Senior Friendly Hospitals & RGPsSenior Friendly Hospitals & RGPsof Ontario of Ontario

HNHB LHIN Board Meeting – June 22, 2011Report of SFH Survey Findings for HNHB LHINReport of SFH Survey Findings for HNHB LHIN

Acknowledgements:Ken Wong, Resource Consultant, RGP of Toronto

Dr. Barbara Liu, Executive Director, RGP of TorontoMs. Anne Pizzacella, CNS, HHS

Ms. Shirley Stewart, Advisor HNHB LHINDavid Jewell, RGP Central, Administrative Director

Thank you to the Ms. Donna Cripps, Ms. S SShirley Stewart, and the HNHB Board, and invited guests

HNHB LHIN/Geriatric Access and Integration Network Senior Friendly Hospital Task Force y pWorking Group◦ LHIN Student contributors: Elizabeth Erent and Jennifer

Gallant◦ RGP Project Assistants: Natasha Voogd and Anisha

Chouhand

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1. Introductions & Background of Senior Friendly Hospital (SFH) Survey & Next Steps – 5 - 7mins

2. Senior Friendly Hospital Survey Report – Summary of findings – 30 mins

3. Self Assessment Aggregate Responses & Summary of Recommendations – 5-7 minsSummary of Recommendations 5 7 mins

4. Questions & Comments – 10 mins

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Senior Friendly Hospital Care in the HNHB LHIN• Background document & self assessment template were distributed to HNHB LHIN hospital CEOs December 2010CEOs, December 2010

• Both documents, RGPs of Ontario endorsed Senior Friendly Hospital Framework

•5 Domains

• Submission of completed surveys March 2011

• “A Summary of Senior Friendly Care in HNHB LHIN Hospitals” in June 2011

Id tifi ti f i i ti i th HNHB • Identification of promising practices in the HNHB LHIN and opportunities for system-level improvement in Senior Friendly Care

• Current - “Roll out” and work plan 2011

Senior Friendly Hospital Care in the HNHB LHIN• Background document & self assessment template were distributed to HNHB LHIN hospital CEOs December 2010CEOs, December 2010

• Both documents, RGPs of Ontario endorsed Senior Friendly Hospital Framework

•5 Domains

• Submission of completed surveys March 2011

• “A Summary of Senior Friendly Care in TC LHIN Hospitals” in June 2011

Id tifi ti f i i ti i th HNHB • Identification of promising practices in the HNHB LHIN and opportunities for system-level improvement in Senior Friendly Care

• Current - “Roll out” and work plan 2011

Five DomainsOrganizational SupportO ga at o a Suppo t

• leadership structures/committees with influence to guideorganizational direction and to champion SFH initiativesorganizational direction and to champion SFH initiatives

• support for organization-wide education on the needs of olderpatients to create a culture that empowers senior friendly care

- 3 tier NICHE-based program that includes clinical, non-clinical, and volunteer staff

• HR practices which encourage development in frailty focusedknowledge and skills

• consulting with stakeholders including older patients and• consulting with stakeholders, including older patients andcommunity partners, when developing programs

Five DomainsProcesses of Care

Clinical protocols:

use of protocols/metrics for:

falls, pressure ulcers, restraints, pain, incontinence, behavioural problems,

delirium, dementia, functional decline, elder abuse, sleep, hydration/ nutrition

prevention of deconditioning and rehabilitation programs for cognitively impaired patients

teamwork and inter-professional practice in hospitalsteamwork and inter-professional practice in hospitals

inter-organizational collaboration for partnership with the community-

Five DomainsEmotional and Behavioural Environment

• Quality programs structured to improve care or service in a waythat considers the needs of seniors

Emotional and Behavioural Environment

- for example, senior-specific elements in patientsatisfaction surveys

F l h i t b tt ti t /f ili i • Formal mechanisms to better engage patients/families in care- admission screening tool to determine preferences in careparticipation

ti t/f il t d l i d i i- patient/family engagement rounds early in admission- programs offering education to the public

Ethics in Clinical Care and Research• services of an ethicist, and having the capacity and resources torespond to unique ethical situations as they arise

Ethics in Clinical Care and Research

p q y

Five Domains

Physical Environment

• Senior friendly resources id d di

Physical Environment

or evidence used to auditphysical spaces

• having staff with expertise on senior friendly design• having staff with expertise on senior friendly designprinciples who contribute to physical planning committees

- geriatrics representation on accessibility committee

• knowledge transfer of senior friendly physical design to guide ongoing environmental changes, development, maintenance

and equipment and furniture procurementand equipment and furniture procurement

What’s Next?What s Next?• HNHB LHIN Senior Friendly Hospital survey reports –June 14, 2011•Senior Friendly Hospital survey reports across theprovince of Ontario to be sent to TC RGP

• RGPs of Ontario working with 13 LHINs to produce• RGPs of Ontario working with 13 LHINs to produceregional SFH summary reports • Coordination by TC LHIN

and RGP of Toronto• 14 LHIN reports will beanalyzed and provincialsummary report of SFHsummary report of SFHcare will be written

•July 2011

What’s Next?What s Next?

PHASE 1 PHASE 2 PHASE 3 - ONGOING

Objective• Identify current

Objective• Monitor and sustain hospital and systemy

state

Plan• Hospital self-

hospital and system improvements

Future StateP f i l d li

Objective • Close the gap

Plan• Hospital self-assessments

• LHIN-level roll-up

P i i l ll

• Prevent functional decline• Improve patient experience• Enable hospital staff

Plan• Implement hospital

improvement plans• Develop key

bl• Provincial roll-up • Improve equityenablers

The Senior Friendly Hospitals Toolkit• online at www.seniorfriendlyhospitals.ca, the toolkit providesclinical resources under the five framework domains, and providesan avenue for knowledge sharing to assist hospitals in their work

The Senior Friendly Hospitals Toolkit

an avenue for knowledge sharing to assist hospitals in their workof becoming Senior Friendly

Senior Friendly Hospitals & RGPs Senior Friendly Hospitals & RGPs of Ontarioof Ontario

Report of SFH Survey Findings for l ld dHamilton Niagara Haldimand Brant

LHIN

Presented by : Ms. Anne ll ClPizzacella, Clinician Nurse

Specialist

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HNHB LHIN: 19.4 % of population > 65 (provincial average 17 %), 2008/20091

HNHB LHIN has the highest number of individuals > 65 in Ontario (200 000 plus)1individuals > 65 in Ontario (200,000 plus)1

Significant growth over the next 10 years :Significant growth over the next 10 years : age 65-74 growing by 43.8%, age 75 and over by 34.1% 2

1Bronskill, SE et al, Aging in Ontario: An ICES Chartbook of Health Service Use by Older Adults. Toronto: Institute for Clinical Evaluative Sciences; 2010.

2 Population Projections, LHIN, Ontario Ministry of Health and Long Term care, IntelliHEALTH2 Population Projections, LHIN, Ontario Ministry of Health and Long Term care, IntelliHEALTH Ontario,

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Definition: Frailty denotes a multidimensional syndrome of loss of reserves (energy, physical ability, cognition, health)( gy, p y y, g , )that gives rise to vulnerability or increased risk of adverse health outcome (Rockwood,2005)

National Population Health Study, Rockwood 20113p y

Frailty rate 22.4 % over 65, increasing to 43.7% over 85

Frail people used health care resources more often

Institute of Clinical Evaluative Sciences 2008/09 1

Ontario Frailty rate, 8% over age 65

20% over age 85

3.Rockwood, K et al. 2011. Changes in Relative Fitness and Frailty Across the Adult Lifespan: Evidence from the Canadian National Population Health Survey. CMAJ

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Seniors in HNHB LHIN represent

20% of hospital ER visits,

63% f t h it l d63% of acute hospital days

83% of hospital ALC days83% of hospital ALC days

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40%

30%

35%

20%

25%

65-74

75-84

85+

10%

15% 85+

0%

5%

ED visits Hospital Days ALC days

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10 h i l i i 2210 hospital corporations representing 22 hospitals

Size varies: 600 bed academic hospital to less than 50 bed rural hospital

12 acute, 5 Rehab/CC, 5 other (4 ambulatory and 1 tertiary care mental health)

70 % pop is urban (Hamilton/Burlington)

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Survey design is not intended to be comprehensive or comparative between hospitals

Potential under reporting/over reporting i e successes and challengesi.e. successes and challenges

Analysis of reported data limited byAnalysis of reported data limited by heterogeneous measures (i.e. falls, ulcers and ED readmission)

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O l SOrganizational Support

Processes of CareProcesses of Care

Emotional and Behavioural Environment

Ethics in Clinical Care and Research

Physical Environment

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50% of hospital corporations have a board commitment to Senior Friendly model of carecommitment to Senior Friendly model of care

30% have a seniors focused committee structure (three hospitals)

80% have a senior executive designated as80% have a senior executive designated as lead for senior care initiatives

80% have identified at least one seniors’ champion (term not defined)

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86% of hospitals have staff dedicated to care of older adults (FTE varies from 0 04 to 10)of older adults (FTE varies from 0.04 to 10)

Strong interest in recruiting/developing staff with specialized competencies in geriatricswith specialized competencies in geriatrics

Challenges:Fi di i d i li d ffFinding experienced specialized staffDedicating already limited staff to seniors issues (small systems)Resources and strategies to educate all staffNo HR strategy for future needs

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S l l lStrategies; in-services, clinical protocols and interdisciplinary rounds

Seniors specific orientation to new staff-four acute sites and one CC-one hour to

done day

Monthly geriatric roundsMonthly geriatric rounds

Seniors month education

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P i d F ili Cli i lPatients and Families – Clinical encounters and Patient Relations

Three hospitals have internally developed senior specific surveys/interviews

All have generic patient satisfaction tools (PICKER)

Community partners-focus groups, forums

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h h l l h hMany high level partnerships to smooth transitions, identify system gaps e.g. CCAC, LHINCCAC, LHIN

Regional programs: ALC, Regional Stroke, Hi fHip fracture

Many partnerships with communityMany partnerships with community service providers including outreach to LTC, “Y”

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Increased CCAC resourcesIncreased CCAC resources

‘Hospital in the home’ alternatives

Enhanced primary care chronic disease management

Enhanced medical and NP resources in LTC

Enhanced End of Life planning and care throughout the system

More support for family and LTC to prevent and manage challenging behaviour

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Board Commitment to a SFH model of care with executive structure in place to design andexecutive structure in place to design and implement initiatives

Two sites have adopted the RGP SFH frameworkTwo sites have adopted the RGP SFH framework

High interest in developing staff geriatric competenciescompetencies

Master Aging Plan

Sharing specialized staff between academic and rural hospitals

Gentle Persuasive Approaches in two Rehab and three acute sites 27

Protocols and Monitoring for Areas of Risk

Successful Geriatric Initiatives

Discharge Planning Practices

Needs of Seniors in the ED

l dSpecialized Geriatric Services

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95% 95%100%

120%g

in P

lace

Hospital - Protocol in Place

Hospital Active

55%

91% 91%

64%

91%

77%86%

68%

86%

60%

80%

Activ

e M

onito

ring Hospital - Active

Monitoring of Metric

32%

50%55%

41%45%

27%

36%

18%

36%

18%23%

20%

40%

60%

with

Pro

toco

l/A

0%

9%

0%

9% 9%

0%

20%

cent

of H

ospi

tals

Perc

Confirmed Risk Area

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Protocols : 80-95% of hospitals have l i l f f ll lprotocols in place for falls, pressure ulcers,

adverse drug reactions, pain management and restraintsand restraints

Monitoring: < 50% of hospitals have monitoring in place for protocols except falls, pressure sores, and adverse drug reactions

No protocol or metric for sleep management

30

10

12

4

6

8

10

Hos

pita

ls

0

2

4

# of

H

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Cross Appointments: i.e.; Director across an acute hospital and a primary care organizationacute hospital and a primary care organization, manger between acute care and CCAC

Community partnerships: Long Term Care Sector,Community partnerships: Long Term Care Sector, Homeless Shelter, the “Y”

Complex Case Resolution committeep

Day therapy program for deconditioned seniors transitioning home

Graduated Discharge – rehab

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HELP in ED – focus on preventing delirium, preserving cognition and functionpreserving cognition and function

GAITE – NP led multidisciplinary assessment p yof at risk seniors in ED

GIMRAC clinic internal med sees patientGIMRAC clinic-internal med sees patient within 24hours of ED visit

Hi-Lo Stretchers with pressure reduction surfaces

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Staff orientation and education Programs

Age-sensitive patient satisfaction measure

Process to help older patients feel informed and involved

Supporting cultural diversity

Supporting attitudes and behaviours of health professional students

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Yes 75%,

Varies in length – one hour to one day

Universal education for restraints and falls

GPA mandatory for all new staff in two Rehab/CCC sitesRehab/CCC sites

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50% yes but50% yes but…

Picker survey, clinical encounters, patient l ti ( t iti )relations, (not age sensitive),

Introduction of senior specific satisfaction i 2011 h i lsurvey in 2011 at one hospital

Patient experience mappingp pp g

Senior specific surveying - HELP patients and GAITE clinic out patients p

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All hospitals support cultural diversity through translators, texts in multiple language

Cultural support from chaplaincy

Aboriginal advocacy programs in 2 hospitalshospitals

None are senior specific p

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Access to ethicist? 70% Yes

Advance Care Directives in place? 45 % yes, one in progress

Most common Ethical issues: Competency, SDM, End of Life Treatment, Living at risk, Interprofessional conflictInterprofessional conflict

Addressing Ethical issues: Capacity Board & Public Guardian, Capacity

Assessors, Psychiatry, policy on consent, interdisciplinary team, CCAC,

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All hospitals reported physical environment as a challenge to SFHchallenge to SFH

Accessibility for Ontarians with Disability Act th t d d t i ifiwas the common standard – not senior specific

2 corporations (7sites) have conducted senior friendly environmental audits using Code Plus

19 of 22 hospitals are making/planning changes 9 o osp ta s a e a g/p a g c a gesto the environment over the next 3 years

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Resources – financial (N=10), human (N=6)

Aging physical environment (N=9)

Culture: competing demands, specialization focus, ageism (N=6), g ( )

Indicators/measurement (N=2)

Specialized knowledge (N=2)

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LHIN wide model of SFH care

LHIN wide standards and metrics with d imandatory reporting

Best Evidence Based Practices for SeniorsBest Evidence Based Practices for Seniors added to accreditation standards

LHIN wide senior specific patient satisfaction tools

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Enhanced community supports

Help with recruitment of specialized i lseniors roles

Dissemination of successesDissemination of successes

Physical environment; standards andPhysical environment; standards and strategies

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Falls Pressure ulcers Hospital utilization (ED, LOS, Diverted d i i ALC d di i i )admission, ALC days, disposition)

Restraint usePressure ulcersPressure ulcersContinenceEducationEducationPhysical Environment

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Senior Friendly Hospitals & RGPs Senior Friendly Hospitals & RGPs of Ontarioof Ontario

Report of SFH Survey –dRecommendations

d b hPresented by : Dr. Sharon Marr

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Self Assessment Question Aggregate All Hospitals ResponseResponse

A1.0 SFH priority or goal 41 % yes

C1.1 Board of Directors and is there an explicit commitment

45 % yesthere an explicit commitmentC1.2 Senior Executive for SFH 64 % yes

C1.4 Designated committee for 41 % yescare of the elderlyC2.1 Protocols & Monitoring 48 % in place

C3.2 Age-sensitive patient 50 % yesC3.2 Age sensitive patient satisfaction

50 % yes

C3.5 Programs/processes to support attitudes and

82 % yes

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behaviours of HCP learners

Self Assessment Question Aggregate All Hospitals Response

C3.4 Support for cultural 95 % yes *ppdiversity among seniors and their families

y

C4.1 Access to ethicist 82 % yes

C4.2 Specific policy on Advance Care Directives

45 % yes

C5 2 SFH di f i h i l 32 %C5.2 SFH audit of its physical environment

32 % yes

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Organizational Support

There is a need for the following:Explicit commitment from all hospital p c t co t e t o a osp taboards with the designation of senior executive role(s)

Development of a committee structure to develop, adopt, and implement the goals p, p , p gand strategies for a Senior Friendly Hospital

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Processes of CareHNHB LHIN should request hospitals to

“clearly state” their QI plans, including EBM practice guidelines, protocols, and measurement tools for a Senior Friendly H it lHospitalStandardization of performance indicators measurement tools andindicators, measurement tools, and monitoring methods are needed

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Processes of CareHNHB LHIN should request the Geriatric

Access & Integration Network (GAIN) in ll b i i h h RGP C l HNHBcollaboration with the RGP Central, HNHB

Hospitals, community organization, and LHIN reps to:LHIN reps to:

Identify and establish EBM best practicesy pFoster the implementation of these Collaboration and partnerships

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Emotional & BehaviouralEnvironmentHNHB LHIN hospitals should have a

h i HR l f h fcomprehensive HR plan for the future needs of our seniors

AHSC including its universities and colleges need to collaborate with HNHB hospitals to educate our future health care providers and leaders

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Emotional & BehaviouralEnvironment – continued

Need for cultural diversity to be senior-specific & explicitly defined

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Ethics in Clinical Care and ResearchAll HNHB LHIN hospital staff should

have timely access to ethical expertise and processes (i.e. Advanced Directives) when managing ethical dilemmas

Capacity building strongly d drecommended

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Physical EnvironmentHealth Capital Investment Branch of the

MOH LTC should incorporate Code Plus design guidelines into their capital planning guidelines and facility

tassessment processAll HNHB LHIN hospitals should conduct regularly scheduled senior friendlyregularly scheduled senior friendly environmental audits

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Physical Environmenty

Need for education andNeed for education and dissemination of Senior Friendly Hospital design guidelines toHospital design guidelines to appropriate staff

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Questions and CommentsComments

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