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Complex continuing care project examines patient needs, service gaps
Imagine an 83-year-old woman admitted to RUH Medicine, with a limited income and no local family support. In the past six months she’s had four emergency department visits from falls and dizziness, and three previous eight-day average admissions for diabetes control, cellulitis and transient ischemic attacks. She receives limited Home Care nursing visits for medication management and leg dressings, and her husband has dementia and lives in a Saskatoon special care home.
Or a morbidly obese 70-year-old man with chronic obstructive pulmonary disorder and a history of colon cancer admitted for respiratory issues and now on oxygen. He has a well-managed colostomy and hasn’t required cancer treatment for two years. He was investigated for a possible gastrointestinal bleed for low haemoglobin and has been transfused. He is stable but the bleed investigations were inconclusive. His frail 71-year-old wife can’t care for him at home, but he doesn’t meet long term care admission criteria.
These are only two examples of the many complex patients found in the Region on any given day that could potentially be better served by an integrated, coordinated complex continuing care model. A project steering committee is charged with developing a strategy in this phase of work, and a working group is currently reviewing data and receiving input to help define the needs and scope of this client population.
The working definition of a complex continuing care population is: patients and clients who have complex (multiple) and continuing (chronic) care needs, who may have a high frequency of interaction or an extended stay with the health-care system, and who may not be well-served by existing care models. This cluster is defined in different ways in different jurisdictions, but can include sub-acute, rehabilitation, geriatric, respite, palliative and medically complex patients.
“The overall purpose of the project is to optimize care for this client population,” says Dave Gibson, Saskatoon Health Region’s Director of Continuing Care and Seniors Health. Gibson co-leads the complex continuing care project with VP Community Services Shan Landry, with support from project managers from Planning, Policy and Performance.
“Other goals are to increase acute care capacity for those who need it by decreasing alternate level of care days, preventing readmissions, and optimizing lengths of stay,” he adds. “We also want to reduce long term care institutionalization rates and increase capacity in home care and primary care by increasing support for our clients and their families.”
Working group members are currently researching utilization data, including alternate level of care data, readmissions, emergency visits, emergency transfers from long term care, heavy users of home care, and use of chronic disease programs. They’re also gathering qualitative data – diagnostic and demographic characteristics, gaps in service, and the challenges faced by these patients and their care providers.
“We know we’re already providing care to these clients through different programs, but not in an integrated way, and there may be gaps in service compared to the need,” says Gibson.
Once the working group and steering committee finalize a Region-specific patient definition in 2009, the project will turn towards best practice and a visioning process to shape a Saskatoon Health Region complex continuing care recommendation and plan.
What is complex continuing care?
The complex continuing care (CCC) project joins several other service alignment projects already underway, and is the result of extensive consultation, planning and review. The project is designed to develop strategies to meet patient needs now and into the year 2021, considering the Region’s challenges of changing provincial demographics, skilled labour shortages, aging infrastructure and historical deficiencies in capital and technological investment. The CCC project will also be responsible for helping to fulfill the Region’s more immediate vision of a three-site model in Saskatoon where SCH is transformed into a leading centre for complex continuing care and ambulatory care.
The Complex Continuing Care steering committee met for the first time on January 19, 2009. The CCC steering committee comprises representatives from many care groups and services, such as:
- rehabilitation,
- geriatrics,
- stroke services,
- CPAS,
- continuing care and seniors’ health,
- chronic disease,
- palliative care,
- home care,
- Parkridge Centre resident care, and
- community services.
The key tasks are to:
1. define the patient population
2. explore best practices
3. assess stakeholder expectations
4. assess the Region’s current care models and systems
5. design a CCC vision and strategy for the future.
The first task, defining the patient population, sets the direction for the other tasks. The Resource Planning Group (RPG) and Hay Consulting Group suggested that the CCC patient population include:
- sub-acute,
- rehabilitation,
- palliation, and
- medically complex long term care patients.
As there are diverse national and international definitions of CCC, the Region will explore these definitions and patient groups further before proceeding with the other tasks.
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