC and other outreach methods. 8% of
If SGS are to
                           the frail seniors are in Long Term Care homes, where certain SGS programs could
substantially reduce       benefit them directly. However, 90% of frail seniors live in the community, so even
demand for long term       the most effective interventions in the long term care setting will miss a substantial
care, then services to     opportunity to reduce risk for most frail seniors in the CE LHIN.

seniors living in the
                           Knowing the specific settings where the frail senior population can be reached is
community must             essential to RSGS program design.
increase
                           Like Exhibit 13 above, Exhibit 14 assigns each frail senior in the LHIN to one segment.
                           For the purpose of this analysis, when these frail seniors receive care in multiple
                           settings, they are assigned to a setting based on a frailty hierarchy that is reflected by
                           the order of the rows in the exhibit. First in the hierarchy is long term institutional
                           care: complex continuing care, long term care or retirement homes. Applying the
                           hierarchy: a senior admitted to both complex continuing care and long term care is
                           assigned to the higher needs complex care segment; a senior discharged from an
                           acute hospital to long term care is assigned to the long term care segment.
                                                                                                                   20
Further segmentation assigns frail seniors by the level of care they received in the
                       past year. For example, Exhibit 14 shows that, in 2010/2011, 12% of frail seniors,
                       (11,589 seniors) had CCAC encounters, but were not admitted to residential care,
                       hospital inpatient, mental health or rehabilitation care. Other hierarchies are
                       possible, but organizing the data in this way reveals potential RSGS intervention
                       settings and case finding tactics.

                       Exhibit 14          Distribution of Frail Seniors By Care Setting
                                   Site                                   Group                                % of Total
                        CCC                                All                                                    1%
                        LTC                                MH Neurodegenerative                                   6%
                        LTC                                MH Other                                               2%
                        LTC                                Non-MH                                                 1%
                        Retirement Home                    All                                                    2%
                        ALSH                               All                                                    1%
                        Community                          IP MH                                                 0.1%
                        Community                          Acute IP with Rehab                                    1%
                        Community                          Acute IP with Home Care                                3%
                        Community                          Acute IP with ED                                       2%
                        Community                          Acute IP Other                                        0.3%
                        Community                          Rehab                                                 0.7%
                        Community                          Home Care (CCAC)                                      12%
70% of LTC residents    Community                          ED                                                    16%
                        Community                          Other                                                 51%
have a                  Priority Population                                                                     96,573
neurodegenerative       Source: DAD, NACRS, OMHRS databases, CCRS, RAI-LTC, RAI-HC, NRRS, Statistics Canada,
                        ALSH statistical data; fiscal year 2010/11.
condition
                       9% of the target population of frail seniors resides in LTC; of these, 70% have a
                       neurodegenerative condition. Overall, the community segment is 90% of the frail
                       senior population. Roughly half (52%) of frail seniors are in the community segment
                       and had no in-year contact with either hospitals or home care. Therefore, physician
                       offices and other community and outreach services are currently the only potential
                       SGS contacts for approximately half of the frail seniors in the LHIN. Adding the acute
                       care and home care rows in Exhibit 14 shows that roughly one third of frail seniors
                       could potentially connect with SGS as part of their hospital or CCAC encounters, in
                       addition to physician and community outreach services.
                       Currently, RSGS could seek out frail seniors in the care settings where they are
                       presenting, but focusing mainly on LTC, hospital and home care clients leaves many
                       seniors without the benefit of specialized geriatric services, and so at risk of health
                       decline.
                       Without increases in community services for frail seniors, there will be many more
                       seniors not covered by SGS in the future. Exhibit 15 shows the number of seniors in
                       2010/2011 and the ten year forecasted increase, for each segment, by geographic

                                                                                                                            21
cluster. Overall in the LHIN, the seniors population at risk is estimated to grow by
                                          27% over the next ten years, with almost 50% growth in Durham, which is twice the
                                          rate of growth as in the North East and four times as much as in Scarborough.

Exhibit 15         Forecast of Frail Seniors by Cluster and Segment
                                                All CE Frail Seniors      Durham Cluster         North East Cluster      Scarborough Cluster
                                              Current     Additional   Current    Additional   Current     Additional   Current     Additional
        Site               Group
                                              2010/11      2020/21     2010/11     2020/21     2010/11      2020/21     2010/11      2020/21

 Segment                                       96,573      122,856     31,213       46,282      28,209      34,911      37,151       41,663
 CCC              All                          1,177         1,522       474         702         283          349         420          471
 LTC              MH Neurodegenerative         5,668         7,229      1,870       2,772        1,745       2,155       2,053        2,302
 LTC              MH Other                     1,616         2,039       497         737         433          533         686          769
 LTC              Non-MH                        847          1,084       285         423         264          327         298          334
 Retirement
 Home             All                          2,250         2,850       653         968         761          944         836          938
 ALSH             All                          1,371         1,744       442         656         399          494         530          594
 Community        IP MH                         130           161        31           46          27          34           72          81
 Community        Acute IP with Rehab          1,037         1,330       355         527         342          422         340          381
 Community        Acute IP with Home Care      3,341         4,267      1,074       1,592        1,115       1,382       1,152        1,292
 Community        Acute IP with ED             2,216         2,783       615         912         639          793         962         1,079
 Community        Acute IP Other                250           314        70          105          70          87          109          122
 Community        Rehab                         644           808        181         268         177          219         287          322
 Community        Home Care                    11,649       14,884      3,929       5,825        3,454       4,275       4,266        4,784
 Community        ED                           15,341       19,578      4,735       7,023        5,313       6,619       5,293        5,936
 Community        Other                        49,035       62,263     16,002       23,727      13,187      16,279      19,847       22,257
 10-Year % Growth                                             27%                    48%                     23%                      12%
 Source: DAD, NACRS, OMHRS databases, CCRS, RAI-LTC, RAI-HC, NRRS, Statistics Canada, ALSH statistical data; fiscal year 2010/11.

                                          Evidently, if RSGS is to contribute to substantially reducing the demand for long term
                                          care, then it must advocate to expand services to seniors living in the community.

                                          Low Income and Rural Senior Populations
                                          In addition to segments defined by clinical condition or setting, RSGS may target low-
                                          income seniors or those living in rural regions. These potentially vulnerable
Rural seniors are 9%                      subpopulations may have higher but unmeasured social and clinical health risks.

less likely to be                         Comprehensive geriatric assessments of a large random sample, of rural, low-income
                                          and other seniors would be the most accurate way to estimate the additional needs
admitted to long term
                                          of rural and low-income seniors; we did not have such a sample. Since the likelihood
care than non-rural                       of long term care admission is highly correlated with frailty, we instead used long
seniors                                   term care admission data in the Central East to compare low income and rural groups
                                          with others. Each senior in the Central East LHIN was assigned an income quintile
                                          using the Statistics Canada Area Based Income Quintile Approach (Statistics Canada

                                                                                                                                               22
PCCF, 2012), and a rural identifier based on their postal code. Comparing the age
                                                standardized LTC admissions within the Central East LHIN, we found that: rural
                                                seniors are 9% less likely to be admitted to long term care than non-rural seniors; low
                                                income seniors are 9% more likely than non-low-income seniors to be admitted to
Low income seniors                              long term care. Further investigation would help understand these differences,
                                                although the absolute differences might not be substantial enough to warrant
are 9% more likely
                                                targeted RSGS strategy.
than non-low income
seniors to be admitted
                                                Consumers of Substantial Health Care Services
to long term care
                                                In the previous section, we identified priority populations within the population of
                                                people aged 75+ years. In this section, we broaden the priority population to include
                                                the few seniors 65+ years that consumed a substantial amount of health care
                                                resources.
                                                Focusing on frequent consumers is a common tactic among established specialized
                                                geriatric services20 and is also consistent with Ontario's broader Health Links initiative.
                                                Within the senior population (65+years), we identified a segment of high users that
                                                could be targeted for specialized geriatric services. We first identified 7,604 people of
                                                all ages and then among them, the 4,900 seniors who used 50% of CE LHIN’s inpatient
                                                hospital resources in 2011/12 (Exhibit 16).

Exhibit 16            Seniors with high hospital use in the CE LHIN, 2011/12

                                                                                                         % Seniors
             # Persons      #                                                                 Avg                                % Seniors
                                                   Total     Average     Total                            Died in    % Seniors
             Admitted    Persons                                                    Avg     Comorbid                             receiving   % Seniors
     Age                           Admissions     Weighted   Weighted   Hospital                         Hospital      with
                 to      with ED                                                    LOS      Dx per                                Home       to HC
                                                   Cases      Cases      Days                               (All     LTC/CCC
              Hospital    Visits                                                            Admission                              Care
                                                                                                          Causes)
     65-69     784        680        1,922         6,906       8.8      27,442      35         2.7         24%         12%         73%           38%
     70-74     870        748        2,190         8,559       9.8      37,476     43.1        2.9         27%         15%         74%           38%
     75-79     968        861        2,337         8,848       9.1      40,479     41.8         3          29%         21%         77%           33%
     80-84    1,067       951        2,526         8,768       8.2      45,920      43          3          29%         27%         83%           34%
     85-89     767        704        1,784         6,073       7.9      36,885     48.1         3          34%         33%         85%           30%
     90+       444        411         951          3,448       7.8      22,817     51.4         3          34%         33%         91%           27%
   All
              4,900      4,355      11,710         42,602      8.7      211,019    43.1        2.9         29%         23%         80%           34%
 Seniors
 Source: DAD, NACRS; FY 2011/12

                                                On average these seniors spent 43 days in hospital; 29% died in hospital and 80%
                                                received home or residential continuing care. Irrespective of age, they are a
                                                multimorbid population, with an average of three significant coexisting diagnoses21.
                                                Since these seniors are frequent users of the health system across different settings

20
   Man-Son-Hing, M., B. Power, A. Byszewski, and W.B. Dalziel. "Referral to specialized geriatric services. Which elderly people living in the
community are likely to benefit? " Canadian Family Physician 43 (1997): 925-30.
21
   This includes their most responsible diagnosis.
                                                                                                                                                       23
(including hospitals), there are opportunities for SGS to improve coordination, quality,
                                         outcomes and cost of health care services for this population.
                                         As described in the previous section on SGS risk reduction, Potentially Avoidable
                                         Hospital use is one kind of risk that can be reduced by SGS services.22 In Exhibit 17, we
                                         show the prevalence of Potentially Avoidable Hospital use in this cohort of 4,900
                                         seniors over a one-year period, with an estimate of the associated total hospital cost
                                         of care.

Seniors with
                                         Exhibit 17          Most Responsible Diagnosis, High Use Seniors
Potentially Avoidable                                                                 Number of
                                                                                                           Estimated
Hospitalizations                          Most Responsible Diagnosis                  Admissions
                                                                                                          Hospital Cost
                                                                                       2011/12
account for 56% of                        Heart Failure                                 1,249             $28,099,552
total hospital costs in                   Diabetes Complications                           789            $26,784,646
the high use cohort                       Injury                                           762            $25,384,271
                                          Chronic Obstructive Pulmonary
                                                                                           915            $21,623,638
                                          Disease
                                          Urinary Tract Infections
                                                                                           717            $17,409,362
                                          Including Pyelonephritis
                                          Hypertension                                     319            $10,920,299

                                          Dehydration and Gastroenteritis                  430             $8,375,955

                                          Septicemia & Severe Sepsis                       151             $4,194,552
                                          Cellulitis                                       168             $3,918,421
                                          Perforated/Bleeding Ulcer                        97              $3,543,673

                                          Angina/Ischaemic Heart Disease                   187             $2,518,046

RSGS has a potential                      Iron Deficiency Anaemia                          46              $1,183,416

role to facilitate                        Pulmonary Edema                                  23               $696,900

strategies to reduce                      Ear, Nose and Throat Infections                  19               $650,879

need for future                           Influenza and Pneumonia                          23               $539,112
hospital services                         Asthma                                           18               $499,664
                                          Pelvic Inflammatory Disease                      10               $453,643
among high risk                           Convulsions and Epilepsy                          8               $236,683
seniors                                   Other Potentially Avoidable
                                                                                           43              $1,065,074
                                          Hospitalizations
                                          All Potentially Avoidable
                                                                                          5,974           $158,097,786
                                          Hospitalizations
                                          Other Hospitalizations                          5,736           $121,983,879
                                          All Hospitalizations                           11,710           $280,088,239
                                         Note:Estimated using Provincial Average Inpatient CPWC $6,575 and Actual Weighted Cases
                                         Source: DAD 2011/12

22
  Kleinpel et al. Reducing Functional Decline in Hospitalized Elderly in Patient Safety and Quality
An Evidence-Based Handbook for Nurses Edited by Ronda G Hughes Rockville (MD): Agency for Healthcare Research and Quality; April 2008.
                                                                                                                                         24
In this example, seniors with a Potentially Avoidable Hospitalization accounted for
                        $158 million, or 56% of total annual hospital cost of the high use seniors cohort.

                        Analyzing the progression of morbidity in the high use population would improve SGS
                        program design. In fact, the consensus of the RSGS Steering Committee was that early
                        interventions meant to prevent or delay health decline should be a focus of RSGS.
Seniors that consumed   RSGS would need to explore SGS specific program components that could address the
a substantial and       needs of these seniors and reduce their progression of morbidity.
disproportionate        An advantage of our segmentation approach is that we can study the experience of
amount of hospital      the high risk seniors in previous years.
resources were often    For the high use senior population, we examined their service use and settings in the
hospitalized in the     two years before they became high users of the acute system. Exhibit 18 below shows
previous two years      the historical inpatient hospital use by CE LHIN’s 2011/12 high use seniors.

                        Exhibit 18           Historical Inpatient Resource Use, High Use Seniors in the CE LHIN

                                                 Number Admitted to Hospital          Total Admissions
                           Age Cohort
                                                 2011/12 (t) *t - 1    t-2      2011/12 (t)    t-1        t-2
                             65-69                  784       233      162        1,922        444        264
                             70-74                  870       295      186        2,190        605        332
                             75-79                  968       301      208        2,337        544        358
                             80-84                 1,067      356      227        2,526        625        334
                             85-89                  767       235      167        1,784        388        246
                              90+                   444       127       93         951         189        134
                          All Seniors              4,900     1,547    1,043       11,710      2,795      1,668
                         Hospital Days            211,019    25,587 14,998
                         *t-1 refers to 2010/11 and t-2 refers to 2009/10
                         Source: 2009/10 - 2011/12 DAD, NACRS

                        We observed that seniors who consumed high levels of hospital resources in
                        2011/2012 had frequently been hospitalized in the previous two years (Exhibit 18 and
                        Exhibit 19). Of the 4,900 seniors in this group, approximately 30% had been admitted
                        to hospital in the previous year, and roughly 20% had been admitted two years
                        previous. Of those seen in the emergency department, 60% had been seen in the
                        emergency department in the previous year and 46% had been seen in the
                        emergency two years before.
                        On average, the 4,900 seniors spent: 43 days in hospital in 2011/2012; 16 days in
                        hospital in 2010/2011 and 14 days in hospital in 2009/2010. Evidently, the morbidity
                        of the frailest seniors increased over time.

                                                                                                                 25
Exhibit 19           Historical ED Resource Use, High Use Seniors in the CE LHIN

                                                        # with ED Visits                    Total ED Visits
                            Age Cohort
                                                  2011/12 (t)   t-1           t-2    2011/12 (t)    t-1      t-2
                                65-69                680        386           295      2,370       1,084     753
                                70-74                748        469           355      2,609       1,394     933
                                75-79                861        508           412      2,970       1,439     987
                                80-84                951        597           426      3,239       1,683     975
                                85-89                704        439           331      2,335       1,125     726
                                 90+                 411        259           200      1,305        645      432
                             All Seniors            4,355      2,658         2,019     14,828      7,370    4,806
                          *t-1 refers to 2010/11 and t-2 refers to 2009/10
                          Source: 2009/10 - 2011/12 DAD, NACRS

                         These seniors had many encounters with the acute system that could have potentially
                         triggered supportive services. Many seniors could also have been intercepted by
                         specialized geriatric programs in the community setting: for example, CCAC services
                         were provided to 33% of high users in the previous years, as shown in Exhibit 20.
High use seniors had     Surprisingly and unlike use of hospital services, use of CCAC services was similar
many encounters with     across all three years.

the acute system that
could have potentially
                         Exhibit 20           Historical Home Care Resource Use, High Use Seniors in the CE LHIN
triggered supportive
services                                             % Seniors to Home Care
                            Age Cohort                        (CCAC)
                                                  2011/12 (t)    t-1     t-2
                                65-69                38%         32%     35%
                                70-74                38%         33%     28%
                                75-79                33%         33%     34%
                                80-84                34%         35%     24%
                                85-89                30%         38%     37%
                                 90+                 27%         28%     48%
                             All Seniors             34%         33%     33%
                          *t-1 refers to 2010/11 and t-2 refers to 2009/10
                          Source: 2009/10 - 2011/12 DAD, NACRS

                                                                                                                    26
II. Meeting the Needs of Frail Seniors in the Central East LHIN
                         In Part I of this report, we described the health risks and service use and settings of
                         frail seniors in the CE LHIN. In Part II we describe available specialized geriatric
                         services and gaps between need and capacity for frail seniors care.

What RSGS                Frail seniors use two broad types of health care services. The first, which we term
                         general services, provide most of frail seniors' ongoing health services and support
Resources are            but are not specifically designed for the frail senior population. The second are
Available?               specialized geriatric services (SGS). Specialized geriatric services are designed by
                         geriatric experts to meet the specific needs of frail seniors and are complements to
                         general health services. It is important to understand that seniors can have excellent
                         access to general health services, such as acute hospitals and home care, yet have
                         poor access to specialized geriatric services, such as comprehensive geriatric
                         assessment.
                         In Exhibit 21, we distinguish general from specialized geriatric services and
                         subsequently detail the specialized geriatric services available in the CE LHIN.

                         Exhibit 21         General and Specialized Geriatric Services

                                      General Geriatric Services              Specialized Geriatric Services
                          Hospital
                                  Acute
SGS interventions can             Rehabilitation
                                  Mental Health
reduce senior health              Complex Continuing Care
risk, especially in               Emergency
                                  Ambulatory
clusters where risk is    Long-Term Residential Care                      Comprehensive Geriatric Assessment
                                  Long term care                            Centralized Referral and Intake
high                              Assisted Living in Supportive Housing            Acute Diversions
                                  Retirement Homes                        Acute, Maintenance and Restorative
                          Community Care                                      Care by Geriatric Specialists
                                  Home Care
                                  Community Support Services
                                  Community Paramedicine
                          Primary Care
                                  Primary Care Physician in solo-
                                  practice
                                  Primary Care Teams

                         The arrows in Exhibit 21 are meant to emphasize that SGS and other health services
                         are complementary and must be coordinated with general geriatric services.
                         Specialized geriatric service types are only broadly defined in Exhibit 21; Exhibit 22
                         more specifically organizes and describes these programs.

                                                                                                               27
Two broad categories of SGS are geriatric and psychogeriatric services. Each of these
                                           is further differentiated by the setting where the service are provided. Each service is
                                           typically provided by the staff of a specifically titled program, for example: Geriatric
                                           Assessment and Intervention Network Clinics.

Exhibit 22         Description of Specialized Geriatric Services in the Central East LHIN23
 Setting             Service          Program                 Description
 Hospital/           Inpatient        Acute Geriatric         ACE Units are inpatient general medicine units for acutely ill seniors who
 Inpatient/          acute            Medical                 require an admission to an acute care hospital and the ongoing expertise of
 Geriatric           geriatric        Unit/Acute Care of      a specialized geriatric team. Individuals are admitted directly from the
                     beds             the Elderly (ACE)       emergency department. These acute care beds are situated in one unit for
                                                              older adults who require short term diagnostic investigation and treatment
                                                              and are at high risk for a prolonged hospital stay due to frailty, multiple
                                                              complex medical, functional, psychosocial problems and/or recent
                                                              functional decline.
                     Inpatient        Geriatric               GATU inpatient units are typically short-stay, non-acute care units
                     geriatric        Assessment and          specifically designed to meet the needs of older adults and managed by
                     sub-acute        Treatment Unit          interprofessional specialized geriatric teams. Specialized equipment is
                     beds             (GATU)                  available to promote safety and independence. Patients stay between one
                                                              and three months.
                                      Geriatric               Geriatric Rehabilitation Units are for older frail persons who require the
                                      Rehabilitation Unit     expertise of a geriatric team and individualized assessment and
                                      (GRU)                   rehabilitation program in order to regain or maximize function and
                                                              independence. These units are often located in Complex Continuing Care
                                                              and the client is typically admitted for a period of one to three months.
                                      Geriatric               Specialized rehabilitation unit for seniors who require a longer course of
                                      Assessment and          therapy with shorter, less frequent periods of rehabilitation. The rehab unit
                                      Rehabilitation Unit     is led by a nurse practitioner with geriatric training and includes inter-
                                      (GARU)                  professional team of physicians, therapists and other allied health providers.
                                      Geriatric               Similar to GARU, but without a geriatrician or physician. GERI works to
                                      Engagement and          maintain function and mobility in seniors with complex chronic conditions
                                      Reintegration Unit      through activation and socialization.
                                      (GERI)
                     Inpatient        Internal Geriatric      A specialized geriatric interprofessional team providing in-hospital
                     geriatric        Consultation Team       consultation and assessment for frail seniors. Consultation teams support
                     consultation     (IGCT)                  the development of care teams in hospital through education and capacity
                                                              building. In some situations the teams participate in ‘case finding’ for ACE
                                                              Units or GRUs to facilitate the seamless transfer from an acute care bed to
                                                              the most appropriate setting.
                     Other            Geriatric               GAP is an interprofessional program that focuses on early intervention for
                     inpatient        Activation              high-risk, frail seniors upon hospital admission. GAP identifies seniors in
                     geriatric        Program (GAP)           need of enhanced therapy services and works to prevent functional or
                     programs                                 cognitive decline, prevent falls or manage wound care. GAP includes
                                                              occupational therapy, physiotherapy, social work and recreational therapy.
                                      VALUE Volunteer         Volunteers Assisting Leisure Interests to Meet Unique Needs (VALUE) is a
                                      Program                 volunteer-based program providing one-on-one support to maintain
                                                              functionality for frail elderly patients in the general inpatient or ACE Unit
                                                              setting. The VALUE program promotes functionality by helping frail elderly
                                                              patients get out of bed, get dressed and remain active.

23
  Content in this table is based on descriptions provided by the programs and P. Reed, 2011. Specialized Geriatric and Psychogeriatric Services in
the Central East LHIN: An Environmental Scan 2011
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