1 Leveraging the Culture of Performance Excellence in Ontario’s Health System HSPRN is an inter-organization Network funded by the Ontario Ministry of Health and Long Term Care Understanding and Identifying Target Populations for System Improvement Virtual Ward. July 2, 2010 W.Wodchis, X.Camacho, I. Dhalla, A. Guttman, E.Lin, G.Anderson

2 Target Populations for System Improvement Populations with high health utilization rates who move from one sector of the health care system (e.g. acute) to another (e.g. community) may represent opportunities to improve quality and reduce costs – primarily by reducing adverse events and preventing acute hospital readmission. While quality of care within providers is being enhanced by performance measurement and reporting, payment incentives and quality improvement programs… Care transitions between providers are fraught with lack of coordination, poor communication, safety issues related to medication management...etc,etc.

Example System Improvement Interventions Care for Complex Patients e.g. Rich et al., (NEJM 1995) RCT of nurse-directed intervention for CHF  90 day Risk of Readmission = 0.56 Naylor et al., (NEJM 1995) RCT of Advanced Practice Nurse-lead intervention including coordination with primary care physician for CHF  1-year Readmissions in intervention group = 1.18/patient vs 1.79 in control Coleman et al., (AIM, 2006) RCT of APN-lead intervention for select conditions  90-day Readmissions in intervention group = 16.7% vs. 22.5% (Odds=0.64) Common components of these interventions: 1.Case management (including discharge planning) 2.Follow-up care in home (24-72 hours) 3.Medication management / reconciliation 4.Patient education/empowerment (Rich, Coleman) e.g. Patient personal health record 3

4 Target Populations for System Improvement Purpose for our study: 1. Identify the Ontario prevalence of populations that have been included in prior transition interventions. 2.Examine the treatment and follow-up patterns of care for these patients. 3.Examine the relationship between follow-up care (as suggested by interventions) and patient outcomes (hospital readmission) in the Ontario population cohort. 4.Examine health system costs associated with total 1- year care for this population.

5 Target Populations for System Improvement What we’ve done: 1.Identify community-based cohort of clients aged 66+ based on Acute care discharge (April 2006-March 2007) with : 1.2 or more ACSC conditions ( Angina, Asthma, COPD, Diabetes, Grand Mal Seizure, Heart Failure, Hypertension ) or any one of the following ‘tracer’ conditions: Stroke, Cardiac Arrhythmia, Spinal Stenosis, Hip Fracture, Peripheral Vascular Disease, Deep Vein Thrombosis or Pulmonary Embolism Follow for 365 days (until March 2008) 2.Describe characteristics of the patients 3.Examine readmission rates to Acute Inpatient Care 4.Examine relationship between follow-up and readmission 5.Understand system utilization and costs

6 Target Populations for System Improvement Data Sources for Ontario, Canada: 1.Canadian Institute for Health Information (CIHI) Discharge Abstract Database. 2.Ontario Health Insurance Program Physician Billing 3.Ontario Home Care Database (service claims) 4.Ontario Drug Benefit Pharmacy Claims 5.Other hospital service databases (Emergency, Rehabilitation, Complex Continuing Care Long Term Care) Data available at the Institute for Clinical Evaluative Sciences.

7 Target Populations for System Improvement Acute DiagnosisPrevalence Cardiac Arrhythmia14, % Stroke8, % ACSC (>1 diagnosis) 7, % Hip Fracture5, % DVT/PE1,8874.8% PVD1,6344.2% Spinal Stenosis1,4183.6% Total38,978

8 Target Populations for System Improvement Summary Characteristics:  Average Age: 79  Slightly more women (56%) except Hip Fracture (75% women)  Average number of medications in prior year = 11  ACSC Average=14.4 and 25% with 19 or more  28% with new medication within 30 days prior to index hospitalization (35% for ACSC conditions)  88% have a Regular family physician

9 Target Populations for System Improvement Post-acute follow-up care: 39% receive home care within 30 days  21% within one day and 25% within 3 days 18% receive home nursing visit within 30 days  9% within one day and 12% within 3 days 52% receive primary care within 30 days  25% within 7 days

10 Target Populations for System Improvement Outcomes :  16,605 (43%) discharged to community  17,727 (45%) discharged to other health care institution  4,646 (12%) died during initial hospitalization Among 16,605 discharged to 30 days  23.4% have ED visit  12.8% readmitted to acute care  3.2% 90 days  38.0% have ED visit  22.2% readmitted to acute care  7.3% dead

11 Target Populations for System Improvement (Among 16,605 discharged to community) Examine likelihood of readmission to acute care within 7-30 days and 7-90 days associated with: 1. Home care nursing visit (show 1 day vs 3 days) 2. Primary care visit (show 7 days) (controlling for host of risk factors using logistic regression - 51 covariates).

12 Target Populations for System Improvement Risk of Readmission to Inpatient Acute Care Independent Variable 7-30 days Adj. Odds Ratio* (95% Confidence Interval) 7-90 days Adj. Odds Ratio* (95% Confidence Interval) Home Nursing Visit within 1 day (vs 2-3 days) 0.72 ł (0.53, 0.98) 0.70 ł (0.55, 0.90) Primary Care Visit within 7 days 0.91 (0.81, 1.03) 0.85 ł (0.78, 0.93) New Filled Prescription 1.07 ł (1.04, 1.10) 1.04 ł (1.01, 1.06) * Adjusted for 51 measures of patient characteristics, prior medical treatment, diagnoses and geography Ł significant at the 5% level Population Discharged to Community n = 16,605

13 Target Populations for System Improvement Summarize Utilization and Costs in 365 days following acute discharge: Index Hospitalization (Hospital and Physician Cost) Subsequent:  Acute Hospital Care (Hospital and Physician Cost)  Rehabilitation Hospital  CCC: Complex Continuing Care Hospital  LTC: Long Term Care Facility  HC: Home Care  Primary and Specialist Physician care  Pharmaceutical (Ontario Drug Benefit - ODB)  ED: Emergency Department (Hospital and Physician Cost)

14 Target Populations for System Improvement Summarize Utilization and Costs in 365 days following acute discharge: Total Population38,978 (0.3% population) Average Annual Cost$35,935 System Cost $1,400,689,862 (3% system cost)

15 Target Populations for System Improvement

16 Target Populations for System Improvement Summary 1.This example population presents significant opportunities for improvement by increasing access to nurse visit at home within one day and physician visit within one week. (and medication reconciliation) 2.Value-proposition: Data represent baseline system cost for evaluating interventions. (e.g. preventing 785 (5%) of readmissions would ‘free-up’ $14,106,792 in acute care costs; provincial target of 30% =$210 Million) Research in Progress: 1.Further examination of subsequent transitions in health system. 2.Other target populations: A. Adult Mental Health and B. Complex Paediatric Populations.

17 What Can We Work On ? e.g. Integration and Transitions of Care Acute LTC Rehab / CCC / Sub-acute Care Community Urgent / ED Care Patient Flow Patient Rebound Primary - Specialist Home Care Pharma e.g. Elderly: Home Care, Primary Care and Medication Management

18 Desired Goal Better Transitions of Care Acute LTC Rehab / CCC / Sub-acute Care Community Urgent / ED Care Patient Flow Patient Rebound Primary - Specialist Home Care Pharma e.g. Elderly: Home Care, Primary Care and Medication Management

19 Transitions Ontario >66 discharged with 2+ ACSC; Acute Died Rehab / CCC / Sub-acute Care Community LTC Initial transition after acute care discharge. n=5,648 N=576 n=805 n=213

20 Transitions Ontario >66 discharged with 2+ ACSC; Acute Died Rehab / CCC / Sub-acute Care Community LTC Initial transition after acute care discharge. n=5,648 N=576 n=805 n=213

21 Transitions Ontario >66 discharged with 2+ ACSC; Acute Died Rehab / CCC / Sub-acute Care Community N=1,538 LTC N=5,648 n=19 n=620 n=82 First 2 transitions after acute care discharge 1-year follow-up. n = 3,381

22 Transitions Ontario >66 discharged with 2+ ACSC; Acute Died Rehab / CCC / Sub-acute Care Community N=1,538 LTC N=5,648 n=19 n=620 n=82 First 2 transitions after acute care discharge 1-year follow-up. n = 3,381

23 Selected 1-year post-discharge visits MeasureCommunityReadmit Number of Primary Care Visits Median [Q25 – Q75] 15 [9-24]29 [17-47] Number of Specialist Visits17 [8-30]45 [22-77] 6 or more Different Physicians 20 or more Different Physicians 70% 4% 96% 44% 4 or more Different Pharmacies10%15% 2 or more ED visits20%73% 2+ Acute Readmissions054% 2+ Post-acute institutions04% Total Number of Provider Visits46 [30-78]126 [75-204]

24 Target Populations for System Improvement 1.Populations that have high health utilization rates and that move from one sector to another have important implications for both the costs and quality of care. 2.These populations are of interest because they may represent opportunities both to improve the quality and reduce the burden and costs on the health care system. 3.There are opportunities for improvement and we should be able to track performance improvements.

What we know about Performance Carl van Walraven (2008) : 3250 patients with 39,469 previous-current visit combinations (12 per patient) in 6 months after discharge. Information about the previous visit was available 22% of the time. …We could improve 25