implementing stroke and orthopaedic best …best practice care delivery targets for primary,...
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© 2012 Hay Group Limited. All rights reserved www.haygroup.com/ca
Implementing Stroke and Orthopaedic Best Practices in the Toronto Central LHIN Analysis of System Wide Impacts
March 31, 2012
www.haygroup.com/ca
Contents
1.0 BACKGROUND, OBJECTIVES AND APPROACH ..................................................... 1
1.1 BACKGROUND ............................................................................................................. 1 1.2 OBJECTIVES ................................................................................................................. 2 1.3 APPROACH................................................................................................................... 3
2.0 CONTEXT FOR CHANGE ............................................................................................... 5
2.1 INTER LHIN DEPENDENCIES ....................................................................................... 5 2.2 POTENTIAL RESTRUCTURING OF SERVICES ............................................................... 10
3.0 TOTAL JOINT REPLACEMENT PATIENT FLOW.................................................. 11
3.1 CURRENT CHARACTERISTICS .................................................................................... 11 3.2 BEST PRACTICE TJR PATIENT FLOW TARGETS.......................................................... 13 3.3 IMPLICATIONS OF IMPLEMENTING BEST PRACTICE TJR PATIENT FLOW TARGETS .... 17 3.4 SITING OF TJR SERVICES ........................................................................................... 20 3.5 RESULTING TJR VOLUMES OF CARE IN TC LHIN REHABILITATION HOSPITALS ...... 21
4.0 HIP FRACTURES PATIENT FLOW ............................................................................ 23
4.1 CURRENT CHARACTERISTICS .................................................................................... 23 4.2 BEST PRACTICE PATIENT FLOW TARGETS ................................................................. 25 4.3 IMPLICATIONS OF IMPLEMENTING BEST PRACTICE HIP FRACTURE PATIENT FLOW
TARGETS ................................................................................................................... 27 4.4 SITING OF HIP FRACTURE SERVICES .......................................................................... 29 4.5 RESULTING HIP FRACTURE VOLUMES OF CARE IN TC LHIN REHABILITATION
HOSPITALS ................................................................................................................ 30
5.0 STROKE STRATEGY ..................................................................................................... 32
5.1 CURRENT CHARACTERISTICS .................................................................................... 32 5.2 BEST PRACTICE PATIENT FLOW TARGETS ................................................................. 34 5.3 SITING OF STROKE SERVICES..................................................................................... 39 5.4 RESULTING STROKE VOLUMES OF CARE IN TC LHIN REHABILITATION HOSPITALS 40
6.0 IMPACT OF THE MSK AND STROKE PATIENT FLOW INITIATIVES ............. 42
6.1 NET IMPACT OF BEST PRACTICE PATIENT FLOW INITIATIVES ................................... 42 6.2 KEY QUESTIONS RELATED TO PATIENT FLOW STRATEGIES ...................................... 43
7.0 COMPLEX CONTINUING CARE INITIATIVES ...................................................... 48
7.1 CURRENT CHARACTERISTICS .................................................................................... 48 7.2 IMPACT OF MUSCULOSKELETAL AND STROKE PATIENT FLOW INITIATIVES ON CCC 52 7.3 PROPOSED CCC INITIATIVES ..................................................................................... 52 7.4 PROPOSALS FOR CHANGE IN CCC PATIENT FLOW..................................................... 54 7.5 KEY QUESTIONS RELATED TO COMPLEX CONTINUING CARE .................................... 55
APPENDIX A: SOURCE OF COST ESTIMATES .............................................................. 59
APPENDIX B: PARTICIPANTS IN FOCUS GROUP TO REVIEW PRELIMINARY
FINDINGS .................................................................................................................................. 63
APPENDIX C: ST. JOHNS REHAB HOSPITAL AND THE TC LHIN ............................. 65
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1.0 Background, Objectives and Approach
1.1 Background
There are several strategies and initiatives being proposed for
implementation in the Toronto Central LHIN to improve stroke and
orthopaedic care that likely will have system wide impacts. Critical
among these are:
Provincial Stroke Strategy
Provincial Care Delivery Targets for Primary Total Joint
Replacements
Patient Flow Proposals for Hip Fracture patients
At the same time, providers of Rehabilitation and Complex
Continuing Care (CCC) services within the LHIN have brought
forward proposals for changes in both their roles and capacity that
could result in changes to CCC and Rehabilitation beds in the system.
The clinical proposals for change have been developed and
recommended by the TCLHIN MSK Flow Implementation Group
(Orthopaedic patient flow proposals), the Rehabilitation Stroke Flow
Task Group working within the TC LHIN (Stroke strategy patient
flow proposals) and individual health system providers (changes in
CCC and rehabilitation roles and capacity).
1.1.1 Stroke Strategy
The three Toronto-area stroke networks and the GTA Rehab Network,
are advocating for a broad-based initiative to realign and improve
stroke care across the Toronto Central and GTA LHINs in line with
the provincial stroke strategy and in partnership with the TCLHIN
hospitals. The initiative focuses on aligning care with known best
practices, enhancing outcomes and improving utilization of health
services. If implemented, it is expected that the initiative will:
Consolidate acute stroke programs to align with critical mass
thresholds,
Refer and admit stroke patients to rehab earlier in an episode of
care,
Admit a greater number of severe stroke patients into high
intensity rehab,
Reduce the number of severe stroke patients being admitted to
low intensity rehab programs, and
Improving stroke,
orthopaedic and CCC care
in the TC LHIN
Aligning stroke care with
known best practices,
enhancing outcomes and
improving utilization of
health services
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Redirect patients with mild stroke to outpatient rehabilitation
programs after discharge from acute care.
1.1.2 Primary Joint Replacement Targets
Based on experience across the health system in the province and best
practice research in the field, the Provincial Orthopaedic Expert Panel
has recommended best practice care delivery targets for primary,
unilateral hip and knee replacements. The targets provide for an
average length of stay of 4.4 days in acute care with 90% of patients
who receive either a primary unilateral hip or knee replacement being
discharged to their homes with their post-acute rehabilitation being
provided in outpatient, home-based and community-based settings.
1.1.3 New Models of Complex Continuing Care
An OHA report1 has suggested that “It is important to recognize that
CCC has been evolving over the past 15 years since the Chronic Care
Role Study, the report of the Chronic Care Implementation Task
Force and the HSRC Change & Transition Report and Planning
Guidelines. CCC hospitals and programs have been focusing more on
restorative and rehabilitation programs and services as a result of less
demand for and thus less focus on long term or continuing complex
care. Rather than staying in hospital, CCC patients are increasingly
being discharged to LTC facilities, to home with home care or to
home. In short, “CCC has evolved into being viewed as a “resource”
rather than a final destination. Increasingly, CCC beds are being used
to enhance the system’s capacity to transition people to lower levels
of care or back to the community.” Many CCC providers in the TC
LHIN have adopted and/or are proposing to adopt this new model of
complex continuing care. They are suggesting that the demand for
continuing care is diminishing and thus fewer beds are needed for this
type of patient. Since 2005, 705 chronic hospital beds have been
closed in Ontario, 143 in TC LHIN hospitals.
1.2 Objectives
TC LHIN wishes to create a system that facilitates the delivery of best
clinical practices related to Strokes, TJR and CCC care. However,
prior to moving to implement the proposed initiatives, the TC LHIN
wishes to fully understand the interaction and overall operational,
facilities and cost implications of these system-wide change
initiatives. Also, if implemented the TC LHIN has indicated that the
1 Optimizing the Role of Complex Continuing Care and Rehabilitation in the
Transformation of the Health Care Delivery System. Ontario Hospital
Association, May 2006.
Best practice care delivery
targets for primary,
unilateral hip and knee
replacements
CCC is increasingly
focusing on rehabilitative
care helping people
transition to lower levels of
care or back to the
community
Create a system that
facilitates the delivery of best
clinical practices related to
Strokes, TJR and CCC care
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proposed initiatives will need to be accommodated within the current
levels of funding for healthcare services.
To better understand and advance these initiatives in a timely and
effective manner, TC LHIN engaged Hay Group Health Care
Consulting to perform a system wide assessment and analysis of:
The stroke strategy patient flow proposals
The orthopaedic (primary unilateral hip and knee replacement)
patient flow strategy
Other changes in CCC capacity under consideration
The analyses have been designed to determine:
Operational implications of the proposed initiatives
Operating cost and savings implications of the proposed initiatives
Any potential gaps resulting from these initiatives and possible
strategies to mitigate them
Capital changes/requirements resulting from these initiatives
The LHIN will review the findings of this study to determine how it
will facilitate and direct the system’s implementation of the proposed
Stroke, Orthopaedic and CCC initiatives.
1.3 Approach
The work of this project was conducted under the direction of a
Steering Committee assembled by the TC LHIN. The membership of
the project steering committee is presented in the following table.
Dr. Barry McLellan (Co-Chair), Sunnybrook
Ella Ferris, St. Michael’s Hospital
Rachel Solomon, Toronto Central LHIN
Marian Walsh (Co-Chair), Bridgepoint
Karima Velji, Baycrest Centre for Geriatric Care
Dr. Rod Davey, University Health Network
Bill Manson, Toronto Central LHIN
Malcolm Moffatt, St. John’s Rehab
Stacey Daub, Toronto Central CCAC
Camille Orridge, Toronto Central LHIN
Dr. Mark Bayley, Toronto Rehab Institute
Vania Sakelaris, Toronto Central LHIN
Carmine Stumpo, Toronto East General Hospital
Mark Hundert, Hay Group Victoria Van Hemert, Central LHIN
Charissa Levy, GTA Rehab Network
Dr. Nicole Nitti, Access Alliance
Chris Sulway
TC LHIN
A system wide assessment
and analysis proposals for
change
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We employed a 7 step workplan to achieve the TC LHIN’s objectives
for this review and develop this report2. The key elements of our
work are presented in the following exhibit.
Exhibit 1: Project Workplan
2 Participants in the Step 5 focus group to review our preliminary findings are
presented in an appendix to this report.
1.0 Project Start-Up
1.1 Project Team Meeting with TC LHIN Lead
1.2 Steering Committee Meeting
1.3 Confirm Attendees and Send Invitations for Focus Groups and Summit
1.4 Assemble Materials
1.5 Arrange for Access to Data
2.0 Review of Stroke Flow Initiative
2.1 Review Background Materials
2.2 Review HSP Responses to Stroke Flow Initiative
2.3 Determine Implications of Stroke Flow Initiative for TC LHIN HSPs
2.4 Determine Implications of Stroke Flow Initiative for HSPs in Other LHINs
2.5 Determine Implications of Stroke Flow Initiative for System
2.6 Summarize Preliminary Findings
3.0 Review of Orthopaedic Flow Strategy
3.1 Review Background Materials
3.2 Review HSP Responses to Orthopaedic Flow Initiative
3.3 Determine Implications of OQS Targets / Orthopaedic Flow Initiative for TC LHIN HSPs
3.4 Determine Implications of OQS Targets / Orthopaedic Flow Initiative for HSPs in Other LHINs
3.5 Determine Implications of OQS Targets / Orthopaedic Flow Initiative for System
3.6 Summarize Findings
4.0 Review of CCC Models of Care Initiatives
4.1 Review Background Materials
4.2 Review CCC HSP Proposals for Models of Care/Capacity Changes
4.3 Determine Implications of Models of Care Changes for TC LHIN HSPs
4.4 Determine Implications of CCC Models of Care Changes for HSPs in Other LHINs
4.5 Determine Aggregated Implications of CCC Models of Care Changes for System
4.6 Summarize Findings
5.0 Focus Group To Review Preliminary Findings
5.1 Develop Focus Group Materials
5.2 Focus Group(s)
5.3 Sumarize Focus Group Input
5.4 Additional Analyses As Required
5.5 Document Findings Related to Each Line of Enquiry
6.0 Integrate Findings from 3 Lines of Enquiry
6.1 Develop Integrated Set of Findings
6.2 Steering Committee Review of Integrated Findings
6.3 Revise/Refine Integrated Set of Findings as Necessary
7.0 Final Report
7.1 Develop Project Report
7.2 Present Project Report to Steering Committee
7.3 Document Findings in Formal Project Report
Project Activity
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2.0 Context for Change
In considering introduction of best practice related to MSK, Stroke
and CCC there are three critical contextual factors that needed to be
taken into account:
Inter-relationship of TC LHIN and adjacent LHINs in provision of
acute, rehabilitation and CCC care for residents of GTA
Difference in Rehabilitation and CCC capacity between TC
LHIN/ GTA and the rest of the province
Potential need to restructure the delivery of service to achieve the
best practice targets
2.1 Inter LHIN Dependencies
As can be seen in the following exhibit, most Orthopaedic and Stroke
care, almost all CCC care and most rehabilitative care for TC LHIN
residents are provided by TC LHIN acute care, CCC and
Rehabilitation facilities. A significant number of residents of other
LHINs also use TC LHIN facilities for Orthopaedic, Stroke, CCC and
rehabilitative care.
Residents of Central LHIN use TC LHIN acute care hospitals for
28% of their TJR care, 25% of their stroke care and 14% of their
hip fractures. Residents of other LHINs are less dependent on TC
LHIN acute care hospitals
A significant proportion of CCC care for residents of Central
LHIN (61%) and much of the CCC care for residents of CE LHIN
(38%) is provided by TC LHIN CCC facilities
25-35% of rehabilitation for residents from Central, CE & CW
LHIN is provided by TC LHIN Rehabilitation facilities
TC LHIN hospitals provide
a significant amount of the
care received by residents of
adjacent LHINs
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Exhibit 2: Utilization of TC LHIN Facilities by Residents of GTA LHINs3
In determining the scope of this study, consideration was given to the
inclusion of St. John’s Rehabilitation Hospital as a TC LHIN
provider. It was recognized that St. John’s is a significant resource
for both TC LHIN acute care hospitals. However, it was determined
that with respect to TJRs, Hip Fractures and Strokes, it would be more
appropriate to consider St. John’s Rehabilitation Hospital to be
outside of the TC LHIN and an external provider. Only 16.2% of St.
John’s inpatient rehabilitation patients live in the Toronto Central
LHIN and patients transferred from TC LHIN acute care hospitals
account for only 27% of St. John’s inpatient TJR, Hip Fracture and
Stroke cases. An analysis of the role of St. John’s in rehabilitation for
patients from TC LHIN acute care hospitals is provided in an
appendix to this report. Rehabilitation and CCC Capacity
2.1.1 Rehabilitation Capacity
TC LHIN has significantly more rehabilitation capacity than other
Ontario LHINs. As can be seen from the following exhibit, the TC
LHIN has over 3 times as many rehabilitation beds per population as
the provincial average.
3 Source: 2010/11 Ontario CIHI DAD, 2010/11 CCRS, 2010/11 NRS, accessed
via MOHLTC IntelliHealth data system.
Unilat.
Hip and
Knee
Hip
FractureStroke
Unilat.
Hip and
Knee
Hip
FractureStroke
Toronto Central 80% 81% 86% 98% 81% 79% 83% 82%
Miss. Halton 21% 8% 9% 12% 17% 35% 11% 10%
Central West 16% 5% 9% 13% 35% 38% 26% 26%
Central East 19% 5% 19% 38% 25% 27% 21% 24%
Central 28% 11% 25% 61% 34% 22% 31% 35%
Rehabilitation Programs
All
RehabCCC
Patient LHIN
(i.e. residence
of patient)
Acute Care
% of all Patients Living in a LHIN Who Received Their Hospital Care in a
Toronto Central LHIN Hospital
Consider St. John’s
Rehabilitation Hospital to be
outside of the TC LHIN and
an external provider with
respect to TJR, Hip
Fractures and Strokes
TC LHIN has significantly
more rehabilitation capacity
than other Ontario LHINs
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Exhibit 3: 2010/11 Rehabilitation Beds per 100,000 Population
4
Even when the high use of TC LHIN beds by residents of the adjacent
LHINs is accounted for, TC LHIN and the adjacent LHINs have over
twice as many rehabilitation beds as the average for the province.
4 Bed numbers by LHIN are from the Ontario MOHLTC Daily Census Summary
reports.
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Exhibit 4: 2010/11 Rehabilitation Beds per 100,000 Population
5
As might be expected given the available capacity the residents of the
TC LHIN use inpatient rehabilitation significantly more than residents
of other LHINs.
Exhibit 5: 2010/11 Utilization Rates (Cases/100,000 Population) for Rehabilitation
5 Bed numbers by LHIN are from the Ontario MOHLTC Daily Census Summary
reports.
Residents of the TC LHIN
use inpatient rehabilitation
more than residents of other
LHINs
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2.1.2 CCC Capacity
Similarly, TC LHIN has significantly more CCC capacity than other
Ontario LHINs. As can be seen from the following exhibit, the TC
LHIN has over 3 times as many CCC beds per population as the
provincial average.
Exhibit 6: 2010/11 CCC Beds6 per 100,000 Population 75+
7
Even when the high use of TC LHIN CCC beds by residents of the
adjacent LHINs is accounted for, TC LHIN and the adjacent LHINs
have over twice as many CCC beds as the average for the province.
This is reflected in the following exhibit.
6 Note: SHSC Veteran’s beds excluded from TC LHIN chronic beds.
7 Bed numbers by LHIN are from the Ontario MOHLTC Daily Census Summary
reports.
TC LHIN has significantly
more CCC capacity than
other Ontario LHINs
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Exhibit 7: 2010/11 CCC Beds8 per 100,000 Population 75+
9
2.2 Potential Restructuring of Services
The Steering Committee for this study considered that it might be
reasonable to consider restructuring of services as part of the process
of implementing the best practice patient flow targets. The committee
established the following criteria for use in determining the siting of
services.
Benefit for patients
Equity of access for patients & families/geographic distribution
Critical mass for quality (e.g. demonstrated volume/outcome
relationship, applied to both inpatient and ambulatory services)
Critical mass for efficiency (applied to both inpatient and
ambulatory services)
Existing physical capacity
Existing clinical expertise
Efficient use of specialized technologies
Co-location of clinically interdependent programs (e.g. acute
programs/services, rehab programs, inpatient and ambulatory)
Facilitates implementation of patient focused clinical pathways
Availability of transportation services for ambulatory care
8 Note: SHSC Veteran’s beds excluded from TC LHIN chronic beds.
9 Bed numbers by LHIN are from the Ontario MOHLTC Daily Census Summary
reports.
Criteria for determining the
siting of services
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3.0 Total Joint Replacement Patient Flow
The patient flow proposals for primary unilateral hip and knee
replacement patients (Total Joint Replacement patients) will provide
for further movement toward best practice by TC LHIN providers.
The proposed enhancements to patient flow will substitute outpatient
rehabilitation for inpatient rehabilitation for more of the Total Joint
Replacement patients cared for in TC LHIN acute care hospitals.
3.1 Current Characteristics
The following table presents the number of Total Joint Replacement10
cases cared for in each TC LHIN acute care hospital, the lengths of
stay and total patient days. As can be seen, Sunnybrook Health
Sciences accounted for over a third of the primary TJR procedures
conducted in TC LHIN hospitals.
Exhibit 8: 2010/11 Total Joint Replacement Patients by Hospital
The following table presents the discharge destinations11
of TJR
patients cared for in each TC LHIN hospital, as documented in the
CIHI 2010/11 DAD data. As can be seen, overall, 34% of TJR
patients were discharged to inpatient rehabilitation.
10
Unilateral Primary Joint Replacements have been identified on basis of CIHI
Case Mix Group assignment: CMG 320 Unilateral Hip Replacement; CMG 321
Unilateral Knee Replacement. Data is from the 2010/11 Ontario CIHI DAD
accessed via IntelliHealth. 11
It should be noted that referral to home care for patients discharged home has not
always been comprehensively reported in the DAD data.
CasesAvg.
LOSCases
Avg.
LOSCases
Avg.
LOS
Sunnybrook HSC 718 4.9 1,020 4.6 1,738 4.7
University Health Network 366 4.8 503 4.5 869 4.6
St. Michael's Hospital 451 4.0 250 4.6 701 4.2
Toronto East General 152 4.4 342 4.2 494 4.3
Mount Sinai Hospital 197 4.9 223 4.5 420 4.7
St. Joseph's HC, Toronto 127 5.7 228 4.9 355 5.2
Grand Total 2,011 4.7 2,566 4.5 4,577 4.6
Hips Knees TJR
Hospital
Substituting outpatient for
inpatient rehabilitation for
more TJR patients
In 2010/11 TC LHIN Acute
Care Hospitals Did 4,577
TJRs
34% of TC LHIN hospital
TJR patients were
discharged to inpatient
rehabilitation
Page 12 www.haygroup.com/ca
Exhibit 9: 2010/11 Discharge Destinations for TJR Patients by Hospital
The following table presents the volume of TJR inpatients cared for
by each of the TC LHIN rehabilitation hospitals, as documented in the
Ontario 2010/11 CIHI NRS database. As can be seen the 2010/11 TC
LHIN annual primary TJR inpatient rehabilitation case volumes
ranged from 11 at Baycrest to 448 at Sunnybrook. The average
inpatient rehabilitation Length of Stay (LOS) for primary joint
replacement cases varies from 4.9 days at Sunnybrook to 27.3 days at
Baycrest.
Exhibit 10: 2010/11 TJR Inpatients by Rehabilitation Hospital
The following table presents the distribution of lengths of stay for
TJR patients in TC LHIN rehabilitation facilities. The median (and
modal) length of stay (LOS) for these patients is 7 days; 97% of
patients are discharged in 30 days or less. . 73% of current patients
in TC LHIN rehabilitation facilities are discharged in 13 days or
less12
.
12
It is interesting to note that in their modeling of potential savings from shifting
TJR cases from inpatient rehabilitation to ambulatory rehabilitation, the GTA
Rehab Network assumed an average rehab LOS of 13 days (slightly longer than
the current average inpatient rehab LOS of 11 days) for those cases to be shifted
from inpatient care
Home,
no HC
Rehab
IP
Home,
w HC
Chronic
IPLTCH Other
Sunnybrook HSC 1,737 65% 31% 4% 0% 0% 1%
University Health Network 868 6% 34% 58% 0% 0% 1%
St. Michael's Hospital 699 28% 51% 19% 2% 1% 0%
Toronto East General 493 41% 32% 24% 2% 1% 1%
Mount Sinai Hospital 420 44% 27% 28% 0% 0% 0%
St. Joseph's HC, Toronto 354 64% 25% 7% 3% 1% 0%
Grand Total 4,571 43% 34% 21% 1% 0% 0%
% Distribution of Discharges by Discharge Disposition# of Live
DischargesAcute Care Hospital
Hospital Cases IP DaysAvg.
LOS
Sunnybrook 448 2,193 4.9
Bridgepoint 304 4,528 14.9
TRI Hillcrest 295 2,808 9.5
Providence Scar. 187 2,718 14.5
West Park 153 2,435 15.9
Toronto East Gen. 130 1,756 13.5
Baycrest 11 300 27.3
Grand Total 1,528 16,738 11.0
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Exhibit 11: Distribution of 2010/11 TC LHIN Rehab IP Total Joint Replacement Cases by LOS
13
3.2 Best Practice TJR Patient Flow Targets
The TC LHIN target is ‘Best Practice’ care for primary Total Joint
Replacement patients. These targets were developed by the TC LHIN
MSK Flow Task Group and accepted by the project Steering
Committee for implementation in the TC LHIN. The key
characteristics of the target patient flow are:
Discharge primary TJR patients with an acute ALOS of 4.4 days
Earlier discharge will be facilitated by changing the model of
acute care both to provide ‘pre-rehab’ care and to initiate
rehabilitation in acute care
Decrease reliance on inpatient rehabilitation for primary TJR
patients
Only 10% of TJR patients (or fewer) should be discharged to
inpatient rehabilitation
90% of TJR should be discharged to home with community
based rehabilitation programs
The characteristics of TJR patients that should continue to go
to inpatient rehabilitation14
relate to a combination of factors
that preclude a safe discharge to the community such as:
13
2010/11 Ontario CIHI NRS data, accessed via IntelliHealth.
0
50
100
150
200
250
1 3 5 7 9 11
13
15
17
19
21
23
25
27
29
Vo
lum
e o
f TC
LH
IN C
ase
s
Inpatient Rehab Length of Stay
‘Best Practice’ care for
primary Total Joint
Replacement patients
Page 14 www.haygroup.com/ca
Patients with significant/active comorbid conditions/pre-
existing or peri-operative complications
Bariatric patients
In exceptional cases only where a patient’s need for
support post-operatively is anticipated to exceed what is
currently available through informal or formal community
resources to support a safe discharge to home
For those primary TJR patients who will still be admitted to inpatient
rehabilitation, we have used a target ALOS of 14 days (i.e. longer
than the current TC LHIN average inpatient rehabilitation LOS of 11
days) to account for the likely higher complexity of patients that will
still need inpatient rehabilitation.
14
GTA Rehab Network Triage & Admission Guidelines for TJR (Guidelines for
the Pre-Admission Process: Primary, Unilateral, Elective TJR, September
2011)suggest the following criteria for discharge of TJR patients to inpatient
rehabilitation:
Discharge to inpatient rehab should only be considered where there is a
combination of concerns in the following areas that precludes a safe discharge to
the community:
1. Overall Functioning/Mobility:
Does the patient have poor pre-operative function as demonstrated by
any of the following:
- The requirement for significant family support or formal
community support services
- Limitations in upper extremities that can impact post-op recovery in
the community (particularly in cases where there will be weight
bearing restrictions)
Is there insufficient strength/tolerance in the non-operative leg to
support the patient’s post-op recovery in the community?
Is the patient limited in his/her ability to understand information
provided?
2. Post-op Risk:
Is the patient at high risk of developing postoperative complications that
may require regular monitoring by healthcare providers?
3. Social Situation:
Are there any barriers in the home environment that cannot be modified
to support a safe discharge home (e.g. stairs; bathroom set-up; type of
home)?
Is the patient’s need for support post-op anticipated to exceed what is
currently available through informal or formal community resources to
support a safe discharge to home?
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With the implementation of the best practice patient flow targets for
primary Total Joint Replacement patients there will be a dramatic
reduction in the number of TJR patients discharged to inpatient
rehabilitation. In 2010/11 34% of TJR patients cared for in TC LHIN
acute care hospitals were discharged to inpatient rehabilitation;
implementation of targets will result in a 70% reduction in admissions
to IP rehabilitation for TJR rehabilitation; an additional 24% of TJR
patients will be discharged from TC LHIN acute care hospitals to
home.
With the implementation of the patient flow targets, admission criteria
to inpatient rehabilitation for TJR patients will become more
restrictive. This will reduce access to TC LHIN rehabilitation
hospitals and units not only for TJR patients discharged from acute
care hospitals in the TC LHIN, but also for TJR patients discharged
from acute care hospitals in the adjacent LHINs .
But there will be a corresponding increase in the use of outpatient
rehabilitation. The 24% of the primary TJRs discharged from TC
LHIN acute care hospitals who used to go to inpatient rehabilitation
will still need rehabilitation; for these patients, inpatient rehabilitation
should be replaced with outpatient rehabilitation.
The MSK Flow Task Group has modeled the potential increase in
ambulatory rehabilitation to support the shift of TJR cases from
inpatient rehabilitation to outpatient rehabilitation.15
The table below
shows the resulting ratios of ambulatory service per ambulatory
rehabilitation case, taking into account the estimates of the
percentages of patients that will require each of the services.
Exhibit 12: Average Ambulatory Service Requirements per TJR Case
15
Final Report, MSK Flow Task Group Initiative Primary, Elective, Unilateral
Total Joint Replacement, June 2011, GTA Rehab Network. Section 7.4,
Appendix D.
TKR THR
Assessments 0.95 0.20
Classes (10 people) 1.04 -
Classes (6 people) - 0.13
Treatment Sessions 2.25 1.61
CCAC Visits 0.80 2.00
GTA Rehab Network
Est. Ratio of
Ambulatory Service
Req'd per Case
Ambulatory Service
Implementation of TJR best
practice patient flow targets
will result in a 70%
reduction in admissions of
TJR patients to IP
rehabilitation
Replacing inpatient
rehabilitation with
outpatient rehabilitation
Page 16 www.haygroup.com/ca
To make the introduction of the best practice patient flow targets for
primary TJR patients feasible, it will be important for these patients to
be able to access outpatient rehabilitation immediately upon discharge
from acute care. Like transfers to inpatient rehabilitation, it must be
made incumbent on facilities charged with providing outpatient TJR
rehabilitation to accept all TJR patients into their programs
independent of the acute facility they were discharged from. And
there should be no delays in admission to outpatient care.
OP rehabilitation services should be provided as close to patients’
homes as feasible; however location of these programs should take
into consideration both economies & qualities of scale. It is
suggested that outpatient rehabilitation for TJR patients should be co-
located with existing musculoskeletal inpatient rehabilitation
programs in order to take advantage of existing competencies and
capacity. The service could be collocated with inpatient programs in
either rehabilitation or acute care hospitals. The marginal cost of
adding one, two or three group sessions per week in an existing
outpatient program will be much less than introducing a new program
in an agency that currently does not provide outpatient rehabilitation
services.
Where feasible, outpatient or community based rehabilitation should
be located close to a patient’s residence; thus it should be assumed
that outpatient rehabilitation for TJR patients cared for in TC LHIN
acute care hospitals will be provided by an outpatient rehabilitation
program in the LHIN where the patient lives.
Outpatient rehabilitation will only be feasible if the patient can get to
it. To facilitate implementation of this best practice patient flow
strategy, the TC LHIN will need work and coordinate service with
community partner organizations to develop adequate transportation
capacity for those who need it. This will likely need to be a
combination of private, volunteer and public transportation services.
Some of these patients, especially in the early stages of their
rehabilitation will require assisted transportation services.
Total Joint Replacement is an elective procedure. For almost all
patients, the staging and locations of care will be based on their status
at the time of scheduling the surgery and thus will be predictable prior
to surgery. Implementation of the best practice patient flow will be
facilitated and the patient experience will be enhanced if the process
includes a comprehensive intake assessment to determine the likely
course of treatment and to inform the patient (and the patient’s
family) of this course of treatment. Patients will then be able to make
arrangements and prepare themselves for their care and needs after
surgery.
Outpatient TJR
rehabilitation programs
must accept TJR discharges
from acute care.
OP rehabilitation services
should be provided as close
to patients home as feasible
Ensure that adequate
transportation is available
for outpatient TJR
rehabilitation patients
Comprehensive intake
assessment
Page 17 www.haygroup.com/ca
3.3 Implications of Implementing Best Practice TJR Patient Flow Targets
The implementation of the best practice patient flow targets for
primary, unilateral total joint replacements will have limited impact
on acute care hospitals but will result in a dramatic change in the use
of post-acute care rehabilitation services in the TC LHIN.
The patient flow targets will have no impact on the number or
primary, unilateral TJR procedures provided by TC LHIN acute care
hospitals and, because the current ALOS (4.59 days,) is already at the
target ALOS (including the allowance for ALC days), there is no
projected change in overall patient days in TC LHIN acute care
hospitals as a result of implementing the TJR patient flow targets.
However, achieving the target of only 10% of primary, unilateral TJR
being discharged to inpatient rehabilitation will result in 1,090 fewer
TC LHIN acute care hospital cases being discharged to inpatient
rehabilitation. In 2010/11, 88.2% of the TJR cases that were
discharged to inpatient rehabilitation were discharged to TC LHIN
facilities. Thus we estimate that 88.2% of the reduction in TJR
patients discharged to inpatient rehabilitation or 962 cases will be
cases that would have gone to a TC LHIN rehabilitation facility. More
stringent admission criteria for Total Joint Replacement patients will
also reduce number of cases admitted to inpatient rehabilitation from
hospitals outside TC LHIN. In 20/11 this would have meant 71 fewer
TJR cases being discharged from acute care hospitals outside the TC
LHIN to inpatient rehabilitation in TC LHIN facilities. Taken
together, this suggests that implementation of the best practice patient
flow targets will result in 1,033 fewer TJR inpatients cases in TC
LHIN rehabilitation facilities. This change is presented in the exhibit
following.
Exhibit 13: Decrease in Inpatient TJR Rehabilitation Patients Cared for in TC LHIN Rehabilitation Facilities, Based on 2010//11 Patterns of Utilization
Acute Care
Hospital LHIN
Live
Disch.
% to IP
Rehab
Target %
to IP
Rehab
Projected
Chg. In
IP Rehab
Cases
% of IP
Rehab
Cases in TC
LHIN
Hospitals
Projected
Chg. In TC
LHIN IP
Rehab
Cases
Proj. Chg. in
TC LHIN IP
Direct Cost at
$3848 per
Case
Toronto Central 4,571 33.9% 10.0% 1,090- 88.2% 962- 3,699,983-$
Other 17,959 8.0% 10.0% - 0.0% - -$
Miss. Halton 1,744 10.0% 10.0% 1- 0.0% - -$
Central West 1,026 13.5% 10.0% 35- 27.5% 10- 37,510-$
Central East 2,976 26.8% 10.0% 500- 5.4% 27- 103,757-$
Central 2,601 42.3% 10.0% 839- 4.1% 34- 132,178-$
Total 30,877 16.8% 10.0% 2,466- 28.7% 1,033- 3,973,428-$
Dramatic change in the use
of post-acute care
rehabilitation services in the
TC LHIN
No change in acute care
hospitals
1,033 fewer TJR IP cases in
TC LHIN Rehab facilities
Page 18 www.haygroup.com/ca
The reduction in inpatient rehabilitation cases will result in:
Savings of $3,973,428 at an estimated $3,848 direct cost per
case16
;
Reduction of 10,326 inpatient rehabilitation patient days at an
estimated ALOS of 10 days per case17
;
The days removed are equivalent to 29.8 beds @ 95% occupancy.
With the reduction in inpatient rehabilitation, there will need to be a
corresponding increase in outpatient rehabilitation; with that
outpatient rehabilitation being provided by facilities in the LHIN
where the patient lives. As has been discussed, some of these patients
will also require home care services prior to being ready to initiate
outpatient rehabilitation. The table following presents the increase in
outpatient and CCAC rehabilitation that will be required for TJR
patients cared for in TC LHIN acute care hospitals who previously
would have been discharged to inpatient rehabilitation18
. The location
of the OP visits is based on the LHIN where these patients live. For
example, while we have estimated a reduction of 962 inpatient
rehabilitation cases discharged from TC LHIN acute care hospitals to
TC LHIN rehabilitation hospitals, some of these patients live outside
the TC LHIN, and the increase in outpatient care will need to be
provided in the LHIN where they live.
The following table shows the estimated increase in outpatient service
(based on the MSK Flow Task Group model19
) required to support the
reduction of 962 inpatient rehabilitation cases.
16
Appendix A describes the source of the cost impact data. Marginal changes in
costs reflect only direct costs. 17
Cases eliminated will be less complex than the cases that continue to be
admitted, as a result they likely have had a shorter than average length of stay.
Thus, we have estimated that the cases redirected to outpatient rehabilitation had
an ALOS of 10 days). 18
The number of outpatient cases and visits in the TC LHIN also includes patients
cared for in acute care in other LHINs who previously would have been
discharged to inpatient rehabilitation. 19
Final Report, MSK Flow Task Group Initiative Primary, Elective, Unilateral
Total Joint Replacement, June 2011, GTA Rehab Network. Section 7.4,
Appendix D
Reduction of approximately
30 rehabilitation beds and
corresponding savings of
approximately $4 million
Page 19 www.haygroup.com/ca
Exhibit 14: Increase in TC LHIN Outpatient Service to Support Achievement of TJR Target
The reduction in admission of TJR patients to inpatient rehabilitation
will impact 71 patients from GTA LHIN hospitals who will no longer
have access to TC LHIN inpatient rehabilitation beds. The projected
increase in outpatient service required to support these patients is
shown below.
Exhibit 15: Increase in GTA LHIN Outpatient Service to Support Achievement of TJR Target in the TC LHIN
. The increase in the need for outpatient rehabilitation and supporting
in-home care will have the following implications for TC LHIN
facilities and the TC CCAC that will provide outpatient rehabilitation
and in-home care for TJR patients:
TKR THR TKR THR Total
Assessments 0.95 0.20 507 86 593
Classes (10 people) 1.04 - 554 - 554
Classes (6 people) - 0.13 - 57 57
Treatment Sessions 2.25 1.61 1,200 689 1,890
2,261 832 3,093
CCAC Visits 0.80 2.00 427 857 1,284
New Ambulatory TKR Cases 533
New Ambulatory THR Cases 429
GTA Rehab Network
Est. Ratio of
Ambulatory Service
Req'd per Case
Estimated New Ambulatory
Service to Support New
Ambulatory TJR CasesAmbulatory Service
Total Outpatient Sessions
TKR THR TKR THR Total
Assessments 0.95 0.20 37 6 44
Classes (10 people) 1.04 - 41 - 41
Classes (6 people) - 0.13 - 4 4
Treatment Sessions 2.25 1.61 89 51 139
167 61 228
CCAC Visits 0.80 2.00 31 63 95
New Ambulatory TKR Cases 39
New Ambulatory THR Cases 32
GTA Rehab Network
Est. Ratio of
Ambulatory Service
Req'd per Case
Estimated New Ambulatory
Service to Support New
Ambulatory TJR CasesAmbulatory Service
Total Outpatient Sessions
Increase of approximately
3,000 outpatient visits at a
cost of approximately
$600,000
Page 20 www.haygroup.com/ca
Increase of 3,093 new TJR outpatient visits for TC LHIN hospital
outpatient departments based on an average of 9 group sessions
per patient20
.
Increased cost of $618,600 for outpatient care based on an
estimated marginal cost of $200 per session per patient21
.
Increase of 1,284 new TJR CCAC home care visits to be provided
by TC CCAC22
. Increased cost of $256,800 for CCAC home care
visits based on an estimated cost of $200 per visit23
.
3.4 Siting of TJR Services
Siting of services was considered in the context of the siting criteria
developed by the Steering Committee for this project.
There was no consideration given, nor any perceived need to modify
the sites where primary, unilateral joint replacement surgery is being
conducted.
However, the committee determined that to achieve both qualities and
economies of scale it would be beneficial to consolidate inpatient
rehabilitation at a smaller number of sites. It is suggested that SHSC,
Bridgepoint, TRI, Providence, and West Park should continue to
provide inpatient rehabilitation. It is further suggested that Baycrest
Centre for Geriatric Care and TEGH should discontinue inpatient
rehabilitation for TJR patients because of historically relatively low
volumes which would diminish even further with the significant
reduction in inpatient TJR rehabilitation patients under the best
practice patient flow proposal.
The committee’s criteria also suggested that TJR outpatient
rehabilitation should be as close to patients’ homes as feasible. In the
first instance, this would suggest that outpatient rehabilitation should
be provided in the LHIN where the patient lives. In that LHIN,
20
We have made no assumptions/no estimates of cost impact of shifting patients
historically receiving home care rehabilitation (or no OHIP rehabilitation) to
hospital OP service. 21
Estimate of $200 per OP patient based on estimated marginal cost of increase in
group MSK OP rehab in facilities currently offering OP MSK rehab. 22
Assumption that 20% of new TJR cases sent home for OP rehab will require
average of 3 new home care visits. 23
It should be noted that TC CCAC is currently funded for in-home therapy for 800
TJR patients who under the proposed model of care probably should be
receiving outpatient therapy. Thus, although not possible to model in this
exercise, it may be that there should be a net decrease in funding for CCAC care
of TJR patients.
Baycrest Centre for
Geriatric Care and TEGH
should discontinue inpatient
rehabilitation
Outpatient rehabilitation
should be co-located with
inpatient rehabilitation
programs
Page 21 www.haygroup.com/ca
outpatient rehabilitation should be located with consideration to both
economies and qualities of scale. To that end, outpatient
rehabilitation should be co-located with inpatient rehabilitation
programs. Thus, outpatient rehabilitation in the TC LHIN should be
co-located with the inpatient TJR rehabilitation programs at SHSC,
Bridgepoint, TRI, Providence and West Park.
3.5 Resulting TJR Volumes of Care in TC LHIN Rehabilitation Hospitals
The calculations presented in the previous sections addressed the
marginal changes in inpatient case volume for TJR rehabilitation in
the TC LHIN hospitals. In addition to these marginal changes in case
volume, we have assumed that all of the TC LHIN inpatient
rehabilitation providers will provide the proposed target average LOS
for the TJR inpatient rehabilitation cases of 14 days for the TJR
patients that continue to be referred for inpatient rehabilitation. The
following exhibit shows the impact of both the reduction in inpatient
cases and provision of the 14 day average LOS for TJR rehabilitation
inpatients at each of the TC LHIN rehabilitation hospitals.
Exhibit 16: Allocation of Inpatient TJR Rehabilitation After Implementation of Best Practice TJR Patient Flow Targets
24
Because some providers were discharging TJR patients in fewer than
14 days, implementing the 14 day average LOS target will actually
add an additional 1,095 inpatient days to the residual TJR inpatient
rehabilitation cases (i.e. the patient day reduction will not be 10,326
as previously presented, but only 9,808 as presented in the exhibit
here), for an additional cost (a reduction in the potential saving) of
$421,575, based on the TC LHIN estimated direct marginal cost of
$385 per day.
24
In this modelling, the historical Baycrest TJR activity has been reassigned to
West Park; the historical TEGH TJR activity has been reassigned 50% to
Bridgepoint and 50% to Providence.
Cases Days LOS Cases Days Beds LOS Cases Days
Sunnybrook 448 2,193 4.9 145 2,032 5.9 14.0 303- 161- 1,490
Bridgepoint 304 4,528 14.9 120 1,674 4.8 14.0 184- 2,854- 1,227
TRI Hillcrest 295 2,808 9.5 96 1,338 3.9 14.0 199- 1,470- 981
Providence Scar. 187 2,718 14.5 82 1,143 3.3 14.0 105- 1,575- 838
West Park 153 2,435 15.9 53 744 2.1 14.0 100- 1,691- 545
Toronto East Gen. 130 1,756 13.5 130- 1,756-
Baycrest 11 300 27.3 11- 300-
Grand Total 1,528 16,738 11.0 495 6,930 20.0 14.0 1,033- 9,808- 5,082
Hospital
Add'l
OP
Visits
2010/11 Actual After Implementation of TargetsChange from
2010/11 Actual
Page 22 www.haygroup.com/ca
Thus, the total cost impact on the best practice TJR patient flow
targets for the TC LHIN inpatient rehabilitation providers will be a
reduction in inpatient costs of $3,859,000 and an increase in
outpatient and in-home care costs of $875,400 ($618,600 hospital
outpatient and $256,800 CCAC) for a net savings of $2,983,600.
Net savings of almost $3
million for TJR
Rehabilitation in TC LHIN
Page 23 www.haygroup.com/ca
4.0 Hip Fractures Patient Flow
The Steering Committee for the project requested that we extend our
scope of work to also consider best practice patient flow proposals
and targets for hip fracture patients. The patient flow proposals for
hip fracture patients will provide for further movement toward best
practice by TC LHIN providers. The proposed enhancements to
patient flow will provide earlier and increased access to inpatient
rehabilitation for hip fracture patients cared for in TC LHIN facilities.
4.1 Current Characteristics
In 2010/11 there were 1,031 adult hip fractures25
treated in TC LHIN
acute care hospitals. The following table presents the length of stay
and intensity of care characteristics of patients treated at each
hospital. As can be seen, the acute ALOS for adult patients ranged
from 8.7 days to 14.2 days. The average number of days spent
waiting for an alternative level of care ranged from 2.4 days to 6.9
days. There was a similarly wide variation in the intensity/complexity
of care requirements for these patients ranging from a low Resource
Intensity Weight (RIW) per case of 2.28 to a high of 3.61.
Exhibit 17: 2010/11 Hip Fracture Patients by Hospital
In 2010/11, 82% of acute care hip fracture patients in TC LHIN acute
care hospitals were admitted to acute care from home and 14% were
admitted from LTCHs.
25
Hip Fractures have been identified on basis of Most Responsible Diagnosis;
ICD-10-CA diagnosis codes S72.0, S72.1, S72.2 as recorded in each hospital’s
Discharge Abstract Data. Data was extracted via IntelliHealth.
Acute Care HospitalIP
Cases
Acute
LOS
ALC
LOS
Total
LOS
% ALC
Days
RIW
Wtd.
Cases
Avg.
RIW/
Case
Sunnybrook HSC 246 14.2 2.6 16.8 15% 713 2.90
St. Joseph's HC, Toronto 179 9.1 5.7 14.7 38% 443 2.48
University Health Network 173 14.0 6.9 20.9 33% 625 3.61
Toronto East General 170 11.2 4.6 15.8 29% 516 3.03
Mount Sinai Hospital 151 10.4 3.5 13.9 25% 359 2.38
St. Michael's Hospital 112 8.7 2.4 11.1 21% 256 2.28
Grand Total 1,031 11.6 4.3 15.9 27% 2,912 2.82
In 2010/11 there were 1046
hip fractures treated in TC
LHIN acute care hospitals
Page 24 www.haygroup.com/ca
Exhibit 18: Source (Residence) and Discharge Disposition of TC LHIN Acute Care Hip Fracture Patients
The following table presents the discharge destinations for hip
fracture patients cared for in each TC LHIN acute care hospital. As
can be seen, in 2010/11 overall, only 63% of live discharges of hip
fracture patients were discharged to inpatient rehabilitation; 6% were
discharged to CCC and 15% to LTCH.
Exhibit 19: Discharge Destination for Hip Fracture Patients by Hospital
The following table presents the volume of hip fracture inpatients26
cared for by each of the TC LHIN rehabilitation hospitals. As can be
seen, the 2010/11 TC LHIN annual adult inpatient rehabilitation hip
fracture case volumes ranged from 35 patients at Sunnybrook to 213
26
The following table presents the 2010/11 volume of hip, femur, and pelvic
fracture inpatient cared for in the TC LHIN rehabilitation hospitals, selected on
the basis of the CIHI Rehabilitation Client Group (RCG) assigned to the case.
For purposes of the hip fracture analysis, only RCGs 08.1 and 08.11 were
selected as representing hip fracture cases. While the other Lower Extremity
Fracture cases may have significant requirements for inpatient rehabilitation,
they have not been included in prior analyses of rates of access to inpatient
rehabilitation after hip fracture.
Patient Source Number %
Home 847 82%
LTCH 148 14%
Other 36 3%
Total 1,031 100%
Rehab
IPLTCH
Home,
no HC
Chronic
IP
Home,
w HCOther
Sunnybrook HSC 230 68% 9% 11% 4% 6% 2%
St. Joseph's HC, Toronto 169 46% 18% 15% 12% 1% 7%
Toronto East General 163 64% 20% 5% 7% 2% 1%
University Health Network 160 63% 16% 2% 8% 10% 2%
Mount Sinai Hospital 146 62% 21% 11% 3% 3% 0%
St. Michael's Hospital 109 74% 9% 8% 0% 6% 2%
Grand Total 977 63% 15% 9% 6% 5% 2%
% Distribution of Discharges by Discharge Disposition# of Live
DischargesAcute Care Hospital
CIHI Rehabilitation Client GroupIP
Cases
Avg.
LOS
(08.1) Orthopaedic Conditions - Status Post Hip Fracture 68 26.3
(08.11) Orthopaedic Conditions - Status Post Unilateral Hip Fracture 569 26.2
(08.2) Orthopaedic Conditions - Status Post Femur (Shaft) Fracture 47 29.4
(08.3) Orthopaedic Conditions - Status Post Pelvic Fracture 102 24.8
(08.4) Orthopaedic Conditions - Status Post Major Multiple Fracture 88 31.1
Grand Total 874 26.7
Only 63% of hip fracture
patients were discharged to
inpatient rehabilitation
Page 25 www.haygroup.com/ca
patients at Providence. The average inpatient rehabilitation LOS for
hip fracture cases varied from 11.6 days at SHSC to 31.4 days at
Baycrest.
Exhibit 20: 2010/11 Hip Fracture Inpatients by Rehabilitation Hospital
4.2 Best Practice Patient Flow Targets
TC LHIN target is ‘Best Practice’ care for hip fracture patients.
These targets were developed as the ‘Ontario Hip Fracture Model of
Care’ by the Bone and Joint Health Network working under the
direction of the Ontario Orthopaedic Expert Panel and have been
accepted for implementation in the TC LHIN. The key characteristics
of the target patient flow are:
80% of (live) hip fracture patients admitted from home or LTCH
should be discharged to inpatient rehabilitation27
.
Discharge hip fracture patients with a target total acute ALOS of
6.5 days28
.
70% hip fracture patients admitted from home should be
discharged to inpatient rehabilitation with average stay in
acute care of 6.5 days.
27
Although a small % of these patients will require LTLD rehabilitation until
‘rehab ready’ it is suggested that they can, and should get LTLD in a
rehabilitation facility rather than in a CCC facility. Using this pathway, the
patient will get access to rehabilitation sooner and won’t need a subsequent
transfer from a CCC facility/unit to a rehabilitation facility/unit. 28
The 6.5 day acute care LOS is based on the Ontario Hip Fracture Model of Care
target for provision of surgery within 48 hours followed by an acute care LOS of
5 days. The GTA Rehab Network has indicated that this suggests a total ALOS
of 6.5 days.
Cases Days LOS
Providence Scar. 213 6,141 28.8
TRI Hillcrest 159 4,161 26.2
Bridgepoint 90 2,325 25.8
West Park 60 1,521 25.4
Baycrest 44 1,382 31.4
Toronto East Gen. 36 781 21.7
Sunnybrook 35 405 11.6
Grand Total 637 16,716 26.2
Hospital2010/11 Actual
Page 26 www.haygroup.com/ca
10% of hip fracture patients admitted from home will require a
longer acute LOS before being able to be discharged to
inpatient rehabilitation29
.
20% of hip fracture patients admitted from LTCH will
discharged to a LTCH after an average stay in acute care of 5
days.
Estimate of 1 day ALC for all hip fracture discharges to allow
for inevitable delays in transfer from an acute care facility to a
rehabilitation facility.
For all hip fracture patients that are discharged to inpatient
rehabilitation the target ALOS in rehabilitation is 24 to 28 days.
However, the model of care also assumes that 15% of patients will
require slow stream rehabilitation. To accommodate this slow
stream population, we have used an overall 34 day ALOS target
for inpatient rehabilitation.
Based on 2010/11 TC LHIN acute care hospital volumes, the graphic
below shows that achievement of the targets would result in an
increase of 169 hip fracture patients transferred from TC LHIN acute
care hospitals to inpatient rehabilitation. There would be a
corresponding decrease of 58 hip fracture patients transferred to
complex continuing care and 135 fewer hip fracture patients
transferred directly to LTC.
29
We have assumed that these patients will require 14 days in acute care, based on
the current median acute LOS for hip fracture patients.
Page 27 www.haygroup.com/ca
Exhibit 21: Impact of Model of Care for Hip Fracture Targets on TC LHIN Acute Care Hospital Discharges of HF Patients to Inpatient Rehabilitation
The implementation of the best practice patient flow targets for hip
fracture patients will dramatically reduce acute care patient days and
costs for hip fracture patients and increase the number of patients
discharged to inpatient rehabilitation. In 2010/11 the acute ALOS for
TC LHIN hospital hip fracture patients was 11.6 days with an
additional 4.3 ALC days; the target is for an ALOS of 6.5 days with 1
day in ALC. Also, there will be an increase of 169 hip fractures
treated in TC LHIN acute care hospitals who will now be transferred
to inpatient rehabilitation; there also will be a corresponding decrease
of 169 hip fractures treated in TC LHIN acute care hospitals who will
no longer be discharged (directly) to CCC or LTCH.
4.3 Implications of Implementing Best Practice Hip Fracture Patient Flow Targets
Overall, the implementation the best practice Hip Fracture patient
flow targets will result in an estimated net savings of $1.64 million in
the TC LHIN.
From Community
883 HFs
From LTCH148 HFs
SURGERY< 48 hours
ACUTE CARE5 day LOS
Tgt. 20% of 130 to LTCH = 26
Patients
20% of 847 Home
INPATIENT REHABILITATION
24 to 28 LOS
18 Deaths, 130 Live
36 Deaths, 847 Live
80% of Live Discharges to IP Rehab = 782 (increase of 169 from 10/11 actual)
1,031 HF Patients in TC LHIN Acute Care Hospitals
Estimated total net savings
of $1.64 million in the TC
LHIN
Page 28 www.haygroup.com/ca
The implementation of the best practice patient flow targets for Hip
Fracture patients will have no impact on the number of patients cared
for in TC LHIN acute care hospitals, but there will be a significant
reduction in the number of patient days required to provide this care.
The estimated reductions in inpatient days and beds, and the potential
savings that would be achieved by each TC LHIN hospital are
presented in the following exhibit. As can be seen, there is a savings
opportunity in acute care of as much as $4.5 million.
Exhibit 22: Decrease in Acute Care Hospital Inpatient Days and Costs
The shortened lengths of stay in acute care hospitals for hip fracture
patients will result in:
Reduction of 8,196 inpatient days in acute care hospitals
Reduction in the use of 25.1 beds in TC LHIN acute care hospitals
Savings of $4,544,305 based on an estimated average marginal
cost per patient day of $549 per day30
The increase in discharges of hip fracture patients to TC LHIN
rehabilitation hospitals will result in:
283 additional inpatient hip fracture rehabilitation cases with
average LOS of 34 days (i.e. 28 day average LOS for most
patients, but 60 day LOS for the estimated 15% of patients
requiring slow stream rehabilitation)
Increase of 9,622 inpatient rehabilitation patient days
The increased patient days will result in a requirement for 27.7
additional beds @ 95% occupancy
Increased cost of $3.92 million at $13,872 per case31
30
Appendix A shows RIW-based marginal per diem cost estimates used for acute
care costing.
Cases IP DaysTotal
LOS
Sunnybrook HSC 246 4,126 16.8 1,956 2,170- 1,200,176-$ 6.6-
St. Joseph's HC, Toronto 179 2,640 14.7 1,423 1,217- 672,973-$ 3.7-
University Health Network 173 3,611 20.9 1,375 2,236- 1,236,314-$ 6.8-
Toronto East General 170 2,690 15.8 1,352 1,339- 740,191-$ 4.1-
Mount Sinai Hospital 151 2,106 13.9 1,200 906- 500,769-$ 2.8-
St. Michael's Hospital 112 1,241 11.1 890 351- 193,882-$ 1.1-
Grand Total 1,031 16,414 15.9 8,196 8,218- 4,544,305-$ 25.1-
Change in
Direct Cost @
$553 Marginal
per Diem
Change
in Beds
@ 90%
Acute Hospital
Actual 2010/11
Days @
LOS Tgt.
Change
in Days
Savings in acute care of
approximately $4.5 million
Increased costs of inpatient
rehabilitation of
approximately $4 million
Page 29 www.haygroup.com/ca
The calculation of these impacts is shown in the exhibit below.
Exhibit 23: Impact of New IP Rehabilitation Hip Fracture Cases on TC LHIN Rehabilitation Providers
The substitution of LTLD in inpatient rehabilitation beds for LTLD in
CCC beds will result in:
Reduction of 58 discharges of hip fracture patients to CCC
Reduction of 3,480 CCC patient days for hip fracture patients at
an estimated ALOS of 60 days per case
The days removed are equivalent to 10.0 beds @ 95% occupancy
Savings of $1.016 million in CCC direct cost at an estimated $292
marginal direct cost per day
We have assumed that the new admissions to inpatient rehabilitation
were previously receiving home based or outpatient rehabilitation and
thus there will be no marginal increase in the volume of ambulatory
or in-home rehabilitation required by TC LHIN hip fracture patients32
.
4.4 Siting of Hip Fracture Services
Siting of services for people with hip fractures was considered in the
context of the criteria established by the Steering Committee for this
project.
There was no consideration given, nor any perceived need to modify
the sites where acute care for hip fracture patients is being provided.
31
Estimated current direct cost per case for TC LHIN hip fracture rehabilitation
patients is $13,872. 32
With the introduction of inpatient rehabilitation for these patients, there might
even be a diminished requirement for outpatient and in-home care.
Acute Care
Hospital LHIN
Live
Disch.
% to IP
Rehab
Target
% to IP
Rehab
Projected
Chg. In
IP Rehab
Cases
% of IP
Rehab
Cases in
TC LHIN
Projected
Chg. In
TC LHIN
IP Rehab
Cases
Proj. Chg. in
TC LHIN IP
Direct Cost at
$13872 per
Case
Toronto Central 977 62.7% 80.0% 169 80.3% 135 1,877,160$
Other 6,507 21.8% 80.0% 3,786 0.1% 5 73,963$
Miss. Halton 570 50.7% 80.0% 167 0.0% - -$
Central West 434 22.6% 80.0% 249 4.1% 10 141,098$
Central East 1,263 40.3% 80.0% 501 13.4% 67 929,211$
Central 1,101 47.8% 80.0% 355 18.3% 65 898,273$
Total 10,852 31.8% 80.0% 5,227 19.2% 283 3,919,705$
Savings in CCC of
approximately $1.0 million
Page 30 www.haygroup.com/ca
However, the committee determined that to achieve both qualities and
economies of scale it would be beneficial to consolidate inpatient
rehabilitation at a smaller number of sites. It is suggested that
Bridgepoint, TRI, Providence and West Park should continue to
provide inpatient rehabilitation for hip fracture patients. TEGH,
although serving a relatively small number of hip fracture patients in
2010/11 has, since then refocused its program to exclude TJR patients
and is accepting a larger number of hip fracture patients. The
Steering Committee determined that TEGH should continue and
expand this refocusing of service on hip fracture patients. However, it
is suggested that Baycrest Centre for Geriatric Care and Sunnybrook
Health Science Centre should discontinue inpatient rehabilitation for
hip fracture patients because of their historically relatively low
volumes of these types of patients33
.
The committee’s criteria also suggested that TJR outpatient
rehabilitation should be as close to patients’ homes as feasible. In the
first instance, this would suggest that outpatient rehabilitation should
be provided in the LHIN where the patient lives. In that LHIN,
outpatient rehabilitation for hip fracture patients should be located
with consideration to both economies and qualities of scale. To that
end, outpatient rehabilitation should be co-located with inpatient
rehabilitation programs. Thus, outpatient hip fracture rehabilitation in
the TC LHIN should be co-located with the inpatient hip fracture
rehabilitation programs at Bridgepoint, TRI, Providence, TEGH and
West Park.
4.5 Resulting Hip Fracture Volumes of Care in TC LHIN Rehabilitation Hospitals
The calculations in the preceding sections addressed the marginal
changes in inpatient case volume for hip fracture rehabilitation in the
TC LHIN hospitals. In addition to these marginal changes in case
volume, we have assumed that all of the TC LHIN inpatient
rehabilitation providers will have the target average LOS for hip
fracture inpatient rehabilitation cases of 28 days for all of their
existing cases and an average LOS of 34 days for the new cases34
.
The following exhibit shows the impact of both the increase in
33
Consideration will need to be given to patients with significant deficits in
cognition. This subset of patients was to have been the focus of Baycrest
rehabilitation service. It will be important for one of the continuing providers to
address the needs of these patients. 34
283 additional inpatient hip fracture rehabilitation cases with average LOS of 34
days (i.e. 28 day average LOS for most patients, but 60 day LOS for the
estimated 15% of patients requiring slow stream rehabilitation)
Baycrest Centre for
Geriatric Care and SHSC
should discontinue inpatient
rehabilitation for hip
fracture patients
Page 31 www.haygroup.com/ca
inpatient cases and the achievement of the 28 day average LOS for
hip fracture inpatients on each of the TC LHIN hospitals.
Exhibit 24: Allocation of Inpatient Hip Fracture Rehabilitation After Implementation of Best Practice Patient Flow Targets
3536
Achievement of the 28 day average LOS target for existing cases will
extend the LOS for many patients and add an additional 1,120
inpatient days, for an additional cost of $554,400, based on the TC
LHIN estimated direct marginal cost of $495 per day.
Thus, the total impact on the TC LHIN inpatient rehabilitation
providers will be an increase of 283 cases at $13,872 per case and an
increase of 1,120 days for existing patients at $495 per day for a total
increase in inpatient costs of $4,474,105.
35
In this modeling, the historical Baycrest HF activity has been reassigned to West
Park; the historical SHSC HF activity has been reassigned equally to
Bridgepoint, TEGH, and Providence. 36
In this modeling we re-set each hospital’s existing activity at 28 days and then
added activity with combination of 28 day cases and 60 day slow stream cases.
And since each hospital will get new activity on the basis of their base activity
they each ended up with the same higher expected ALOS of 29.8 days.
Cases Days LOS Cases Days Beds LOS Cases Days
Providence Scar. 213 6,141 28.8 324 9,684 27.9 29.8 111 3,543
TRI Hillcrest 159 4,161 26.2 230 6,854 19.8 29.8 71 2,693
Bridgepoint 90 2,325 25.8 147 4,382 12.6 29.8 57 2,057
West Park 60 1,521 25.4 150 4,483 12.9 29.8 90 2,962
Baycrest 44 1,382 31.4 - - - 44- 1,382-
Toronto East Gen. 36 781 21.7 69 2,055 5.9 29.8 33 1,274
Sunnybrook 35 405 11.6 - - - 35- 405-
Grand Total 637 16,716 26.2 920 27,458 79.2 29.8 283 10,742
Hospital2010/11 Actual After Implementation of Targets
Change from
2010/11 Actual
Total increase in inpatient
rehabilitation costs of
approximately $4.5 million
Page 32 www.haygroup.com/ca
5.0 Stroke Strategy
The patient flow proposals for caring for stroke patients will provide
for further movement toward best practice by TC LHIN providers.
The proposed enhancements to patient flow for stroke patients will:
Lead to the consolidation of inpatient acute care for stroke
patients in Acute Stroke Units.
Provide for earlier and increased access to inpatient rehabilitation
for stroke patients cared for in TC LHIN facilities.
Provide for a higher intensity of rehabilitation care for patients in
both acute and rehabilitative care facilities.
5.1 Current Characteristics
In 2010 there were 2,259 adult stroke patients37
treated in TC LHIN
acute care hospitals. The following table presents the length of stay,
and intensity of care characteristics of these patients. As can be seen,
the acute ALOS for adult stroke patients ranged from 9.2 to 11.1 days.
The average number of days spent in acute care waiting for an
alternative level of care ranged from 1.5 to 14.1 days. There was a
similarly wide variation in the average intensity/complexity of care
for stroke patients ranging from a low adult Resource Intensity
Weight (RIW) of 2.51 to a high of 4.61.
37
Strokes have been identified on basis of Most Responsible Diagnosis: ICD-10-
CA I60 to I64. TIA patients have not been included in the stroke population for
purposes of examination of acute care and post-acute rehabilitation
requirements. In 2010/11, the characteristics of Ontario acute care stroke and
TIA patients were as shown below. TIA patients are clearly a different patient
population from the hemorrhagic and ischemic strokes. CIHI does not include
TIA patients as strokes for purposes of their annual health indicators for stroke
patients.
025-Hemorrhagic Event of CNS 2,870 12.3 880 1,990 31% 24%
026-Ischemic Event of CNS 7,374 15.3 946 6,428 13% 32%
028-Unspecified Stroke 3,864 11.5 516 3,348 13% 22%
029-Transient Ischemic Attack 2,888 4.6 11 2,877 0% 2%
Average
LOS
In-Hosp
MortalitySurvivorsDeathsCasesCase Mix Group
% of
Survivors to
Rehab IP
2, 259 stroke patients treated
in TC LHIN acute care
hospitals
Page 33 www.haygroup.com/ca
Exhibit 25: Stroke Patients by Hospital
It should be noted that over 27% of the days that stroke patients spend
in acute care hospitals are spent waiting for an alternative level of
care.
The following table presents the discharge destinations for stroke
patients cared for in each TC LHIN hospital. As can be seen, overall,
only 27% of live discharges of stroke patients were discharged to
inpatient rehabilitation and only and additional 4% were discharged to
CCC. 11% of live stroke discharges were discharged to home with
support; 40% were discharged to home with no documented home
care support. 13% of discharges were transferred to another acute
care hospital, which could reflect repatriation of patients to a hospital
closer to home or transfer of complex patients to a hospital with
greater acute care capabilities.
Exhibit 26: Discharge Destination for Stroke Patients by Hospital
The following table presents the volume of stroke rehabilitation
inpatients cared for by each of the TC LHIN rehabilitation hospitals.
As can be seen, the 2010/11 TC LHIN annual adult inpatient
rehabilitation stroke case volumes ranged from 30 patients at
Baycrest to 197 patients at Toronto Rehab. The average inpatient
rehabilitation LOS for stroke cases varied from 27.1 days at
Providence to 46.6 days at Bridgepoint.
Acute Care HospitalIP
Cases
Acute
LOS
ALC
LOS
Total
LOS
% ALC
Days
RIW
Wtd.
Cases
Avg.
RIW/
Case
University Health Network 704 11.1 3.7 14.8 25% 2,533 3.60
Sunnybrook HSC 546 10.8 3.9 14.7 26% 1,853 3.39
St. Michael's Hospital 537 10.4 1.5 11.9 13% 2,074 3.86
St. Joseph's HC, Toronto 196 10.4 5.5 15.9 35% 562 2.86
Toronto East General 183 9.2 5.4 14.6 37% 460 2.51
Mount Sinai Hospital 93 10.9 14.1 25.0 56% 429 4.61
Grand Total 2,259 10.7 3.9 14.6 27% 7,910 3.50
Home,
no HC
Rehab
IP
Acute
IP
Home,
w HCLTCH Other
University Health Network 613 37% 25% 10% 17% 6% 5%
Sunnybrook HSC 479 39% 30% 18% 7% 4% 2%
St. Michael's Hospital 474 45% 29% 18% 6% 1% 1%
Toronto East General 163 34% 34% 4% 7% 12% 9%
St. Joseph's HC, Toronto 154 42% 12% 1% 12% 16% 16%
Mount Sinai Hospital 82 44% 28% 9% 9% 6% 5%
Grand Total 1,965 40% 27% 13% 10% 6% 4%
% Distribution of Discharges by Discharge Disposition# of Live
DischargesAcute Care Hospital
27% of days in acute care
hospital spent as ALC
Only 27% of live discharges
of stroke patients were
discharged to inpatient
rehabilitation
Page 34 www.haygroup.com/ca
Exhibit 27: Stroke Rehabilitation Patients by Hospital
5.2 Best Practice Patient Flow Targets
The TC LHIN target is to provide the best practice patient care
pathways for stroke patients. These targets were developed by the TC
LHIN Stroke Flow Task Group.
5.2.1 Stroke Care in Acute Care Hospitals: Acute Stroke Units
The TC LHIN is targeting to move toward best practice acute care for
stroke patients. The key characteristics of this best practice model
are:
Acute care for stroke patients should be provided on Acute Stroke
Units
In acute care hospitals, stroke patients should be co-located on
acute stroke units (ASU’s). Although these ASU’s may be part of
larger medical units, the staffing of these larger units should be
organized to provide assignment of specialized care and a
dedicated/trained therapeutic team who would be available to
patients on the Acute Stroke Unit
The ‘critical mass’ for quality acute care is 200 stroke admissions
and the minimum ‘unit’ size for quality is 6 beds38
Achieving the best practice targets for acute care for stroke patients
will require consolidation of acute stroke care in a smaller number of
acute care hospitals. The recommendation to consolidate acute stroke
units, including the discontinuation of Mt. Sinai and TGH to receive
stroke patients was made by the GTA Rehab Network and 3 Toronto
Area stroke networks in 2011. This recommendation was accepted by
the Steering Committee for this project and plans are currently
underway to move in this direction. Acute care for stroke in the TC
38
It should be noted that few of the ASUs in the TC LHIN will have sufficient
patient volume to use 6 beds at 95% occupancy; however, the staff of the
medical unit that admits stroke patients should be trained to provide the
necessary, best practice acute and rehabilitative care for these patients.
Hospital Cases IP DaysAvg.
LOS
Toronto Rehab 197 8,241 41.8
Providence Scar. 182 4,925 27.1
Bridgepoint 145 6,757 46.6
West Park 125 4,915 39.3
Baycrest 30 849 28.3
Grand Total 679 25,687 37.8
Acute care for stroke
patients should be provided
on Acute Stroke Units
Create 5 ASUs in TC LHIN
Page 35 www.haygroup.com/ca
LHIN will be consolidated in 5 hospitals who should be instructed to
create Acute Stroke Units. SJHC, UHN (Toronto Western Hospital),
SMH, TEGH and SHSC are designated as the sites to create Acute
Stroke Units. These hospitals and their ASUs will need to find
additional rehabilitation resources to provide the required enhanced
care for stroke patients.
Stroke patients should be directed and/or transferred to hospitals with
ASUs for inpatient care. Because of historically low patient volumes,
it has been suggested that Mount Sinai Hospital and the Toronto
General Hospital site of the University Health Network should no
longer admit stroke patients for inpatient care; they will transfer any
stroke patients that present at their ED and that require admission to
the ASU at the Toronto Western Hospital site of the University Health
Network. This will increase the volume of stroke patients cared for at
the TWH site of UHN.
5.2.2 Rehabilitation for Stroke Patients
The TC LHIN target is to provide the best practice care pathways for
stroke patients. These targets will provide earlier access to more
intensive rehabilitation services for more stroke patients. The key
characteristics of the target patient flow for stroke patients are:
Stroke patients should be discharged from acute care to
rehabilitative care in 5 days for ischemic strokes and 7 days for
hemorrhagic strokes
35% of (live) stroke patients should be discharged to inpatient
rehabilitation39
Target of 1 day of ALC status for stroke patients being discharged
to rehabilitation
To ensure early access to rehabilitation for stroke patients,
inpatient rehabilitation programs should work in collaboration
with acute inpatient care and establish processes for 7 day per
week admission to stroke rehabilitation
There should be a change in the modalities of inpatient
rehabilitation for stroke patients
Severe strokes should receive inpatient HTSD rehabilitation
39
The 35% target for discharge of stroke patients to inpatient rehabilitation should
be viewed as an initial target; the Stroke Flow Task Group suggested that the
target should be from 35% to 50% of stroke patients to inpatient rehabilitation.
Once the system has adjusted to the structural characteristics of the patient flow
model presented here, consideration should be given to increasing the target to
50% of stroke patients to inpatient rehabilitation.
Stroke patients should be
directed and/or transferred
to hospitals with ASUs for
inpatient care
Earlier access to more
intensive rehabilitation
services for more stroke
patients
Page 36 www.haygroup.com/ca
Most moderate strokes should receive outpatient
rehabilitation; some should receive inpatient HTSD
rehabilitation
All mild strokes should receive outpatient rehabilitation
No (or very, very few strokes) should receive LTLD (Those
that receive LTLD would be those who are not rehab ready
and that need to receive LTLD rehabilitation prior to
admission to HTSD rehabilitation)
There should be an increase in the intensity of HTSD
rehabilitation for stroke patients
Rehabilitative therapy for stroke patients should be provided 7
days per week
Stroke rehabilitation patients should receive a minimum of 3
hours of therapy time per day
The increased intensity of rehabilitative care will allow for a
decrease in the ALOS for inpatient rehabilitation
The ALOS for severe strokes should decline from 90 days to
56.5 days
Outpatient rehabilitation should be provided as close to patients’
homes as feasible
Outpatient rehabilitation for stroke patients is much less
expensive than in-home rehabilitation provided by CCAC
As a result, CCACs should focus on personal support for
stroke patients who are getting OP rehabilitation
The implementation of the best practice patient flow targets for stroke
patients will dramatically reduce the acute care patient days for stroke
patients. In 2010/11 the acute ALOS for stroke patients was 10.7
days plus an average of 3.9 additional days waiting for discharge to an
alternate level of care.
In addition to decreasing the amount of time stroke patients wait as
ALC patients for admission to rehabilitation, implementing the targets
will also increase the number of stroke patients that are discharged to
inpatient rehabilitation. In 2010/11 only 27% of live stroke
discharges in TC LHIN hospitals went to IP Rehab; 3% were
discharged to outpatient rehabilitation; 4% were discharged to CCC
(i.e. 80 patients); 6% were discharged to LTCH; 10% to home care,
39% to home with no reported support services. To achieve the
targeted 35% of stroke patients discharged to inpatient rehabilitation
there will need to be an increase of 170 patients admitted to inpatient
Best practice patient flow
targets for stroke patients
will dramatically reduce the
acute care patient days for
stroke patients
Page 37 www.haygroup.com/ca
rehabilitation and a corresponding decrease of 170 patients admitted
to CCC or discharged to home.
Also, it is unclear how many patients being discharged to home
currently are able to access outpatient rehabilitation and how many
are not. During implementation of this new model of care, the LHIN
should investigate access to outpatient stroke rehabilitation for
moderate and mild strokes. If there is inadequate capacity and/or
barriers to access then these should be addressed.
5.2.3 Implications of Implementing Best Practice Stroke Patient Flow Targets
Overall, the implementation of the best practice stroke patient flow
targets will result in an estimated net savings of $10.3 million in the
TC LHIN.
The implementation of the best practice patient flow targets for stroke
patients will have no impact on the number of stroke patients cared
for in TC LHIN acute care hospitals, but there will be a significant
reduction in the number of days required to provide this care.
The estimated reductions in inpatient days and beds, and the potential
savings that would be achieved by each TC LHIN hospital are
presented in the following exhibit. As can be seen, there is a savings
opportunity in acute care of as much as approximately $11.9 million.
Exhibit 28: Decrease in Acute Care Hospital Inpatient Days & Costs
As can be seen, in 2010/11 there were 33,001 acute care days for
stroke patients in TC LHIN hospitals, including 8,923 ALC days.
The target reduction in lengths of stay in acute care hospitals for
stroke patients will result in:
Reduction of 17,391 inpatient days in acute care hospitals
Potential reduction of 50.3 beds (at 95% occupancy) in acute care
hospitals
Cases IP DaysTotal
LOS
Hemorrhagic Stroke 926 15,520 16.8 8.0 7,408 8,112- 5,572,944-$ 23.5-
Ischemic Stroke 1,129 15,578 13.8 6.0 6,774 8,804- 6,048,348-$ 25.5-
Unspec. Stroke 204 1,903 9.3 7.0 1,428 475- 326,325-$ 1.4-
Grand Total 2,259 33,001 14.6 7.0 15,610 17,391- 11,947,617-$ 50.3-
Red'n in
Beds @
95%
Avg.
LOS
Tgt.
Type of Stroke
Actual 2010/11
Days @
LOS Tgt.
Change
in Days
Reduced Direct
Cost @ $687
Marginal per
Diem
Savings in acute care of
approximately $11.9 million
Page 38 www.haygroup.com/ca
Savings of $11.9 million in acute care based on an estimated
marginal direct care cost per patient day of $68740
The increase in discharges of stroke patients to TC LHIN
rehabilitation hospitals will result in:
170 additional inpatient stroke rehabilitation cases with average
LOS of 37.9 days
Increase of 6,443 inpatient rehabilitation patient days
The increased patient days will result in a requirement for 18.6
additional rehabilitation beds @ 95% occupancy
Increased cost of $4.046 million
Estimated current direct cost per case for TC LHIN stroke
rehabilitation patients is $19,86541
Assume 20% increase in direct cost to $23,838 per case to
reflect the service intensification required under the best
practice targets42
The calculation of these impacts is shown in the exhibit below.
Exhibit 29: Impact of Achievement of Stroke Rehabilitation Targets on TC LHIN Rehabilitation Providers
40
Appendix A shows derivation of marginal direct cost using RIW per diem
values and 2010/11 TC LHIN OCDM costs. 41
Appendix A shows the derivation of the TC LHIN inpatient rehabilitation
marginal case costs. 42
It is unclear whether the rehabilitation hospitals will require additional resources
to provide for this intensification of care or whether they will be able to redirect
current resources to provide for this best practice approach to stroke
rehabilitation. For modelling purposes, we have assumed that additional
resources will be required.
Acute Care
Hospital LHIN
Live
Disch.
% to IP
Rehab
Target
% to IP
Rehab
Projected
Chg. In
IP Rehab
Cases
% of IP
Rehab
Cases in
TC LHIN
Projected
Chg. In
TC LHIN
IP Rehab
Cases
Proj. Chg. in
TC LHIN IP
Direct Cost at
$23838 per
Case
Toronto Central 1,965 27.1% 35.0% 156 81.4% 127 3,021,859$
Other 7,230 27.9% 35.0% 511 0.3% 2 36,146$
Miss. Halton 1,095 26.0% 35.0% 98 0.4% 0 8,218$
Central West 571 22.4% 35.0% 72 15.6% 11 267,619$
Central East 1,288 36.5% 35.0% - 14.5% - -$
Central 1,184 26.4% 35.0% 102 29.2% 30 711,962$
Total 13,333 28.1% 35.0% 939 16.5% 170 4,045,803$
Increased costs of inpatient
rehabilitation of
approximately $4.05 million
Page 39 www.haygroup.com/ca
The substitution of LTLD in inpatient rehabilitation beds for LTLD in
CCC beds will result in:
Reduction of 70 discharges of stroke patients to CCC
Reduction of 6,300 CCC patient days for stroke patients at an
estimated ALOS of 90 days per case
The CCC days removed are equivalent to 18.2 beds @ 95%
occupancy
Savings of $1.840 million in CCC direct cost at an estimated $292
marginal direct cost per day
5.3 Siting of Stroke Services
Siting of services for stroke patients was considered in the context of
the criteria established by the Steering Committee for this project.
As has been discussed, achieving the best practice targets for acute
care for stroke patients will require consolidation of acute stroke care
in a smaller number of acute care hospitals. As noted earlier, the
recommendation to consolidate acute stroke units, including the
discontinuation of Mt. Sinai and TGH to receive stroke patients was
made by the GTA Rehab Network and 3 Toronto Area stroke
networks in 2011. This recommendation was accepted by the Steering
Committee for this project and plans are currently underway to move
in this direction. Acute care for stroke in the TC LHIN will be
consolidated in 5 hospitals who should be instructed to create Acute
Stroke Units. SJHC, UHN (TWH), SMH, TEGH and SHSC are
designated as the sites to create Acute Stroke Units. These hospitals
and their ASUs will need to find additional rehabilitation resources to
provide the required enhanced care for stroke patients. .
Stroke patients should be directed and/or transferred to hospitals with
ASUs for inpatient care. Mount Sinai Hospital and the Toronto
General Hospital site of the University Health Network will no longer
admit stroke patients for inpatient care; they will transfer any stroke
patients that present at their ED and that require admission to the
ASU at the Toronto Western Hospital site of the University Health
Network. This will increase the volume of stroke patients cared for at
the TWH site of UHN.
The committee also determined that to achieve both qualities and
economies of scale it would be beneficial to consolidate inpatient
stroke rehabilitation at a smaller number of sites. It is suggested that
Bridgepoint, TRI, Providence and West Park should continue to
provide inpatient stroke rehabilitation. It is suggested that Baycrest
Savings in CCC of
approximately $1.0 million
Create 5 ASUs in TC LHIN
Stroke patients should be
directed and/or transferred
to hospitals with ASUs for
inpatient care
Baycrest Centre for
Geriatric Care should
discontinue inpatient
rehabilitation for stroke
patients
Page 40 www.haygroup.com/ca
Centre for Geriatric Care should discontinue inpatient rehabilitation
for stroke patients43
because of historically relatively low volumes44
.
The committee’s criteria also suggested that stroke outpatient
rehabilitation should be as close to patients’ homes as feasible. In the
first instance, this would suggest that outpatient rehabilitation should
be provided in the LHIN where the patient lives. In that LHIN,
outpatient rehabilitation for stroke patients should be located with
consideration to both economies and qualities of scale. To that end,
outpatient rehabilitation should be co-located with inpatient
rehabilitation programs; programs that, by definition, will possess
neuro-rehabilitation capability. Thus, outpatient rehabilitation in the
TC LHIN should be co-located with the inpatient stroke rehabilitation
programs at Bridgepoint, TRI, Providence, and West Park.
5.4 Resulting Stroke Volumes of Care in TC LHIN Rehabilitation Hospitals
The resulting stroke service volumes at the TC LHIN rehabilitation
facilities are presented in the exhibit following45
.
43
Consideration will need to be given to patients with significant deficits in
cognition. This subset of patients was to have been the focus of Baycrest
rehabilitation service. It will be important for one of the continuing providers to
address the needs of these patients. 44
Discontinuing stroke rehabilitation will facilitate the hospital’s continued
operation of all of its CCC beds. The hospital had proposed to close 14 CCC
beds to provide funding for the necessary enhancements to its stroke
rehabilitation services. 45
It should be noted that we have not modelled any reduction in ALOS for stroke
rehabilitation patients. Although the Stroke Strategy has suggested the
increased intensity of rehabilitation for stroke patients would reduce the LOS in
rehabilitation; there was no suggestion as to what the resultant ALOS should be
nor how much of a reduction from current lengths of stay might be achieved. As
a result our modelling has not provided for any reduction in ALOS. If a
reduction is ALOS is achievable with the increased intensity of care, then
additional savings in days and dollars might be realized from implementation of
the stroke strategy.
Page 41 www.haygroup.com/ca
Exhibit 30: Allocation of Inpatient Stroke Rehabilitation After Implementation of Best Practice Patient Flow Targets
46
The best practice patient flow targets for stroke patients will provide a
net savings within the TC LHIN of close to $10 million comprised of
a significant reduction in acute care costs of approximately $12
million, a reduction in CCC costs of approximately $2 million and an
increase in rehabilitation costs of approximately $4 million.
46
In this modelling, the historical Baycrest Stroke activity was reassigned to West
Park.
Cases Days LOS Cases Days Beds LOS Cases Days
Toronto Rehab 197 8,241 41.8 246 10,308 29.7 41.8 49 2,067
Providence Scar. 182 4,925 27.1 228 6,160 17.8 27.1 46 1,235
Bridgepoint 145 6,757 46.6 181 8,452 24.4 46.6 36 1,695
West Park 125 4,915 39.3 194 7,210 20.8 37.2 69 2,295
Baycrest 30 849 28.3 30- 849-
Grand Total 679 25,687 37.8 849 32,130 92.7 37.8 170 6,443
Hospital2010/11 Actual After Implementation of Targets
Change from
2010/11 Actual
Best practice targets for
stroke patients will provide a
net savings of close to $10
million
Page 42 www.haygroup.com/ca
6.0 Impact of the MSK and Stroke Patient Flow Initiatives
6.1 Net Impact of Best Practice Patient Flow Initiatives
Taken together the musculoskeletal and stroke patient flow initiatives
will have a significant impact on the use and cost of hospital services
in the TC LHIN.
6.1.1 Bed Requirements
Implementation of the proposed patient flow initiatives will reduce
the bed requirements in the TC LHIN. Taken together, the net impact
of the initiatives will be a potential reduction of 80.7 beds:
75.4 fewer acute care beds will be required
22.9 more rehabilitation beds will be required
28.2 fewer CCC beds will be required
6.1.2 Operating Costs
The reduction in patient days and the restructuring of service delivery
will provide an opportunity to reduce TC LHIN costs for hospital
operations. Using the marginal costs of adding and reducing patient
days, we estimate that the net impact of the proposed patient flow
initiatives will be a savings of $13.5 million. The anticipated cost
savings and increases are:
$16.5 million cost saving in IP acute care
$5.0 million cost increase in IP rehabilitation
$2.86 million cost saving in IP CCC
$0.62 million cost increase in OP rehabilitation
$0.25 cost increase in CCAC
The proposed changes in discharge destinations for TJR, Hip Fracture
and Stroke patients discharged from TC LHIN acute care hospitals
will also have an impact on rehabilitation providers in LHINs
adjacent to TC LHIN.
The following exhibit shows the impacts of achievement of the
proposed targets by TC LHIN HSPs.
A potential reduction of 80.7
beds
Net TC LHIN hospital
system saving of $13.5
million
Page 43 www.haygroup.com/ca
Exhibit 31: Overall Impact of Achievement of Proposed Targets
6.2 Key Questions Related to Patient Flow Strategies
Questions were postulated by the LHIN to guide the review of the
proposed Patient Flow Strategies and Initiatives. The following
sections present the questions and the answers that have been
provided through the analyses and consultations conducted as part of
this review.
Given the best practice guidelines for orthopaedics, what would be the system need for acute/rehab beds, community services (CCAC) and hospital based or community based ambulatory facilities? What is the delta/gap relative to current resources?
As discussed in chapters 3 and 4 of this report. The net impact of the
proposed best practice guidelines for TJR and hip fracture patients on
the required service capacity of TC LHIN providers is:
Provider
LocationActivity Measure
Joint
Replaceme
nt
Hip
Fractures
Orthopaedic
Total ImpactStrokes Net Impact
Acute IP Cases - - - - -
Acute IP Days 8,218- 8,218- 17,391- 25,609-
Acute IP Costs 4,544,305-$ 4,544,305-$ 11,947,613-$ 16,491,918-$
Acute IP Beds 25.1- 25.1- 50.3- 75.4-
Rehab IP Cases 1,033- 283 750- 170 580-
Rehab IP Days 9,231- 10,742 1,511 6,443 7,954
Rehab IP Costs 3,551,853-$ 4,474,105$ 922,252$ 4,045,803$ 4,968,055$
Rehab IP Beds 26.6- 31.0 4.4 18.6 22.9
OP Rehab Visits 3,093 3,093 3,093
OP Rehab Costs 618,600$ 618,600$ 618,600$
CCC IP Cases 58- 58- 70- 128-
CCC IP Days 3,480- 3,480- 6,300- 9,780-
CCC IP Costs 1,016,160-$ 1,016,160-$ 1,840,000-$ 2,856,160-$
CCC IP Beds 10.0- 10.0- 18.2- 28.2-
CCAC Home Visits 1,284 1,284 1,284
CCAC HC Visit Cost 256,800$ 256,800$ 256,800$
2,676,453-$ 1,086,360-$ 3,762,813-$ 9,741,810-$ 13,504,623-$
Imp
act
on
TC
LH
IN P
rovid
ers
TC LHIN $ Totals
Page 44 www.haygroup.com/ca
As can be seen there is no service gap as a result of these changes.
The net impact is to free up capacity to address other system needs.
If there are proposed changes to beds/services – what are the associated funding implications to the institutions and the system?
The funding implications of the proposed changes to accommodate
the best practice guidelines for TJR and hip fracture patients are
presented in the exhibit following. As can be seen there will be a net
savings opportunity of approximately $3.8 million.
For orthopaedics, given the projected change in needs (beds, community and outpatients) how and where should they be grouped and located across the TCLHIN, considering quality of care, efficiency and geographical services?
As has been discussed in chapters 3 and 4, there should be no change
in the location of acute care services for TJR and hip fracture patients.
Inpatient and outpatient rehabilitation for TJR should be provided by
SHSC, Bridgepoint, TRI, Providence and West Park and should be
discontinued by TEGH and Baycrest. Similarly inpatient and
outpatient rehabilitation for hip replacement patients should be
provided by Bridgepoint, TRI, TEGH, Providence and West Park and
should be discontinued by SHSC and Baycrest.
Activity MeasureJoint
Replacement
Hip
Fractures
Orthopaedic
Total Impact
Acute IP Cases - - -
Acute IP Days 8,218- 8,218-
Acute IP Beds 25.1- 25.1-
Rehab IP Cases 1,033- 283 750-
Rehab IP Days 9,231- 10,742 1,511
Rehab IP Beds 26.6- 31.0 4.4
OP Rehab Visits 3,093 3,093
CCC IP Cases 58- 58-
CCC IP Days 3,480- 3,480-
CCC IP Beds 10.0- 10.0-
CCAC Home Visits 1,284 1,284
Activity MeasureJoint
Replacement
Hip
Fractures
Orthopaedic
Total Impact
Acute IP Costs 4,544,305-$ 4,544,305-$
Rehab IP Costs 3,551,853-$ 4,474,105$ 922,252$
OP Rehab Costs 618,600$ 618,600$
CCC IP Costs 1,016,160-$ 1,016,160-$
CCAC HC Visit Cost 256,800$ 256,800$
Page 45 www.haygroup.com/ca
For orthopaedics, how should patients residing outside of the TC LHIN but receiving acute care in the TC LHIN be managed post-acutely?
TJR and Hip Fracture patients should continue to receive inpatient
rehabilitation care in the facilities that have been providing care to
them in the past be that in the TC LHIN or in their home LHIN.
However, patients requiring outpatient rehabilitation should be able to
receive their outpatient care in a facility close to where they live. The
facility should have experience and capability in musculoskeletal
care. For both qualities and economies of scale, facilities that provide
outpatient rehabilitation should also be providing inpatient
rehabilitation.
Given present state, how should the implementation of the musculo-skeletal patient flow changes be sequenced in alignment with the stroke flow recommendations?
The first MSK initiatives that should be implemented are the changes
in the discharge destinations for primary Total Joint Replacement
patients. The first step in implementing the TJR patient flow changes
will need to be the creation of sufficient outpatient rehabilitation
capacity to accommodate the additional outpatient volume that will be
created by this initiative. There will also be a need for the TC LHIN
to mandate a change in behaviour of those facilities charged with
providing outpatient rehabilitation for TJR patients and work with
neighboring LHINs regarding access to local programs for their
residents. These HSPs should no longer be able to refuse admission
to their outpatient rehabilitation program for patients referred to them
from an inpatient TJR program in an acute care hospital.
Implementation of the best practice TJR care pathway will free up
inpatient rehabilitation capacity that can be used to more quickly
admit hip fracture patients to inpatient rehabilitation. To facilitate this
earlier admission, rehabilitation hospitals and programs will need to
ensure that they have the capability to address the needs of hip
fracture patients with comorbid conditions.
Changes to achieve the best practice patient flow targets for stroke
patients can be initiated concurrently with the musculoskeletal patient
flow changes.
Where are the risks to the HSPs and the system with the implementation of these changes in MSK and Stroke care?
There is very little risk to HSPs with the implementation of the best
practice patient flow strategies. The strategies will provide for
improved care and better outcomes for patients being cared for by TC
LHIN providers.
Page 46 www.haygroup.com/ca
The only major risk may be that the rehabilitation providers may not
have sufficient resources to expand, enhance and intensify their
service offerings for stroke rehabilitation patients.
Similarly, rehabilitation hospitals may not have the financial and/or
human resources that are necessary to care for rehabilitation patients
with comorbid conditions.
Also, if rehabilitation hospitals are not able to or elect not to admit
patients in a timely fashion, then the acute care hospitals will not be
able to achieve their length of stay targets and the estimated levels of
savings. In the current state, acute care hospitals will always be
dependent on an approval from inpatient our outpatient rehabilitation
services to accept a patient.
Finally, there is a risk if outpatient capacity is not created and/or not
made available to TJR patients being discharged from acute care;
these patients will not be able to be discharged from acute care if the
outpatient care is not made available and accessible.
What are the risks inherent to the new plan? How could the LHIN mitigate these risks?
The risks have been identified above. The LHIN will need to
facilitate the changes by making sure that resources are reallocated
among sectors and providers to ensure that the necessary capacity and
capabilities are available in a timely fashion to ensure the appropriate
sequencing of the implementation of the strategies. Once the
structural and patient flow changes have been implemented the LHIN
will need to ensure that rehabilitation HSPs accept TJR, Hip Fracture
and Stroke patients being discharged to them from acute care in a
seamless and timely fashion; if that is not the case the acute care
hospitals will not be able to achieve the LOS and related savings
targets47
.
What are the supporting and enabling structures required to support the system changes? (e.g. transportation to outpatient services)
The only enabling structure that will be required to facilitate the
implementation of these changes will be the availability of assisted
transportation services.
47
It has been suggested that the LHIN will need to implement a no-refusal policy
that supports the acute care LOS targets. Enforcement of the policy may require
real-time monitoring and measurement of admission delays with penalties for
non-compliance.
Page 47 www.haygroup.com/ca
What evaluation framework should be used to measure the overall change and impact?
The framework for measuring the impact of the strategies should
reflect the objectives and potential benefits of each. The following
measures should be used to evaluate each of the strategies:
TJR Strategy
Acute ALOS
% of patients discharged to rehabilitation
Rehabilitation ALOS
Additional TJR patients admitted to outpatient rehabilitation
Continued high quality patient outcomes
Hip Fracture
Acute ALOS
Average ALC days per patient
% of Hip Fracture Patients Discharged to IP Rehabilitation
Rehabilitation ALOS
Improved patient outcomes
Stroke
Acute ALOS
Average ALC days per patient
% of Stroke Patients Discharged to IP Rehabilitation
Rehabilitation ALOS
Improved patient outcomes
Page 48 www.haygroup.com/ca
7.0 Complex Continuing Care Initiatives
7.1 Current Characteristics
As has been discussed, TC LHIN has significantly more CCC beds
per population48
than any other LHIN and provides this service to
many of the surrounding GTA LHINs.
Exhibit 32: CCC Beds in the TC LHIN
Most patients cared for in CCC beds are discharged to CCC from an
acute care hospital. In 2010/11 more than three quarters of TC LHIN
CCC hospital patients came directly from acute inpatient care. The
following exhibit presents the source of admissions to CCC beds in
the TC LHIN.
48
For CCC beds per population statistics we have used beds per 100,000
population over 75 years of age. Although there are many people admitted to
CCC programs who are younger than 75 years, the population that uses CCC is
predominantly those people over 75 years of age. Bed numbers are taken from
the MOHLTC Daily Census Summary reports for 2010/11.
TC LHIN has significantly
more CCC beds per
population than any other
LHIN
Page 49 www.haygroup.com/ca
Exhibit 33: Source of CCC Patients in TC LHIN CCC Hospitals
The characteristics of patients discharged from acute care to CCC are
reflected by the most responsible reason for care in the acute care
hospital as indicated by the case mix group (CMG) assigned to the
patient on discharge from acute care. The following table shows the
20 CMGs with the highest total number of Alternate Level of Care
(ALC) days for patients discharged to CCC from TC LHIN hospitals.
As can be seen, despite the large number of CCC beds in the TC
LHIN, patients who are discharged from acute care to CCC wait a
significant amount of time for admission to a CCC facility. In
2010/11, TC LHIN acute care hospitals had 13,900 ALC days for
patients ultimately discharged to beds; this is equivalent to 40 acute
care beds (at 95% occupancy). Over one third (34%) of the days
spent in acute care hospitals for patients who were discharged to CCC
were spent as ALC waiting for admission to the CCC bed. It is
interesting to note that the types of patients who wait the longest
(more than 25 days on average) for admission to CCC are those
requiring ‘medically complex’ care. And many other medically
complex patients (plus some hip fracture and stroke patients) have an
average ALC period of over a week.
Transfer From# of
Residents
% of
Residents
Acute IP 2,930 77%
Rehab IP 273 7%
Lodge/Retirement Home 188 5%
Home 170 4%
Home Care 93 2%
IP Continuing Care 71 2%
LTCH 60 2%
Other 20 1%
Ambul Care 10 0%
Grand Total 3,815 100%
Patients who are discharged
from acute care to CCC wait
a significant amount of time
for admission to a CCC
facility
Page 50 www.haygroup.com/ca
Exhibit 34: ALC Days for Patients Discharged to CCC from Acute Care in TC LHIN
49
In 2010/11 there were 3,815 CCC patients discharged from TC LHIN
CCC beds. The distribution of these discharges by hospital is
presented in the following exhibit. It is interesting to note the wide
variation in ALOS for patients discharged from these facilities.
Shorter ALOS for a facility likely indicates that more of the facility’s
beds are being used for shorter stay programs such as Slow Stream
Rehabilitation50
(LTLD).
49
The Grand Total row in this table reflect the CMGs listed with more than 200
ALC days and other CMGs that were not listed. It is the Grand Total for all
cases discharged to CCC. 50
And/or Palliative Care.
Case Mix Group Cases
Avg.
Acute
LOS
% ALC
Avg.
ALC
LOS
ALC Days
Grand Total 1,775 15.2 34% 7.8 13,900 670-Dementia 31 9.2 80% 37.4 1,160
810-Palliative Care 236 13.8 25% 4.5 1,072
650-Multisys/Uns Ste Infect w Intv 6 43.3 63% 75.3 452
801-Oth Adm w Oth Int 5 72.2 54% 85.0 425
026-Ischemic Event of CNS 52 19.1 29% 7.9 412
727-Fixation/Repair Hip/Femur 37 13.1 43% 9.9 366
196-Heart Failure wo Cardiac Cath 43 12.9 39% 8.3 359
221-Colostomy/Enterostomy 9 47.3 43% 35.8 322
487-Lower Urinary Tract Infect 62 9.6 34% 5.0 307
437-Diabetes 4 24.3 75% 71.0 284
401-Decub Ulcer/Ulcer Low Limb NEC 8 30.0 54% 35.5 284
654-Other/Unspecified Septicemia 43 14.3 31% 6.5 280
139-Chronic Obstructive Pulmon Dis 35 10.7 43% 7.9 278
477-Renal Failure 25 12.6 45% 10.1 253
132-Malignant Neoplasm Resp Sys 52 10.4 31% 4.7 244
038-Neoplasm Central Nervous Sys 36 13.1 33% 6.4 232
007-Thor/Maj Int Spine/Canal/Vert 1 273.0 46% 229.0 229
671-Organic Mental Disorder 27 10.6 44% 8.5 229
284-Hepatobiliary/Pancreatic Mal 31 9.1 44% 7.2 222
023-Parkinson Dis/Parkinsonian Dis 7 10.0 74% 28.7 201
Page 51 www.haygroup.com/ca
Exhibit 35: CCC Discharges by Hospital
This is corroborated by the high percentage of patients discharged
from TC LHIN CCC hospitals that are categorized as ‘Special
Rehabilitation’ patients. As can be seen in the following exhibit, over
50% of patients discharged from TC LHIN CCC beds are categorized
as special rehabilitation patients.
Exhibit 36: RUGs Categories for TC LHIN CCC Discharges
The following exhibit presents the discharge destination for
discharges from TC LHIN CCC Hospitals. As can be seen, over half
of the discharges from TC LHIN CCC are transferred to care
destinations that reflect movement along the continuum of care.
Cases DaysAvg.
LOS
Avg.
CMI
Providence Healthcare 943 90,602 96 0.99
Bridgepoint Hospital 849 161,151 190 1.02
Baycrest Hospital 753 96,612 128 1.24
Sunnybrook HSC 386 109,381 283 1.06
TRI - Bickle Instit. 265 145,421 549 1.07
Toronto East General 243 23,783 98 0.88
Salvation Army Grace 179 59,974 335 0.92
West Park Healthcare 135 76,997 570 1.12
Runnymede HC 56 57,274 1,023 1.06
Bloorview Kids Rehab 6 7,435 1,239 1.16
Grand Total 3,815 828,630 217 1.06
Discharges During FY 2010/11
Hospital
RUG Category on Final Assessment Cases% of
CasesDays
Avg.
LOS
1 Special Rehabilitation - Ultra High 4 0% 480 120
2 Special Rehabilitation - Very High 46 1% 3,513 76
3 Special Rehabilitation - High 128 3% 9,178 72
4 Special Rehabilitation - Medium 1,253 33% 183,701 147
5 Special Rehabilitation - Low 544 14% 117,139 215
6 Extensive Care 825 22% 250,963 304
7 Special Care 372 10% 109,393 294
8 Clinically Complex Care 503 13% 113,296 225
9 Impaired Cognition 30 1% 5,406 180
11 Reduced Physical Functions 110 3% 35,561 323
Grand Total 3,815 100% 828,630 217
All Special Rehab 1,975 52% 314,011 159
Over 50% of patients
discharged from TC LHIN
CCC beds are categorized as
special rehabilitation
patients
Page 52 www.haygroup.com/ca
Exhibit 37: Discharge Destination for Discharges from TC LHIN CCC Hospitals
7.2 Impact of Musculoskeletal and Stroke Patient Flow Initiatives on CCC
Implementation of the proposed patient flow initiatives for
Musculoskeletal and Stroke patients will reduce the need for LTLD
rehabilitation as provided by CCC facilities for most of the patients
addressed by these initiatives. This potentially will reduce the
utilization of CCC by the equivalent of 28.2 CCC beds. This provides
an opportunity to close these beds and use the associated funding for
other purposes or to use these beds to reduce the delays in
accommodating medically complex patients transferred from TC
LHIN acute care hospitals51
.
7.3 Proposed CCC Initiatives
An OHA report has suggested that “It is important to recognize that
CCC has been evolving over the past 15 years since the Chronic Care
Role Study, the report of the Chronic Care Implementation Task
Force and the HSRC Change & Transition Report and Planning
Guidelines. CCC hospitals and programs have been focusing more on
restorative and rehabilitation programs and services as a result of less
demand for and thus less focus on long term or continuing complex
care. Rather than staying in hospital, CCC patients are increasingly
being discharged to LTC facilities, to home with home care or to
home. In short, “CCC has evolved into being viewed as a “resource”
rather than a final destination. Increasingly, CCC beds are being used
to enhance the system’s capacity to transition people to lower levels
51
Or the beds could be redesignated as rehabilitation beds and then used to make
up for the additional rehabilitation beds that will be required to facilitate
implementation of the MSK and Stroke Patient Flow Strategies.
Transfer To# of
Residents
% of
Residents
Deceased 1,111 29%
Home 769 20%
Home Care 578 15%
LTCH 464 12%
Acute IP 446 12%
Lodge/Retirement Home 223 6%
Rehab IP 134 4%
Other 53 1%
IP Continuing Care 37 1%
Grand Total 3,815 100%
An opportunity to reduce
delays in accommodating
medically complex patients
from TC LHIN acute care
hospitals
CCC facilities are focusing
more on rehabilitative care
with a diminishing focus on
continuing complex care
Page 53 www.haygroup.com/ca
of care or back to the community.” Many CCC providers in the TC
LHIN have adopted and/or are proposing to adopt this new model of
complex continuing care. There is an increasing focus on specialized
short-stay programs and/or LTLD (Slow Stream) rehabilitation.
There is a growing reluctance to admit patients without secure
discharge destination because of a fear that they may become long-
stay or ALC patients who would reduce the capacity and thus the
‘throughput’ in the hospitals’ shorter-stay programs. The CCC
initiatives proposed for 2012/13 by the HSPs will continue this trend
towards a diminishing focus on continuing care and an increasing
emphasis on shorter-stay and rehabilitative care.
Exhibit 42, following, presents proposals by TC LHIN HSPs and the
resultant changes in capacity in CCC and rehabilitation in the TC
LHIN for 2012/13. As can be seen, although there will be a net
increase of 17 CCC beds, it is the result of opening the remainder of
the beds at Runnymede alongside the closure of 88 beds in other
facilities. The HSP proposed changes are:
Proposals to close an additional 88 CCC beds in 2012/13
Proposed bed closures focus on beds related to needs of
medically complex patients
Plans are to use funds provided by CCC bed closures to
fund enhancements in LTLD programs and programs in
the facilities’ rehabilitation beds and
address operating cost pressures
Proposal to open the remaining 105 CCC beds at Runnymede
The HSP initiatives along with the 28 CCC beds freed up by the MSK
and Stroke initiatives will potentially provide as many as 45
additional CCC beds and/or the related funding to address the needs
of medically complex patients who have been experiencing
difficulties and delays in accessing CCC beds.
There are also proposals to close 13 rehabilitation beds and use the
funds provided by the bed closures to pay for enhanced care for stroke
patients. However, if these beds are closed, it may be difficult to
accommodate the proposed musculoskeletal and stroke patient flow
initiatives that will require 22.9 additional rehabilitation beds for
successful implementation. The HSP initiatives to close 13 beds
along with the additional 22.9 beds required by the MSK and Stroke
initiatives will potentially result in a shortage of 35.9 rehabilitation
beds in the TC LHIN.
Proposals provide for 17 bed
net increase in CCC capacity
Additional CCC beds will be
available to address needs of
medically complex CCC
patients
Plans to close 13
rehabilitation beds will
impede implementation of
patient flow initiatives
Page 54 www.haygroup.com/ca
Exhibit 38: Proposed CCC and Rehabilitation Capacity Changes for 2012/13
7.4 Proposals for Change in CCC Patient Flow
To reduce the number of patients waiting for admission to CCC there
are several process and flow initiatives that could be implemented.
The TC LHIN should encourage CCC facilities to provide LTLD
rehabilitation for appropriate patients. However, all appropriate
patients should have equal access to LTLD; even those who might be
difficult to discharge to a ‘lower’ level of care on completion of the
rehabilitative care. It would be better for patients to access
rehabilitation quickly in CCC LTLD programs rather than wait for
rehabilitation while in ALC status in an acute care bed. If the patient
ends up being ALC in the CCC bed, at least the patient will be able to
continue receiving appropriate and rehabilitative care while waiting
for placement.
Similarly, the TC LHIN should insist that all CCC facilities continue
to provide continuing care for medically complex patients. As part of
their care regimen, these medically complex patients will also require
rehabilitative services. Some may regain functioning to facilitate
discharge/some may not. Those that cannot be discharged should
continue to be cared for in the CCC facility.
Rehab CCC
Beds Beds Beds Change Beds Change
Bridgepoint 96 343 91 -5 313 -30Increase volume of
outpatient TJR
patients
Enhanced Stroke RehabEnhance care for 14 beds for
stroke patients
Baycrest 32 210 32 0 196 -14Increase volume of
Stroke Rehab visits
Focus on stroke and
stop doing MSK
Close 14 CCC to provide funding
for focus on Strokes
West Park 123 158 115 -8 132 -26Increase volume of
MSK visits
Enhance Neuro and
MSK Rehab
Decrease of 26 CCC beds to fund
deficit
Providence 87 193 87 175 -18Enhance OP as
continuation of IP
care
Enhance LTLD
Rehabilitation
Increase throughput by
enhancing CCAC capability
Runnymede NA 95 - - 200 105Open remainder of
facility
Received $6.3M for last 67
unopened CCC beds.
TRI 209 208 209 0 208 0 No change proposed
SHSC 20 35 20 0 35 0 No change proposed
TEGH 13 75 13 0 75 0 No change proposed
Grace 0 100 0 0 100 0 No change proposed
Total 580 1417 567 -13 1434 17
New Programs CommentsFacility
Current State Proposed State
Ambulatory
CCCRehab
All appropriate patients
should have equal access to
LTLD
Additional CCC capacity
should be used to ensure
timely admission of
medically complex patients
to CCC facilities in the TC
LHIN
Page 55 www.haygroup.com/ca
The TC LHIN should also insist that CCC facilities admit medically
complex patients as they are referred to them by acute care hospitals.
TC LHIN CCC facilities should be able to accommodate all clinically
complex patients (including patients with wounds, decubiti,
tracheostomies, g-tubes, etc). As hospitals, they should be able to
provide the necessary medical direction and skilled nursing to meet
the needs of these more complex patients. A CCC facility is a more
appropriate care setting for these patients than waiting as an ALC
patient in an acute care hospital. CCC facilities should be working to
ensure that patients are getting the ‘right care, in the right place at the
right time’. Often, under the current funding and care delivery
models, the right place for medically complex patients is CCC. The
additional capacity that will be created in CCC should be used to
ensure timely admission of medically complex patients to CCC in the
TC LHIN. Given the abundance of CCC beds in the TC LHIN, there
is no reason for patients to be waiting extended periods of time as
ALC in acute care prior to admission to a CCC bed.
7.5 Key Questions Related to Complex Continuing Care
The TC LHIN has postulated the following questions related to the
rehabilitation and CCC service changes that are being contemplated
or implemented by TC LHIN rehabilitation and CCC providers.
What is the profile of the patients who currently occupy the impacted beds/services? There is a need to understand the patient populations (other than stroke and orthopaedic) that are currently served by the impacted programs/services? How many remaining beds are there for these types of patients? Is the affected patient population in anyway different from other organization’s bed population? What other capacity exists to serve these populations?
Beds that are being closed in CCC are currently occupied by
medically complex patients requiring care that is currently only
available in CCC facilities. The opening of 105 beds at Runnymede
could more than compensate for the closure of beds in other CCC
facilities. Additionally, CCC beds currently used for LTLD will be
freed up by the Stroke and MSK initiatives and will provide
additional CCC capacity for medically complex patients. There is no
other current capacity available to appropriately and adequately care
for these medically complex patients.
It has been suggested that LTCH’s can more appropriately
accommodate these medically complex patients who require
continuing care. Perhaps that is true for some; but given the current
funding models for LTCH’s, their care capacity would be
overwhelmed if they were asked to admit very many, if any of these
Given the abundance of
CCC beds in the TC LHIN,
there is no reason for
patients to be waiting
extended periods of time as
ALC in acute care prior to
admission to a CCC bed
Page 56 www.haygroup.com/ca
types of patients. The current funding model will not support the
intensity of medical management and supervision and skilled nursing
care that these types of patients require; under our current models of
funding and care, the appropriate place for these patients is CCC.
Who will manage the care of the impacted patients/patient groups post system/hospital changes? Will these patients be absorbed into other programs currently available? If so, which programs/services?
If more CCC beds are not made available to medically complex
patients, they will wait even longer in acute care for admission to
CCC. Alternatively, they will be discharged to LTCH’s that are
currently not funded or staffed to be able to provide appropriate care
for these patients. Currently, the only appropriate placement for these
patients requiring active medical management of their care and skilled
nursing services are hospitals that provide CCC.
What is the net loss to throughput attributed to CCC/Rehab bed closures/models of care changes and how can the new Runnymede capacity be best utilized?
CCC Beds
The loss of CCC beds due to bed closures is 88.
The gain of CCC beds due to changes in the MSK and Stroke
models of care is 28.
The net loss of CCC beds will be 60 beds.
Runnymede beds should be used to make up for this loss of
beds and Runnymede should use its beds to provide care for
medically complex patients.
Rehabilitation
The loss of Rehabilitation beds due to closures is 13 beds.
The changes in MSK and Stroke models of care will require
22.9 additional rehabilitation beds in the TC LHIN.
If the HSPs are allowed to close rehabilitation beds, then there
will be a shortage of 35.9 rehabilitation beds in the TC LHIN.
Perhaps the HSPs should be allowed to use the savings from
closing beds that had previously been used to provide LTLD
rehabilitation for Stroke and MSK patients to open additional
rehabilitation beds.
Page 57 www.haygroup.com/ca
Given present state, how should the implementation of these changes be sequenced?
Runnymede beds should be opened in advance of the HSP proposed
closure of CCC beds in other facilities (if allowed).
The TC LHIN and its HSPs will need to determine how to fund the
intensification of Acute Stroke Care and Stroke Rehabilitation
services. Should the HSPs be expected to find the funds to provide
necessary care for their patients or will the TC LHIN augment
funding to provide for the service intensification?
The TC LHIN and its HSPs will also need to determine how the
savings from HSP proposals for closing of CCC beds (if allowed)
should be applied. Can/should these savings in CCC be used to fund
the opening of necessary additional rehabilitation beds?
The TC LHIN will need to determine whether it should allow its
HSPs to close rehabilitation beds when more will be needed to
facilitate implementation of the Stroke and MSK patient flow
initiatives.
Once the funding issue is determined, additional MSK and Stroke
rehabilitation beds should be introduced before any HSP is allowed to
close a rehabilitation bed.
Where are the risks to the HSPs and the system with the implementation of these changes?
If CCC and rehabilitation HSPs are allowed to reduce capacity to fund
operations then there will be even more congestion in acute care. The
patients that will wait will be the most vulnerable and those with the
greatest need for CCC and rehabilitative care. Experience has shown
that access to CCC will be delayed for medically complex patients
and access to rehabilitation will be delayed for patients with comorbid
conditions that will complicate their care in the rehabilitation hospital.
What evaluation framework should be used to measure the overall change and impact?
The evaluation framework should focus on ensuring timely access to
appropriate care for patients needing continuing and/or rehabilitative
care.
The key metric that should be used to measure the overall
effectiveness of the proposed changes in CCC is the average ALC
days for medically complex patients admitted to CCC.
Page 58 www.haygroup.com/ca
Similarly, the key metric to measure the necessary changes in
rehabilitation should be:
First the percentage of stroke, hip fracture and TJR patients
admitted to inpatient rehabilitation.
Second, but equally important, the average ALC days in acute
care for hip fracture and stroke patients admitted to rehabilitation.
And finally, the average ALC days in acute care for other patients
admitted for rehabilitation
Page 59 www.haygroup.com/ca
Appendix A: Source of Cost Estimates
119© 2010 Hay Group. All Rights Reserved
TC LHIN 2010/11 OCDM Inpatient Costs
Acute Care
Direct per diem cost is 73.4% of total per diem cost
Estimate marginal per diem cost at 60% of average per diem cost (acute costs “front end loaded” due to interventions; costs of days at end of stay will be lower)
Inpatient Rehab
Direct per diem cost is 68.8% of total per diem cost
Estimate marginal per diem cost at 80% of average per diem cost
Inpatient CCC
Direct per diem cost is 70.3% of total per diem cost
Estimate marginal per diem cost at 80% of average per diem cost
Total Cost per Patient Day 1,714$
Direct Cost per Patient Day 1,258$
Overhead Cost per Patient Day 456$
Total Cost per Weighted Case 6,447$
Direct Cost per Weighted Case 4,731$
Overhead Cost per Weighted Case 1,716$
Total Cost per Patient Day 718$
Direct Cost per Patient Day 494$
Overhead Cost per Patient Day 224$
Marginal per Diem Cost (80% of Direct) 395$
Total Cost per Patient Day 519$
Direct Cost per Patient Day 365$
Overhead Cost per Patient Day 154$
Marginal per Diem Cost (80% of Direct) 292$
Page 60 www.haygroup.com/ca
120© 2010 Hay Group. All Rights Reserved
Inpatient Rehab Case Cost Estimates Derived from OCCI Case Cost Data
Direct case costs for use with addition or reduction of full
cases in TC LHIN IP rehab
Patient Group
OCCI Avg.
Rehab Cost
(FY 2007,
2008)
Ontario
Avg.
Rehab
LOS
(10/11)
Estimated
Cost per
Diem
Per Diem
Cost
Relative
to TJR
Est. TC
LHIN Per
Diem
Cost
Direct
Cost per
Diem
(69% of
total)
LOS for
Costing of
Marginal
Cases
Est. TC
LHIN Direct
Case Cost
Replacement of
Lower Extremity5,900$ 12 492$ 100% 558$ 385$ 10.0 3,848$
Fracture of Lower
Extremity15,193$ 24 633$ 129% 718$ 495$ 28.0 13,872$
Stroke 22,832$ 34 672$ 137% 762$ 526$ 37.8 19,865$
Page 61 www.haygroup.com/ca
122© 2010 Hay Group. All Rights Reserved
TC LHIN 2010/11 OCDM Outpatient Costs
OP costs averaged for all OP visits
Quality of outpatient cost data is suspect
Assume efficiencies for group/class therapy
Estimate of $100 per visit for group outpatient rehab visits in hospital setting
TC LHIN HospitalReported
OP Visits
Total Cost
per Visit
Direct Cost
per Visit
Overhead
Cost per
Visit
Baycrest 22,324 463$ 319$ 144$
Bridgepoint Hospital 15,620 169$ 120$ 48$
Mount Sinai Hospital 305,059 242$ 178$ 63$
Providence HC, Scarborough 4,754 399$ 268$ 132$
St. John's Rehabilitation 1,999 1,515$ 1,027$ 488$
St. Joseph's HC, Toronto 129,531 192$ 149$ 43$
St. Michael's Hospital 382,561 237$ 171$ 66$
Sunnybrook HSC 339,076 223$ 173$ 50$
Toronto East General 96,403 285$ 205$ 79$
Toronto Rehab 80,015 583$ 388$ 195$
University Health Network 418,224 357$ 259$ 98$
West Park 13,614 323$ 238$ 85$
Acute 1,670,854 264$ 195$ 69$
Rehab CCC 138,326 498$ 337$ 161$
Page 62 www.haygroup.com/ca
121© 2010 Hay Group. All Rights Reserved
TC LHIN 2010/11 OCDM Inpatient Acute Care Costs
Marginal direct costs determined by type of acute care patient to reflect costs of adding additional acute care days or removing acute care days
Achievement of savings may be dependent on ability to consolidate reduction in acute inpatient days
Acute Care
Patient TypeCases
Total
Days
Total
Wtd.
Cases
Avg.
RIW per
Case
Avg.
RIW per
Day
Est. Per
Diem
Cost
Est.
Marginal
Direct Per
Diem Cost
Hip Fracture 784 11,633 2,266 2.890 0.195 1,256$ 553$
Stroke 2,300 33,797 8,176 3.555 0.242 1,560$ 687$
Uni. Hip 2,011 9,406 1,931 0.960 0.205 1,324$ 583$
Uni. Knee 2,566 11,591 1,735 0.676 0.150 965$ 425$
Hips and Knees 4,577 20,997 3,667 0.801 0.175 1,126$ 496$
Page 63 www.haygroup.com/ca
Appendix B: Participants in Focus Group to Review Preliminary Findings
Participant Name Organization
TC LHIN HEALTH SERVICE PROVIDERS
Acute Hospitals
Joanne Zee University Health Network
Lynda McColl University Health Network
Mary Ann Neary University Health Network
Dina D’Agostino-Rose University Health Network
Natalie Cournoyea University Health Network
Shelley Sharp University Health Network
Lois Fillion Sunnybrook Health Sciences Centre
Keith Rose Sunnybrook Health Sciences Centre
Anne Marie MacLeod Sunnybrook Health Sciences Centre
Jim O’Neill St. Michael’s Hospital
Ella Ferris St. Michael’s Hospital
Sonya Canzian St. Michael’s Hospital
Dr. James Waddell St. Michael’s Hospital
Donna Rensetti West Park Healthcare Centre
Julie Sullivan Mount Sinai Hospital
Ellen Malcolmson St. Joseph’s Health Centre
Mark Vimr St. Joseph’s Health Centre
Liz Ferguson Hospital for Sick Children
Melody Hicks Hospital for Sick Children
Catherine Barclay Hospital for Sick Children
Dr. Benjamin Alman Hospital for Sick Children
Dr. Peter Weiler, Toronto East General Hospital
Carmine Stumpo Toronto East General Hospital
Tracy Kitch Mount Sinai Hospital
Rehab/CCC Hospitals
James Fox Providence Healthcare
Maggie Bruneau Providence Healthcare
Josie Walsh Providence Healthcare
Marian Walsh Bridgepoint Health
Jane Merkley Bridgepoint Health
Reva Adler Bridgepoint Health
Marilyn Wharton Toronto Grace Health Centre
Lisa Dess Runnymede Healthcare Centre
Karima Velji Baycrest Centre for Geriatric Care
Community
Kathryn Wise Toronto Central Community Care Access Centre
Carol Millar Toronto Central Community Care Access Centre
Page 64 www.haygroup.com/ca
Participant Name Organization
GTA HEALTH SERVICE PROVIDERS AND LHINS
Treva McCumber York Central Hospital
Alexis Dishaw Humber River Regional
Mary Wheelwright Headwaters Health Care Centre
Maryam Pourtangestani Humber River Regional
Malcolm Moffatt St. John’s Rehabilitation
Susan Woollard North York General Hospital
Debra Carson The Credit Valley Hospital and Trillium Health Centre
Jane Casey Southlake Regional Health Centre
Riki Yamada Southlake Regional Health Centre
Liz Buller William Osler Health System
Leanne Mckenzie William Osler Health System
Yvonne Ashford Central Community Care Access Centre
Jennifer Scott Central Community Care Access Centre
Karyn Lumsden Central West Community Care Access Centre
Caroline Brereton Mississauga Halton Community Care Access Centre
James Meloche Central East LHIN
Victoria Van Hemert Central LHIN
Liane Fernandes Mississauga Halton LHIN
Brock Hovey Central West LHIN
Shehnaz Fakim Mississauga Halton LHIN
Annette Marcuzzi Central Local Health Integration Network
NETWORKS
Jacqueline Willems Southeast Toronto Regional Stroke Network
Nicole Pageau West GTA Stroke Network, The Credit Valley Hospital and Trillium Health Centre Trillium Health Centre
Beth Linkewich North & East GTA Stroke Network
Charissa Levy GTA Rehab Network
Page 65 www.haygroup.com/ca
Appendix C: St. Johns Rehab Hospital and the TC LHIN
St. John’s Rehab Activity by Rehab Group
St. John’s Activity by Program by Patient LHIN
Rehab Program Cases DaysAvg.
LOS
Other 990 21,557 21.8
Unilateral Knee 462 5,493 11.9
Unilateral Hip 454 8,035 17.7
Other MSK 294 5,114 17.4
Hip Fracture 211 5,876 27.8
Stroke 161 5,057 31.4
Brain Dysfunction 54 1,570 29.1
Grand Total 2,626 52,702 20.1
CentralToronto
Central
Central
EastOther
Grand
Total
Brain Dysfunction 25 8 5 16 54
Hip Fracture 124 50 18 19 211
Other 423 209 188 170 990
Other MSK 171 33 46 44 294
Stroke 86 36 20 19 161
Unilateral Hip 263 57 69 65 454
Unilateral Knee 250 32 79 101 462
Grand Total 1,342 425 425 434 2,626
% of Cases 51.1% 16.2% 16.2% 16.5% 100.0%
Patient LHIN
Rehab Program
Only 16.2% of St. John’s
inpatient rehabilitation
patients live in the Toronto
Central LHIN
Page 66 www.haygroup.com/ca
Source of St. John’s Patients – Acute Hospitals – All Programs
Patients transferred from TC LHIN acute care hospitals account for
45% of St. John’s inpatient cases and 49% of inpatient days; but most
of these patients are for programs other than TJR, Hip Fracture and
Stroke.
Source of Inpatient Cases Cases DaysAvg.
LOS
North York Gen. 753 13,336 17.7
Sunnybrook 487 11,781 24.2
UHN 334 6,464 19.4
St. Michael's 255 4,680 18.4
Southlake Reg. 151 2,257 14.9
Markham Stouff. 129 1,845 14.3
Humber River - York Finch 103 2,672 25.9
Mount Sinai 86 1,863 21.7
Wm. Osler - Etob. 85 1,346 15.8
Scarb. Grace 82 2,164 26.4
Humber River 46 872 19.0
St. Joseph's Toronto 25 751 30.0
Scarborough Gen. 21 441 21.0
York Central 15 428 28.5
Wm. Osler - Brampton 12 565 47.1
Other 42 1,237 29.5
Total 2,626 52,702 20.1
Central LHIN Hospital 1,202 21,476 17.9
Toronto Central Hospital 1,189 25,571 21.5
% from TC LHIN Hospital 45% 49%
Page 67 www.haygroup.com/ca
Source of St. John’s Patients – Acute Hospitals – Unilateral Hip and Knees
Patients transferred from TC LHIN acute care hospitals account for
22% of St. John’s inpatient TJR cases and 25% of inpatient TJR days
Source of Inpatient Cases Cases DaysAvg.
LOS
North York Gen. 294 4,146 14.1
Southlake Reg. 122 1,484 12.2
Markham Stouff. 102 1,208 11.8
Sunnybrook 78 1,574 20.2
Wm. Osler - Etob. 70 864 12.3
Humber River - York Finch 47 1,023 21.8
St. Michael's 41 525 12.8
Mount Sinai 40 715 17.9
UHN 36 436 12.1
Scarb. Grace 31 640 20.6
Humber River 25 339 13.6
Scarborough Gen. 13 305 23.5
St. Joseph's Toronto 8 175 21.9
RVHS Centenary 2 16 8.0
Wm. Osler - Brampton 2 24 12.0
Other 5 54 10.8
Total 916 13,528 14.8
Central LHIN Hospital 593 8,231 13.9
Toronto Central Hospital 204 3,435 16.8
% from TC LHIN Hospital 22% 25%
Patients transferred from TC
LHIN acute care hospitals
account for only 22% of St.
John’s inpatient TJR cases
Page 68 www.haygroup.com/ca
Source of St. John’s Patients – Acute Hospitals – Hip Fractures
Patients transferred from TC LHIN acute care hospitals account for
33% of St. John’s inpatient HF cases and 31% of inpatient HF days
Source of Inpatient Cases Cases DaysAvg.
LOS
North York Gen. 63 1,722 27.3
Sunnybrook 43 1,159 27.0
Humber River - York Finch 30 858 28.6
Scarb. Grace 20 529 26.5
Mount Sinai 9 252 28.0
St. Joseph's Toronto 7 136 19.4
St. Michael's 6 134 22.3
Wm. Osler - Etob. 6 285 47.5
Humber River 6 162 27.0
Southlake Reg. 5 146 29.2
Union Villa 4 112 28.0
UHN 4 125 31.3
York Central 3 134 44.7
Scarborough Gen. 2 41 20.5
York Region Maple Health Centre 1 36 36.0
Other 2 45 22.5
Total 211 5,876 27.8
Central LHIN Hospital 108 3,038 28.1
Toronto Central Hospital 69 1,806 26.2
% from TC LHIN Hospital 33% 31%
Patients transferred from TC
LHIN acute care hospitals
account for only 33% of St.
John’s inpatient HF
Page 69 www.haygroup.com/ca
Source of St. John’s Patients – Acute Hospitals – Strokes
Patients transferred from TC LHIN acute care hospitals account for
48% of St. John’s inpatient Stroke cases and 47% of inpatient Stroke
days
Source of Inpatient Cases Cases DaysAvg.
LOS
Sunnybrook 40 993 24.8
North York Gen. 39 1,205 30.9
UHN 26 873 33.6
Scarb. Grace 13 511 39.3
Humber River - York Finch 8 285 35.6
Markham Stouff. 8 237 29.6
Humber River 5 167 33.4
St. Michael's 5 188 37.6
St. Joseph's Toronto 4 220 55.0
Mount Sinai 3 91 30.3
Wm. Osler - Etob. 3 63 21.0
Wm. Osler - Brampton 3 100 33.3
Guelph General 1 80 80.0
Markham Stouffville Hosp-Uxbridge Site 1 13 13.0
Trillium 1 8 8.0
Other 1 23 23.0
Total 161 5,057 31.4
Central LHIN Hospital 61 1,907 31.3
Toronto Central Hospital 78 2,365 30.3
% from TC LHIN Hospital 48% 47%
Patients transferred from TC
LHIN acute care hospitals
account for 48% of St.
John’s inpatient Stroke
cases
Page 70 www.haygroup.com/ca
Source of St. John’s Patients – Acute Hospitals – TJR, HF, and Strokes
Patients transferred from TC LHIN acute care hospitals account for
27% of St. John’s inpatient TJR, HF, and Stroke cases and 31% of
inpatient TJR, HF, and Stroke days
Source of Inpatient Cases Cases DaysAvg.
LOS
North York Gen. 396 7,073 17.9
Sunnybrook 161 3,726 23.1
Southlake Reg. 127 1,630 12.8
Markham Stouff. 111 1,461 13.2
Humber River - York Finch 85 2,166 25.5
Wm. Osler - Etob. 79 1,212 15.3
UHN 66 1,434 21.7
Scarb. Grace 64 1,680 26.3
Mount Sinai 52 1,058 20.3
St. Michael's 52 847 16.3
Humber River 36 668 18.6
St. Joseph's Toronto 19 531 27.9
Scarborough Gen. 15 346 23.1
Wm. Osler - Brampton 5 124 24.8
York Central 4 147 36.8
Other 16 358 22.4
Total 1,288 24,461 19.0
Central LHIN Hospital 762 13,176 17.3
Toronto Central Hospital 351 7,606 21.7
% from TC LHIN Hospital 27% 31%
Patients transferred from TC
LHIN acute care hospitals
account for 27% of St.
John’s inpatient TJR, HF,
and Stroke cases
Page 71 www.haygroup.com/ca
Source of St. John’s Patients – Acute Hospitals – All Other Programs52
However, patients transferred from TC LHIN acute care hospitals
account for 63% of St. John’s inpatient “Other” cases and 64% of
inpatient “Other” days. It is in these other programs that St. John’s
provides significant support for TC LHIN acute care hospitals.
52
Other than TJR, HF, and Stroke
Source of Inpatient Cases Cases DaysAvg.
LOS
North York Gen. 357 6,263 17.5
Sunnybrook 326 8,055 24.7
UHN 268 5,030 18.8
St. Michael's 203 3,833 18.9
Mount Sinai 34 805 23.7
Southlake Reg. 24 627 26.1
Markham Stouff. 18 384 21.3
Scarb. Grace 18 484 26.9
Humber River - York Finch 18 506 28.1
York Central 11 281 25.5
Humber River 10 204 20.4
Wm. Osler - Brampton 7 441 63.0
Wm. Osler - Etob. 6 134 22.3
St. Joseph's Toronto 6 220 36.7
Scarborough Gen. 6 95 15.8
Other 26 879 33.8
Total 1,338 28,241 21.1
Central LHIN Hospital 440 8,300 18.9
Toronto Central Hospital 838 17,965 21.4
% from TC LHIN Hospital 63% 64%
Patients transferred from TC
LHIN acute care hospitals
account for 63% of St.
John’s inpatient “Other”
cases