Continuing the Journey Toward Best Practice in Supportive Housing/media/sites/mh... ·...

Continuing the Journey Continuing the Journey Toward Best Practice in Toward Best Practice in

Supportive HousingSupportive HousingMH LHIN’s Adventure in Changing the Landscape

Change is worth the effort!Change is worth the effort!

An Overview of Mississauga An Overview of Mississauga Halton LHINHalton LHIN’’s Strategic s Strategic

Approach to Address ALC Approach to Address ALC ChallengesChallenges

Narendra ShahCOO

September 16, 2009

Where is the Mississauga Halton Where is the Mississauga Halton LHIN Headed in the Next 2 Years?LHIN Headed in the Next 2 Years?

LHIN Priorities With Respect to System Expectations Focus on Appropriate Level of Care Alleviated hospital bed and ED pressures Reduce or dampen demand for LTC beds (priority 2 group) Reduce ED visits for CTAS 4, 5 (less of a concern for MH LHIN)

How? Increase alternates to staying in hospital – more options for seniors post

hospital phase All HSPs in LHIN have ALC/ER as their top priority too – community

providers must step up to care for the frail and elderly with complex needs Divert the culture from default to LTC placement by actively increasing

community options Integrated-LHIN-wide approach Performance based system-all new investments must meet performance

requirements

Transformation of Community Sector to Address Transformation of Community Sector to Address Impact of Seniors With Complex Health NeedsImpact of Seniors With Complex Health Needs

Change in culture from preponderance of discharges of ALC patients to LTC homes

Create alternatives to LTC homes as the default with significantinvestments by:I. Investing in expanded community capacity to provide options to

LTC beds, particularly Supports for Daily Living (traditionally called “supportive housing”)

II. Targeting investment in direct and diversion programs to enable faster discharge of ALC patients and improve assess to treatment time in ERs (i.e. Wait At Home and Restore)

III. Wait at homeIV. Supports to manage behaviourally difficult patients

Find alternatives for those residents who currently reside in LTC homes who do want to go back to the community thereby free up much needed LTC beds for those who need these beds (Dr. Hirdes review noted 12% of LTC clients can be in lighter settings).

Enhance capacity of existing community programs such as adult day programs to take care of higher need seniors

Major changes are neededMajor changes are needed

" We can't solve problems by using the same kind of thinking we used when we created them."

MH LHIN Community Investments for Faster MH LHIN Community Investments for Faster DischargeDischarge

MH LHIN Community Investments to Decrease MH LHIN Community Investments to Decrease ED Wait Times & DemandED Wait Times & Demand

THANK YOU

"We occasionally need to shed We occasionally need to shed off old habits & items that off old habits & items that burden us without adding to our burden us without adding to our lives. lives. "

Author: Dr. Myles Monroe Edited

Continuing the Journey Continuing the Journey Toward Best Practice in Toward Best Practice in

Supportive HousingSupportive HousingMH LHIN’s Adventure in Changing the Landscape

Presentation Focus Presentation Focus –– Before & AfterBefore & After

Presentation Focus Presentation Focus –– Before & AfterBefore & After

Beginning the JourneyBeginning the Journey

Established Working Group Completed Inventory

Reviewed Service Offerings Analyzed Current State

Identified Gaps

ThoughtThought

What We Looked LikeWhat We Looked LikeInventory – Service Offerings – State - Gaps

Supportive Housing: Inventory & Service Supportive Housing: Inventory & Service OfferingsOfferings

Target population = people who require low income housing + services

1 model of service delivery (buildings & units) – no other innovation, at times supports housing/landlord focus and mandate

Expansion – costly capital requirements to build, permission to expand (can create a NIMBY mentality)

Inconsistent service administration – core services, landlord agreements ‐ right of first refusal

Duplication with other services/sectors on the healthcare continuum

State & Identified GapsState & Identified Gaps

Housing sites not targeted/poor rationale for where sites established

No measure of “most in need” for those brought on service Anecdotally based measurement – qualitative and quantitative measures lacking

Long wait lists (2 to 10 years) Funding, amount of service per client, yearly costs, costs per hour of service – inconsistent


SH Populations excluded Gap: Individuals whose housing needs are

established/satisfactory but need services only

Gap: Access to services - individuals not living in a SH building


SH Role/Function in Health SystemGap: Not understood – not positioned within continuum of

care between acute, LTC or CCAC Community services –lack of clarity in moving people through the health system (ie: either keep clients requiring a higher level of care or discharge early – can’t handle)

SH DataGap: Minimal – no indicators – variety of agency specific

assessment tools utilized (minimal validity and reliability) –no joint gathering of data for the sector – inability to show value to the system


SH ServicesGap: Service provision not standardized –

deliverables not articulated – loose accountability

Outreach Services are only currently funded for the physically disabled and ABI populationsGap: This service is not funded for seniors

Outreach Services were designed and funded to only be available between 6:00am and 12:00amGap: The only alternative for “overnight” service is moving to a

Supportive Housing Residence

Supportive Housing within the Continuum of Care

Research Research –– Showing Us a Showing Us a PicturePicture

University of Waterloo Research Study – Dr. John Hirdes

ThoughtThought

Lighter Care Services Needed?Lighter Care Services Needed?

Hirdes et al Nov 18, 2008

SH CCACWt. Lst.

CCACComm

LTC CCCALC

CCCNon-ALC

*SAMPLE SIZE 321 205 1419 802 136 375

Lowest level of care that could appropriately address this person’s needs TODAYHome with no services - 21 2 - - -Home with community support services (excl CCAC) 9 16 8 - - -Home with home care (provided by a CCAC) 8 34 82 2 2 -Supportive housing 81 3 2 1 - -Retirement home 2 15 5 7 4 1Group home / Mental health residence - - - 2 1 -Rehabilitation hospital / unit - - - - 4 4Convalescent care in long term care home - - - - 5 2Long term care home 1 12 2 86 62 10Complex continuing care hospital/unit - - - - 21 78In-patient psychiatry - - - - - -Palliative care / Hospice care - - - - - 6Acute Hospital - - - 1 - 1

Impairment in Specific Impairment in Specific IADLsIADLs and and ADLsADLs amongamongSupportive Housing Clients, MH LHIN, 2008Supportive Housing Clients, MH LHIN, 2008

IADLs Not Independent ADLs Not Independent


Comparing MH LHIN Supportive Housing Clients Comparing MH LHIN Supportive Housing Clients With Ontario CCAC ClientsWith Ontario CCAC Clients

Cognitive Performance Scale MAPLe Score


www.interrai.org

John P. Hirdes, Ph.D.

Rate of Nursing Home Admissions Within 90 Days of Rate of Nursing Home Admissions Within 90 Days of Assessment by MAPLe Level, Ontario, Derivation SampleAssessment by MAPLe Level, Ontario, Derivation Sample

www.interrai.org

John P. Hirdes, Ph.D.

Hirdes October 16, 2007

Rates of Admission to Long Term Care Home within Rates of Admission to Long Term Care Home within 90 Days of Assessment, by Crude Clinical 90 Days of Assessment, by Crude Clinical Complexity Measure, Supportive Housing Clients, 8 Complexity Measure, Supportive Housing Clients, 8 CCAC StudyCCAC Study

0

10

20

30

40

50

0 1 2

Count of Areas with Clinical Complexity

% A

dm

itte

d t

o L

TC

Shades of Grey Across Shades of Grey Across the Continuum of Carethe Continuum of Care


Independent Healthy End of Life

…… but we really need to think of but we really need to think of needs in multidimensional spaceneeds in multidimensional space


Independent Healthy End of Life

Schematic Representation of Need:Schematic Representation of Need:More likely DistributionsMore likely Distributions


Why do people in different service Why do people in different service settings have overlapping settings have overlapping distributions of need?distributions of need?

Good reasons

◦ Similar needs in one domain, but different level of needs in another domain◦ Changes in need levels of

time Improved Declined

◦ Needs are unstable

Bad reasons

◦ Misplaced◦ Needs incorrectly assessed

at admission◦ More appropriate service

setting not available◦ Inadequate funding methods


Comparisons Comparisons –– Showing Showing Us a PictureUs a Picture

Ontario and Alberta – What’s the Difference and What’s the Message?

Supportive Housing In OntarioSupportive Housing In Ontario

Making The ChangeMaking The ChangeOur Journey to the Centre of the Earth

ThoughtThought

……or die in the trying!or die in the trying!

Moving to ImproveMoving to Improve

2007/08MH LHIN Supports for Daily Living

TOTAL: 1,018 Clients





Changing Changing ““Supportive HousingSupportive Housing””

ItIt’’s A New Way of Service s A New Way of Service –– 3 Models3 Models

Staff scheduled over 24hrsStaff housed on siteDesignated buildings offer units

in partnership with servicesUnits can be rent geared to

income (RGI), low income, life lease

Supports for Daily Living in Designated Buildings (Traditional)

Staff scheduled over 24hrs Staff housed in one building

– travel to other buildings/townhouses/houses/trailer parks within clustered designated neighbourhood

Housing is arranged separately from services

Supports for Daily Living in Designated Neighborhoods (Hub & Spoke)

Housing need not required Staff scheduled 24/7/365 Staff on mobile patrol to assist with

pre-scheduled bookings and/or unscheduled requests

Customer Care Representatives able to respond to urgent situation – day evening and overnight - live

24 hour availability to meet ER patients at residence to “settle in” (replaces Home at Last)

Supports for Daily Living - Mobile

SDL Core Service Offerings SDL Core Service Offerings Personal Support Services:Personal Hygiene activities: Washing, bathing, mouth care, hair care, menstrual care, preventive skin care, changing dressings (not wound care), routine hand and foot care

Personal routine activities of Daily Living:Transferring/positioning, turning, dressing/undressing, assistance with eating, toileting (diapering, emptying/change leg bag, catheterization, bowel routine), exercise, escort to medical appointments, medication assistance (pre measured)

Homemaking Services:Light dusting, sweeping, vacuuming, mopping floors, washing dishes/countertops, cleaning and disinfecting bathrooms, cleaning mirrors.Laundry, ironing, mending, grocery shopping, banking, paperwork, menu planning, preparing meals, caring for children

Attendant Services:Combination of Personal Supports and Homemaking services offered at clients’preferred pre-determined time and pre-determined task they cannot physically do for themselves.

To This To This : : Supports for Daily Living within the Supports for Daily Living within the Continuum of CareContinuum of Care

Making Further ChangesMaking Further Changes

Centralized Tracking & Intake

Recognized need for central intake & keeping track of what was available – faster movement of clients – greater consistency of assessment being completed –referral information is done and ready-to-go – screening is completed

SDL Coordinator

Provides 1 person contact for referrals from CCAC, hospitals, other

Identified gaps and issues in process are brought forward to SDL Leadership Group for resolution

Training needs of agencies are recognized and brought forward

Knowledge of SDL – provides clarity to referring sources

9/15/2009 51

9/15/2009 52

Glossary Number Eligibility Category Description Examples

1 Meets MOHLTC basic requirements for service

The SDL candidate must meet the minimum age as determined by the MOHLTC to receive SDL services

The SDL candidate must be currently Insured under OHIP

16+ for physical disability, ABI, HIV/AIDS

65+ for seniors/elderly (some negotiation on a case by case basis)

Has a valid Ontario Health Card

2 Has a RAI MAPLe score of 3 or higher

The SDL candidate must have a RAI-CHA score or a RAI-HC score of a MAPLe 3, 4, or 5

The CCAC RAI-HC MAPLe score can be utilized if completed at time of referral –if none, then a RAI-CHA is required

3 Demonstrates a need for Personal Support/Attendant Services throughout a 24hr period

The SDL candidate must demonstrate a need for Personal Support/Attendant Services provided throughout a 24hr period - otherwise needs can be met through visitation services (CCAC or other provider)

History of falls & requires assistance with toileting in night

Requires turns during the night

Requires medication monitoring throughout 24hr period

Requires frequent checks

4 Service requirements fit within the SDL per day limits

SDL service limits are used as a further marker to the RAI MAPLe scores

The SDL candidate does not require more than the service limits as assigned by the funder.

A senior could require on average 1.5 to 2 hrs of service in a 24hr period

Episodic events may require an adjustment in time until recovery

Improvement in health may see a decrease in time to less than 1.5 hrs/day

SUPPORTS FOR DAILY LIVINGEXAMPLE: Glossary for Appropriateness Checklist and Eligibility Decision Tree

SDL Communications SDL Communications -- MaterialsMaterials

Health Care Providers Case Managers Patients/Families SDL Providers Physicians SDL Vignettes (stories from the field)

Driving Driving Home the Home the MessageMessageThere are alternatives to LTC

You can leave LTC for another option

The right needs in the right place

Don’t “medicalize” the elderly – they can get better

Launch of Communication Tools in Marketing Campaign

Education and Re-Education of Case Managers

Target session with family Doctors

Advertising in selected publications

SDL SDL -- New LogoNew Logo

•Recognition of housing

•Greater emphasis on the services required to create a supportive environment for living

•To use this, must meet standards, implement C.H.A. and implement new framework

•Communication launch will identify that this logo identifies only an approved provider of SDL Services who can meet the standards

Our Vision & Strategic Directions

Supports for Daily Living (SDL) services are fully integrated and clearly recognized as a valued resource both within the

health care system, our consumers and the broader community.

Supports for Daily Living (SDL) services are widely available across the MH-LHIN, are easily accessible through a

centralized registry, and are provided by experienced long-term employees who love their work.

Toward Shared and Effective Resources Toward a New Legacy for SDL within the Health Care Community Toward Creating Change through a Stable and Established SDL

Network

ThoughtThought

Hearing From Those Hearing From Those Effected By The ChangesEffected By The Changes

Our Guests Present Their Experiences

What We Are SeeingWhat We Are SeeingTrends and Impacts to Date

ThoughtThought

Working with Others to Make it WorkWorking with Others to Make it Work

CCAC and SDL: Working together“Change needs friends”

Build credibility with your work and what you do Start with PASSION/or your MISSION

Look at tactical issues together find wins & efficiencies Understand each others business, needs and interests

Seek to understand, then be understoodBuilding professional relationships = long term success

Success or Failure Rides on Success or Failure Rides on ChampionsChampions

SDL Leadership Group has championed the cause of change

The amount of work cannot be under-estimated and is not for the faint of heart

Motivation can ebb and flow – need leaders in the group to keep moving forward

Make sure you let them know WIIFM If you promise something deliver Communicate, communicate, communicate

SDL Impacts SDL Impacts –– ½½ Year ComparisonsYear Comparisons3 Agencies Reporting3 Agencies Reporting

SDL Impacts SDL Impacts -- Full Year Projection Full Year Projection Comparisons Comparisons -- 3 Agencies Reporting3 Agencies Reporting

SDL Impacts on Hospital SDL Impacts on Hospital –– Clients Clients who would otherwise be ALCwho would otherwise be ALC

SDL Trends and SuccessesSDL Trends and Successes

Trends:Trends:

◦ Higher intake of mental health clients, those with medication admin issues, those with nutrition issues

◦ One provider seeing trend in much older client (ie: average age of 91 years) and those coming into SDL at younger age (65+) are due tomental health/medication issues

◦ Predominance of female clients

◦ Those coming onto service have few if any networks of support – very isolated - alone

SDL Trends and SuccessesSDL Trends and Successes

Successes:Successes:◦◦ MAPLe scores increasing for client intake MAPLe scores increasing for client intake –– greater acuity greater acuity –– right client right client

entering SDL entering SDL –– BeforeBefore: MAPLe average of 2 to 3 : MAPLe average of 2 to 3 –– CurrentCurrent: MAPLe : MAPLe average of 3 to 4average of 3 to 4

◦◦ Those entering SDL service over time showing either decrease or Those entering SDL service over time showing either decrease or stabilization in MAPLe acuity scores stabilization in MAPLe acuity scores –– getting better/stabilizing and can getting better/stabilizing and can be maintained for a longer periodbe maintained for a longer period

◦◦ Families and Doctors seeing changes in clients Families and Doctors seeing changes in clients ––need for this qualitative need for this qualitative information as part of effective evaluationinformation as part of effective evaluation

◦◦ Decreases in EMS calls also being noted in buildings where SDL iDecreases in EMS calls also being noted in buildings where SDL is the s the ““first responderfirst responder”” –– if EMS attends, few ER transfers as EMS if EMS attends, few ER transfers as EMS ““patches patches them upthem up”” and leaves because client has SDL Servicesand leaves because client has SDL Services

We Leave You With These Words of We Leave You With These Words of AdviceAdvice

It’s hard to turn the Queen Mary around –perceptions and attitudes make the difference between success and failure

Stay the course – change takes time and this kind of system change is not a quick win, but it also cannot drag on

Keep moving forward even in the face of resistance

It’s a good thing to have a sense of humour!

In conclusionIn conclusion

Best Practice Information SessionBest Practice Information Session

Supports for Daily Living (SDL) Supports for Daily Living (SDL) -- What it is and Why it What it is and Why it MattersMatters

This concludes the presentation. Thank you for joining and we hope you have found the information beneficial.

Presentations seen today are available on the link below.

An area for further questions is also available within the link.http://www.mississaugahaltonlhin.on.ca/Form.aspx?ekfr

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