BY NORM TOLLINSKY

In January 2008, half of Timmins District Hospital’s 112 acute care beds were taken up by alternate level of care (ALC) patients, most of them frail seniors no longer in need of acute care but with nowhere else to go.

It was a crisis situation, recalled Carlo De Lorenzi, director of clinical services. Less than a year later, Timmins District Hospital is winning accolades for the success it has had in tackling the problem. The percentage of ALC patients at the hospital has fallen from 50 per cent to 28 per cent and approximately 50 patients have been discharged or redirected from Emergency back into the community with the support and care they required.

Timmins District Hospital attributes its success to three initiatives: the adoption
of the Identification of Seniors-at-risk Screening Tool (ISAR), wrap-around funding from the Northeast Local Health Integration Network (LHIN) and the Flo Collaborative, a quality improvement program designed by the Centre for Healthcare Quality to expedite the flow of patients from acute care back into the community.

ISAR, a tool developed by Dr. Jane McCusker of McGill University, is used to identify at-risk seniors in a hospital emergency department. Assessments conducted by a social worker at Timmins District take into consideration problems with memory, mobility and eyesight, as well as the number of times a patient has been hospitalized.

“If the patient doesn’t pass the first level, then they’re provided with a second level assessment that’s a little more comprehensive,” said De Lorenzi. “If they fail that, they are linked with community services such as the Community Care Access Centre or the Red Cross.”

A social worker hired to administer the ISAR tool meets face-to-face with seniors in Emergency during the day, while patients who arrive at Emergency in the evening are followed up the next business day.

Approximately 20 per cent of patients cared for in Emergency at Timmins District are 65 years of age and older, accounting for up to 6,000 visits per year. Of those, approximately 20 per cent are admitted to hospital, said De Lorenzi. “What we’re hoping to accomplish with the ISAR program is to try to reduce avoidable admissions because, with the proper support in the community, many of these patients could remain in their homes. ISAR helps us identify them and link them up.”

Wrap-around funding

Wrap-around funding in the amount of $235,000 per year was given to Timmins District to provide ALC patients in the hospital and at-risk seniors in Emergency with the support they require to return to the community.

“We’re actually paying for services like nursing care, topping up CCAC services and covering the cost of personal support workers,” said De Lorenzi. Wrap-around funding, for example, was used to provide an MS patient with a wheelchair ramp at his home. It has also been tapped to cover the cost of emergency communication services, oxygen, occupational therapy assessments, walkers and bathroom safety products.

An additional 64 long-term care beds have been approved for Timmins, but won’t be ready for another three years, hence the need for short-term solutions that allow seniors to remain in their own homes. Because of the shortage of long-term care beds in the city, Timmins District has also dipped into its wrap-around fund to cover the cost of food and nursing support for ALC patients discharged to retirement homes.

When Sudbury Regional’s ALC problem reached a crisis point this past fall, the Timmins wrap-around program was held up as a model for other hospitals in the region. The Northeast LHIN allocated $288,000 to fund the program in Sudbury and another $267,000 to be shared by North Bay and Sault Ste. Marie.

Sudbury Regional had 100 acute care beds occupied by ALC patients in November, forcing the cancellation of surgeries and a decision to no longer accept emergency patients from hospitals in northeastern Ontario in all but the most life-threatening cases.

Flo Collaborative

The Flo Collaborative, the third program that has played a role in alleviating the Timmins ALC problem, is “aimed at improving the effectiveness and timeliness of patient transitions through the health care continuum,” said Joan Ludwig, director of clinical services.

One of 29 hospitals in Ontario piloting the program (the only other site in Northern Ontario is Thunder Bay Regional Health Sciences Centre), the Flo Collaborative focuses on process improvements to promote timely discharge.

Interdisciplinary teams consisting of nurses, pharmacists, social workers, physiotherapists and CCAC staff work together to streamline patient care through daily bedside rounds. There are also daily “bullet rounds” with doctors that bring team members up to speed on the care plans for all of the patients in the unit.

“The day you’re admitted to acute care is the day we start planning your discharge,” said Ludwig. “We have whiteboards in all patient rooms indicating the estimated discharge date and we talk about a provisional discharge destination.”

Family members often make a point of visiting during the bedside rounds, held daily at 1:15 pm, to stay in the loop.

“The key to its success has been the improvement in communication between the members of the interdisciplinary team and working with the patient and family, but also the improvement in networking and communication with the CCAC,” said Ludwig. “It’s a change in culture and a different way of looking at the health-care continuum.”

Despite Timmins’ success, the hospital is still operating at 100 per cent capacity, well above the 85 per cent capacity for which it is staffed, so hospital administrators have submitted a proposal for another six medical beds.

Sudbury Regional is also skeptical about relying solely on programs such as wrap-around funding to relieve its ALC problem and was successful in lobbying for 24 transitional beds.

Northeast LHIN CEO Rémy Beaudoin agrees that the system may need more resources, but still thinks the best solution is to move ALC patients into the community.
“Rather than go with the expensive beds and institutions approach, if we align and enrich the community programs, we think we can make some significant inroads into ALC ratios in hospital,” he said.

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