Physiotherapy Changes In Ontario

Current and Future State

Central East LHIN Board of Directors

June 24, 2013

Overview

1. Current State

2. Physiotherapy Reform – areas where changes will occur:

i. In-Home

ii. Long Term Care

i. Physiotherapy

ii. Exercise Classes/Activation

iii. Community Exercise Classes/Falls Prevention

iv. Clinic

v. Family Health Care Settings

3. Next Steps

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Current Patient Eligibility and Care Settings Regulation 552 of the Health Insurance Act prescribes the non-universal patient coverage, care settings and

payment model for OHIP-funded physiotherapy services.

• OHIP funds physiotherapy on a fee for service (FFS) basis when rendered by Designated Physiotherapy Clinics (DPCs) in a

clinic setting (11% of billed services), in a patient’s home (29% of services), and in LTC Homes (60% of services)

• ~90 DPCs are in operation in Ontario – an increase in number of DPCs requires legislative change

• Geographically concentrated in GTA

Care Settings

• Residents of Long-Term Care (LTC) Homes

• Patients over 65 years (90% of billed services), those under 20 (<1% of services) and MCSS clients between 20 and 64

• People of all ages needing physiotherapy in their home or after overnight hospitalization

Current Patients Served

• OHIP pays $12.20 per physiotherapy service for up to 100 services/person/year + 50 additional services in cases of

exceptional need

• A single referral (physician or RN in LTC) entitles a patient to services indefinitely subject to assessments by a

physiotherapist employed by a DPC

Payment Model Fees and Services

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Rationale for Change The current service delivery approach and open-ended fee-for-service funding model for OHIP-funded

physiotherapy have resulted in inequitable access for patients, accountability issues and an aggressively

growing financial pressure.

• The projected expenditures for OHIP physiotherapy are set to double the existing allocation by 2014, despite a 70% increase

in allocation in 2010/11

• Utilization of OHIP funded physiotherapy in LTC Homes has increased 130% from FY 2005 to FY2011, in home services

utilization has increased 600% during the same period

• $12.20 fee/service for up to 150 services/year inappropriately encourages provision of a high volume of services to lower

acuity patients, maximization of the numbers of patients and is a disincentive for providers to conclude care

• Regulation 552 does not define physiotherapy explicitly, and physiotherapy treatment has been reframed by some providers

from a goal-oriented, time-limited treatment plan for a specific condition, illness or injury to activation/exercise/maintenance

programs of indefinite duration

Utilization and Value

• There is no provider incentive to treat complex patients and those living in individual dwellings; instead, those easiest to

provide services to (low complexity, group living arrangements) receive them

• Limited patient access to clinic based services; eligible patients may not have access to a DPC (most DPCs are concentrated

in the GTA)

Patient access

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50%

100%

150%

200%

250%

300%

2005 2006 2007 2008 2009 2010 2011

Public Sector Health Expenditures Growth

Physio Hospitals Physicians Drugs

• OHIP physiotherapy is one of the fastest growing expenditures in the health care system. Rate of growth since 2005 is triple that of hospitals, drugs and physician expenditures

• Utilization growth, which has averaged 18-20% annually since 2007, is largely provider driven and cannot be controlled by the funder • In home physiotherapy services have increased from $12M in 2007 to a projected $81M in 2013 and $100M in 2014. • In LTC homes,100% of residents are receiving services billed to OHIP on a FFS basis as physiotherapy (compared to 32%

of residents in Nova Scotia, the next highest jurisdiction in Canada) • Community ambulatory clinic services are growing at a much slower rate and account for only 11% of overall expenditures

Growing Expenditures

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Government Announcement

• New/Enhanced Physiotherapy funding:

• $33M - CCACs (for in-home PT)

• $58.5M - LTCHs (for one-one PT)

• $10.1M - LTCH exercise/activation classes

• $10M - Community Exercise Classes/Falls Prevention

• $44.5M - OHIP Clinic PT (increase of $24M)

• $2M - Family Health Care Settings

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Long-Term Care

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Long-Term Care Homes (LTCH) Overview:

• Providers currently bill OHIP for resident physiotherapy in LTC homes

• With the changes, homes will receive direct funding through LHINs to provide physiotherapy

• Residents who have an assessed need for physiotherapy in their plan of care will receive one-on-one, episodic

physiotherapy in their LTC home to help them restore their mobility and function

• There will be enhanced tracking and reporting measures (clinical and financial) in place to reflect the physiotherapy

each resident receives, as prescribed by a registered health professional, in their plan of care

• Residents will also continue to enjoy services provided as part of the LTC home’s recreation and social activities

program, like exercise classes

• LTCHs are also funded to provide Occupational Therapy, Speech Language Therapy, exercise/activation classes, and

recreational and social activities within their annual funding

• This funding will be augmented ($10.1M) to ensure continued access to these services

• These programs are developed in each home based on input from residents and families

Outcomes:

• Appropriate and resident-specific care

• Promotion of wellness in the LTCH

• Restoration/recovery of their pre-injury/pre-surgery function, in convalescent care beds, allowing residents to return

home sooner

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Implementation Considerations/Future State:

• Physiotherapy and exercise/activation classes are different services and will be treated as such

• these changes will ensure residents are getting the care they need

• $58.5M will be allocated to homes, through the LHINs, for one-on-one, resident-specific, appropriate

physiotherapy as prescribed by a registered health professional

• $10.1M will be allocated to homes, through the LHINs, for continued access to exercise/activation classes

and to support convalescent care beds

• Funding Policy and reporting will define accountability and funding conditions, and monitoring of expenditures

and care plans will occur

• Homes will be advised of the changes on LTCHomes.net, and webinars about the funding changes will be

held to help homes prepare and to ask questions

• Residents will also receive information about the changes through their homes and through Residents

Councils

Long-Term Care (cont’d)

Local Activity – LTCH Stream

• Once the funding letter is received from the Ministry, work will be underway to issue funding

letters to LTCHs and amend LSAA’s

• Homes determine how they are going to ensure service provision – directly or indirectly

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Family Health Care Settings

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Family Health Care Settings Current State/Overview:

• Limited integration of physiotherapy into family health care settings, with a small number of Community Health Centres currently employing Physiotherapists

Implementation:

For 2013/14….

• Program-based integration of physiotherapists into primary care settings (i.e. integration of

physiotherapists into chronic disease management, healthy aging, seniors care programs, etc.)

• Call for Applications process in the Spring/Summer for Community Health Centres (CHCs), Family

Health Teams (FHTs), Nurse Practitioner Led Clinics (NPLCs) and Aboriginal Health Access Centres

(AHACs) for approval of new physiotherapy positions and to fill existing vacancies

• Evaluation based on ability to integrate physiotherapists into existing interdisciplinary primary health care

programs, demonstrated need in community/patient population, address service gaps and avoid

duplication of services being introduced through other reforms

Future State:

• Physiotherapists to become an interdisciplinary health care provider that primary care organizations are

eligible to receive funding for

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Family Health Care Settings

Outcomes:

• Enhancement of interdisciplinary primary health care programs and services delivered to

Ontarians through the integration of physiotherapy into family health care settings

Local Activity: Family Health Care Stream

• There has been one provincial teleconference on this stream

• There is not as much impetus in this stream as the August 1 imperative does not apply

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In-home Physiotherapy (CCAC)

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In-home Physiotherapy Overview/Current State:

• The fourteen CCACs in Ontario provide simplified access to home and community care. Over 637,000 Ontarians

receive home care services

• CCACs provide assessment and eligibility determination for the provision of home care services to people in their

homes, schools and communities

• Physiotherapy is one of many services that CCACs can arrange on behalf of eligible clients. To be eligible, one must

require the physiotherapy services to remain home or enable one to return home from a hospital or other health care

facility. The services must be reasonably expected to result in progress towards rehabilitation or maintenance of

functional status

• Key statistics on CCAC physiotherapy:

• Total number of CCAC physiotherapy clients in FY2011-12 was 91,530

• Clients aged 65+ represent 65% of all patients that received CCAC physiotherapy services in FY2011-12

• Total number of CCAC physiotherapy visits in FY2011-12 was over 400,000

• In addition to in home services provided by the CCACs including physiotherapy, OHIP also funds physiotherapy

services on a fee for service basis for anyone requiring physiotherapy in their home because of their condition or illness

with a physician referral

• ~64,000 patients received services in their home billed to OHIP as physiotherapy on a per service, per person basis.

Many of these services are provided in congregate or group settings, such as Retirement Homes and Seniors

Apartments/Condos

In-home Physiotherapy (cont’d)

Future State:

• CCACs will be the single point of access for in-home physiotherapy services

• All clients receiving in-home CCAC physiotherapy will access service and be assessed for physiotherapy services in the same manner

• Assessment for physiotherapy will be part of a more comprehensive assessment of supports needed to keep seniors at home

• Opportunity to expand options for providing physiotherapy in group/congregate settings

Implementation Considerations:

• Focused/extra case management time to review the current waiting lists and initiate service

• Assess the current clients receiving OHIP in-home physiotherapy

• Review and agree on the threshold for eligibility determination that aligns more with the needs of the applicant

• Explore opportunities to develop standardized criteria for physiotherapy services in a group/congregate setting

• Establishing care pathways based on best practice evidence

• Establishing standardized messaging and communications for current and future CCAC clients

• CCACs will engage current contracted service providers regarding any need for increased capacity

• Ministry seeks to engage as soon as possible with system partners to implement these changes

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In-home Physiotherapy (cont’d)

Outcomes:

• Up to 60,000 more clients per year, including seniors will receive CCAC physiotherapy services

• $33M additional investment in CCAC physiotherapy services

• Current waiting list cleared and reduced wait time for service initiation

• Best practice/care pathways for the delivery of physiotherapy – resulting in improved client outcomes and

appropriate service levels

• Standardized benchmarking for performance and client outcomes

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Local Issues/Concerns: In-home Stream

• Clarity required on the functions/roles and access to:

• In home physiotherapy (CCAC)

• Community PT Clinics

• Process to move from current state to future state is very time intensive with the CCAC needing to connect

with every Retirement Home

• CCAC will likely have to ramp up providers to manage the extra volumes then determine the steady state

• Anticipate spikes in MLPA indicator due to fluctuations in client volumes

• Despite every reasonable effort to determine where clients are currently being served, it is anticipated that

there will be some transition issues to be management after August 1, 2013.

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Clinic-based Physiotherapy

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Clinic-based Physiotherapy Implementation:

• Transition of service delivery description, eligibility requirements, accountability from Health Insurance Act to a

contract-based framework

• Allocate funding among LHINs

• Clarify PT funding and delivery model details

• Flow funds for services delivered effective Aug 1, 2013 via funding agreement

• Initiate an application process for new points of access for delivery of clinic-based PT services

Future State:

• Continue current patient eligibility requirement for physician or nurse practitioner referral to fund up to an additional

90,000 patients annually

• Community ambulatory physiotherapy to restore movement caused by injury, pain and/or decreased function (e.g.

MSK conditions)

• Total budget of $44.5M including existing providers

• Increased number of access points to improve geographic access to services

• Enhanced reporting requirements – e.g. diagnostic conditions

• Services subject to terms and conditions of funding agreement rather than a regulatory framework

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Clinic-based Physiotherapy (cont’d)

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Outcomes:

• Provide care to more patients with better geographic equity

• Restructured payment model is more responsive to need, higher quality care

• Physiotherapy funding and data reporting approach will more ably support future health

system funding reform planning

• Evaluation and transition to full LHIN responsibility for funding and service delivery for

community ambulatory PT

• Downstream modification/evolution of funding and delivery of ambulatory physiotherapy

services and integration with Health System Funding Reform and other physiotherapy and

rehab initiatives in the community

Clinic-based Physiotherapy (cont’d)

Central East LHIN Considerations for Recommendations on Siting Clinics:

• Demographics e.g. concentrations of seniors

• Data for those who have received OHIP funded physiotherapy (OHIP billings)

• Frailty Index data from RSGS work

• CCAC data on current utilization of physiotherapy services (total joint replacement) as well as identifying a cohort that might best be suited towards clinic services vs 1:1 therapy

• Available outpatient rehab information

• Performed a convergent analysis to identify geographic areas that would seem to indicate a demand for community based physiotherapy

• Input provided to the Ministry on June 21, 2013.

• Ministry to review information, consider inputs from their end and then engage the LHINs in further discussion around sitings/volumes.

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Local Issues/Concerns: Clinic-based Stream

• The Ministry is seeking LHIN input to where community clinics should be located (June 21st)

• There is no provincial/consistent methodology to determine this.

• There are many moving parts related to rehabilitation in Ontario currently and an apparent lack of

integration amongst them.

• As noted earlier, the interface of this stream and the in-home (CCAC) stream is unclear.

• LHINs do not currently know which Designated Physiotherapy Clinics (DPCs) have agreed to

work within the new funding formula – Central East has 11 DPCs (7 Scarborough, 3 Durham, 1

Kawartha Lakes)

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Community Exercise and Falls

Prevention Classes

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Exercise and Falls Prevention Classes

Context

• The Ministry is investing $10M to benefit approximately 130,000 seniors by:

• Ensuring that seniors affected by changes in the delivery of physiotherapy services will

continue to receive exercise and falls prevention classes, and

• Adding more exercise and falls prevention services in communities across the province

in order to increase access to regular physical activities and falls prevention programs

for more seniors

• Each Local Health Integration Network (LHIN) will receive funding to:

• Maintain the exercise and falls prevention services affected, locally, by the

physiotherapy changes, and making these services available in the same locations, to

the extent possible, to avoid disruptions for seniors

• Expand exercise and falls prevention classes to improve access to these services for

more seniors in more communities across LHIN geographic areas

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Context: Outcomes

• Improved supports for seniors to stay healthy and at home longer by increasing

availability and access to regular exercise and falls prevention classes

• Regular physical activity positively affects seniors’ overall well-being,

functional capacity, strength, and ability to better manage chronic conditions

• Reduced falls and hospitalizations due to falls among seniors

• Falls are the leading cause of preventable injuries among seniors with an

estimated annual cost to Ontario’s health care system of $962 million

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• Total investment of $10M:

• $8M will be dedicated for exercise classes (Central East = $971,600)

• $2M will be dedicated for falls prevention classes (Central East = $242,900)

• These services are expected to be free of charge to seniors and there are no limits on the

number of classes a senior may attend, and are intended to be offered in multiple locations,

including Retirement Homes, community centres, Elderly Person Centres, Seniors

Apartments, other

Context: Investment

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Context: Implementation Considerations

• The LHINs will lead a process to determine the communities, locations, and types of

exercise/falls prevention programs that would be offered to meet the needs and

interests of seniors; LHINs will work with key stakeholders including Retirement

Homes, Service Providers, Public Health Units to decide program parameters

• LHINs will undertake a process to select the service providers that will deliver the

services. Any Call for Proposals must be restricted to organizations that can be

approved as agencies under the Home Care and Community Services Act, 1994

(HCCSA). These organizations are not-for-profit corporations, co-operatives,

municipalities and First Nations

• However, approved agencies can provide services directly or indirectly under the

HCCSA. Therefore, community services can be provided by approved agencies

indirectly through agreements with service providers (which can be for-profit or not-

for-profit organizations)

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• The exercise/falls prevention classes affected by the physiotherapy changes

should begin as of August 1st, 2013

• Where exercise and/or falls prevention classes are provided in Retirement

Homes they should be open to both residents and non-resident seniors within

the community

• New/expanded exercise and falls prevention classes will roll out in phases

through fall and winter

Context: Implementation Considerations

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Context: Future State

• Exercise and falls prevention classes will be available in a variety of locations

and communities within LHIN boundaries for more seniors than ever before

• Exercise classes will be offered multiple times per week in multiple locations, all

year round (e.g. 4 times per week, 48 weeks per year)

• Falls prevention classes will also be offered multiple times per week in multiple

locations, in a series of 12 week sessions

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Central East LHIN Process

• Leveraged existing HSPs as Lead/Preferred Providers in each of the three

geographic clusters in Central East

• Released an Expression of Interest with the primary intent to identify locations of

existing OHIP funded classes as well as opportunities for expansion

• Received 128 submissions as of June 14th (and still coming in)

• All reviewed and translated into the new parameters.

• Initial plan developed and submitted to the Ministry on June 14th.

• The Plan is provisional as there is still much work to be done with lead agencies and

the receivers of the services.

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Local Issues/Concerns: Falls/Exercise Stream • Extensive response to Expression of Interest issued by Central East LHIN, as outlined in Briefing

Note, although entire budget has not yet been committed and only 40 of 73 Retirement Homes

responded. Follow up phone calls were made to the remaining.

• Working with lead agencies to determine how to best operationalize classes

• The timing to transition these services by August 1 is a material consideration, particularly if a

lead agency is subcontracting, as the procurement process needs to be built in.

• As in the in-home stream, it is expected that there will be locations that have not been identified

as of August 1. A contingency plan will need to be in place to mitigate this to the extent possible.

• The funding that has not been committed to date will be applied over the next few months as

additional information comes forward.

• Intent is to replace existing OHIP funded classes by August 1 and then new/expanded classes

will roll out over Q3. Consideration to move some exercise funding to falls prevention pool

• Consideration of indirect costs still under discussion with Ministry – significant risk for providers

• Very resource intensive process

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Preliminary Allocations

2013/14 Notional

Allocations

Total Anticipated

Locations/Classes

Total Anticipated

Unique Clients

Served

Exercise $971,600 405 14,175

Falls Prevention $242,900 253 2,530

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The Provisional Plan

Exercise Classes

Replacement

Classes

New

Classes

# of Clients Provisional

Allocation

84 45 3,470 $309,600

Falls Prevention Classes

160 107 2,725 $256,320

Total $565,920

Still To Be

Allocated $648,580

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Next Steps

• Ongoing discussions with lead agencies to provide details of the falls/exercise classes

provisional plan and determine next steps for operationalizing the replacement sites for

August 1.

• Continue to participate in the regular communication networks with LHIN leads and

Ministry;

• Work with the Central East CCAC to coordinate next steps as they begin discussions

with the community on the in-home stream.

• Work with the Ministry on determination of community clinic sites

• Awaiting further detail on the primary care stream – not August 1 dependent.

• Awaiting funding letters (exercise/falls, LTC, CCAC)

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Motions

• Be it resolved that the Central East LHIN Board of Directors endorses the provisional

plan for Exercise and Falls Prevention classes as outlined in the presentation and

delegates authority to the Chief Executive Officer to determine specific service

provider allocations as the plan evolves over the coming weeks.

• Be it resolved that the Central East LHIN Board of Directors agrees with the

population based approach used to develop recommendations for demand for client-

based physiotherapy services in Central East.

• Be it resolved that the Central East LHIN Board of Directors directs Management to

report back to the Board in July 2013 on the status of all five streams related to the

physiotherapy changes in Ontario.

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Key Timelines Related to Reform

• Provincial announcement – April 18, 2013

• Regulation change and implementation – August 1, 2013

• Exercise/Falls Prevention stream initiated provincially – April 26, 2013

• Call for applications for additional community clinic providers - June 19, 2013

• LTCH Funding and Financial Policies – July/August 2013

• Transition of existing providers from HIA to TPA – August 1, 2013

• Exercise/Falls Prevention classes begin – from August 1, 2013 onwards

• Implementation of PT in Family Health Care Settings – Fall 2013

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