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Implementing Stroke and Orthopaedic Best Practices in the Toronto Central LHIN Analysis of System Wide Impacts

March 31, 2012

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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


3.2 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


4.2 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


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.


reports.


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.


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

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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

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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

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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

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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

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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

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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

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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


programs

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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

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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

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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.


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


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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%






Grand Total 977 63% 15% 9% 6% 5% 2%



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


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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


TRI Hillcrest 159 4,161 26.2


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

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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.

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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

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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

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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


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However, the committee determined that to achieve both qualities and


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




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

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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.


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


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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.


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

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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


Sunnybrook HSC 479 39% 30% 18% 7% 4% 2%





Grand Total 1,965 40% 27% 13% 10% 6% 4%



27% of days in acute care

hospital spent as ALC

Only 27% of live discharges

of stroke patients were

discharged to inpatient

rehabilitation

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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



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

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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

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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

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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


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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


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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


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


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

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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




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.

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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.


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

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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

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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

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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$

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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.

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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.

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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

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7.0 Complex Continuing Care Initiatives


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.


more CCC beds per

population than any other

LHIN

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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

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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

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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

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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

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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


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

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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


to CCC facilities in the TC

LHIN

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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

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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.

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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.

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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

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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


Estimate marginal per diem cost at 80% of average per diem cost

Inpatient CCC


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$


Marginal per Diem Cost (80% of Direct) 395$

Total Cost per Patient Day 519$

Direct Cost per Patient Day 365$


Marginal per Diem Cost (80% of Direct) 292$

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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$

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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$

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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$

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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

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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

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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


patients live in the Toronto

Central LHIN

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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%

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Source of St. John’s Patients – Acute Hospitals – Unilateral Hip and Knees


22% of St. John’s inpatient TJR cases and 25% of inpatient TJR days


LOS

North York Gen. 294 4,146 14.1




Wm. Osler - Etob. 70 864 12.3


St. Michael's 41 525 12.8

Mount Sinai 40 715 17.9

UHN 36 436 12.1

Scarb. Grace 31 640 20.6




RVHS Centenary 2 16 8.0


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


Patients transferred from TC


account for only 22% of St.

John’s inpatient TJR cases

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Source of St. John’s Patients – Acute Hospitals – Hip Fractures


33% of St. John’s inpatient HF cases and 31% of inpatient HF days


LOS



Humber River - York Finch 30 858 28.6





Wm. Osler - Etob. 6 285 47.5


Southlake Reg. 5 146 29.2

Union Villa 4 112 28.0

UHN 4 125 31.3



York Region Maple Health Centre 1 36 36.0

Other 2 45 22.5

Total 211 5,876 27.8






account for only 33% of St.

John’s inpatient HF

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Source of St. John’s Patients – Acute Hospitals – Strokes


48% of St. John’s inpatient Stroke cases and 47% of inpatient Stroke

days


LOS

Sunnybrook 40 993 24.8


UHN 26 873 33.6



Markham Stouff. 8 237 29.6





Wm. Osler - Etob. 3 63 21.0


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






account for 48% of St.

John’s inpatient Stroke

cases

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Source of St. John’s Patients – Acute Hospitals – TJR, HF, and Strokes


27% of St. John’s inpatient TJR, HF, and Stroke cases and 31% of

inpatient TJR, HF, and Stroke days


LOS






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







Other 16 358 22.4

Total 1,288 24,461 19.0







John’s inpatient TJR, HF,

and Stroke cases

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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


LOS



UHN 268 5,030 18.8

St. Michael's 203 3,833 18.9


Southlake Reg. 24 627 26.1

Markham Stouff. 18 384 21.3






Wm. Osler - Etob. 6 134 22.3



Other 26 879 33.8

Total 1,338 28,241 21.1







John’s inpatient “Other”

cases

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