2015/16 Quality Improvement Plan for CCAC
"Improvement Targets and Initiatives"
2015/16 Quality Improvement Plan for CCAC
"Improvement Targets and Initiatives"
AIM
Quality dimension Objective
Safety To reduce falls among long-stay home care clients
Measure
Measure/Indicator
Percentage of adult long-stay home care clients that have a fall on their follow-up RAI-HC
Assessment
Current performance Target
36.10% 35%
Change
Planned improvement initiatives
(Change Ideas) Methods Target justification
Previously stated a target of reducing falls to 33% by 2017 based on achieving comparable performance with
CCAC peers. Falls rates locally and across the province have increased, likely related to increase in age and complexity of the long stay population. Target of 35% reflects these changes and aligns to current provincial average rates of falls
1)Continue roll out of standardized falls protocol for complex seniors who have been identified as high risk for falls
1) Continue implementation of standardized falls protocol for complex patients at routine reassessments
2) Support 30 day follow-up with patient by CC
3) Monitor reported falls for all complex patients "
Process measures
% complex patients who triggered the falls CAP on the RAI-HC, who have a service plan in compliance with falls protocol (as of reassessment) and have had a 30 day follow-up from their Care Coordinator
Goal for change ideas
80% of complex patients identified as high risk have a falls plan in place in line with falls protocol by Feb
2016
Comments
A standardized protocol for patients at high risk of falls was developed and has been tested with 30 complex patients. 8 of the 12 patients who have had a 6 month reassessment continued to have a falls plan in place and reported fewer falls in the previous 90 days. We are aiming to expand to all complex patients at risk of falls and continue to monitor the impact of compliance to the protocol and follow-up with patients at 30 days.
2)Expand implementation of standardized falls protocol to
Adult Chronic population identified as high risk for falls
"1) Introduce falls protocol for adult chronic patients at routine reassessents 2) Support 30 day follow-up with patient by the CC 3) Monitor reported falls for all adult chronic patients"
% adult chronic patients who have triggered the falls CAP on the RAI-HC, who have a service plan in compliance with falls protocol (as of reassessment) and have had a 30 day follow-up from their Care Coordinator
50% of adult chronic patients identifed as high risk have a falls plan in place in line with falls protocol by Feb 2016
Adult Chronic population are a large population and have a high rate of falls so we aim to expand our falls protocol to this group. The protocol is implemented at 6 month reassessments so we do expect to reach at most half of this population over the next 9-12 months.

Safety To reduce falls among long-stay home care clients
Percentage of adult long-stay home care clients that have a fall on their follow-up RAI-HC
Assessment
36.10% 35% Previously stated a target of reducing falls to 33% by 2017 based on achieving comparable performance with
CCAC peers. Falls rates locally and across the province have increased, likely related to increase in age and complexity of the long stay population. Target of 35% reflects these changes and aligns to current provincial average rates of falls
Effectiveness To reduce the number of unplanned ED visits among home care clients
Percentage of home care clients with an unplanned, less-urgent ED visit within the first 30 days of discharge from hospital
9.6% 7%
2015/16 Quality Improvement Plan for CCAC
"Improvement Targets and Initiatives"
3)Establish audit plan to manage compliance to falls protocol
1) Develop audit plan including frequency of audits Audit process and reporting with appropriate and percentage of charts to be audited
2) Develop audit tool, and reports follow-up from managers is in place
3) Train auditors/managers and implement audit and management follow-up"
100% complete by
Q4
Support change in practice and identify barriers to change
Target in line with provincial average performance for CCACs
1)Expand collection of local performance data by implementing ED-CCAC notification system at remaining hospital sites in the south east region
1) Partner with the remaining two hospitals in the south east to complete regional implementation of an ED-CCAC notification system
2) Incorporate new data into local ED visit indicators for monitoring and analysis
Data from remaining two hospital sites will be incorporated into local ED visit indicator.
100% complete by
October 2015
Expanding our ED CCAC notification system was identified in our last year's improvement plan. We have initiated this work in partnership with local hospitals and the LHIN, and will complete it in the early part of the coming year.
2)Investigate strategies to reduce less urgent ED visits related to skin/wound for short stay and post-surgical patients
1) chart audit for patients who have presented to
ED with CTAS 4 or 5 for skin/wound and post surgical complications
2) engagement with service providers and/or patients
3) design and test a small scale intervention to reduce ED visits 4) develop an indicator to measure target population and monitor
% of Chronic Adult Seniors who present to ED by 1) planned change month to test by
November 2015 2) tested intervention by March 2016 with a single ED dept
Reviewing ED presentations in one of our geographic areas indicates that approximately 10% of less urgent visits (CTAS 4&5) in one of our regions are related to skin/wound.
Some appear to be planned but further investigation is warranted.
3)Investigate the linkage between 1) Review of available research
PSW service level and frequency of ED visits for chronic senior patients of CCAC.
2) Engage a small sample of patients to understand the circumstances leading up to their last ED visit
3) Develop a service intervention to test
4) Conduct a small test
5) Develop measurement system to evaluate change and monitor for 6-12 months"
% of Chronic Seniors who present to ED by month
Have test designed and initiated by
Feb 2016
Initial analysis of the available data related to ED visits for a 6 month period highlights that chronic seniors present to the ED at a higher frequency. There is some research to indicate that different supports in the home can prevent ED visits and we aim to investigate and test options.

Effectiveness
Access
To reduce avoidable hospital admissions among home care clients
Percentage of home care clients who experienced an unplanned readmission to hospital within 30 days of discharge from hospital
17.70%
To reduce service wait times
5 Day Wait Time - Personal
Support for Complex Patients: % of complex patients who received their first personal support service within 5 days of the service authorization date.
87.5%
17.70%
2015/16 Quality Improvement Plan for CCAC
"Improvement Targets and Initiatives"
Maintain current performance level
For the next fiscal year, we are aiming to maintain current hospital readmission rates. No specific improvement activities are planned as we are prioritizing efforts to reduce unplanned ED visits, falls, and wait times.
87.5% Maintain current performance level
1)Routine monitoring of wait times at Quality and Patient
Safety Committee
1) Develop a local measure for 5 day wait times for PSW and implement a quarterly review
Local measure established and quarterly review implemented
Review in place by
December 2015
For the next fiscal year, we are aiming to maintain current wait time for PSW for complex patients. The volume of patients whose wait exceeded 5 day is very low and predominantly driven by the availability of the patient. Since our performance is currently better than the provincial benchmark, we are electing to focus our efforts on other improvement initiatives
5 Day Wait Time - Nursing Visits: % 92.50% of patients who received their first nursing visit within 5 days of the service authorization date.
94% Target in line with provincial average performance for CCACs
1)Further analysis to identify reasons why a small percentage of patients who are available for service do not receive nursing within 5 days
"1) Audit 20% of patient charts for patients over a six month period, who waited more than 5 days for nursing service but whose available date indicates availability
2) consultation with nursing service providers on process for booking first visits, and reasons for delay with specific patients from audit "
Primary reasons for delay identified with plans for improvement in place
100% completed by September 2015
Analysis of 6 months of wait time data indicates that the majority of patients who do not receive nursing service within 5 days are not available within 5 days.
2)Assess risk of providing more nursing service in a clinic setting on wait times for patients.
1) Audit 20% of patient charts in a six month period for patients who wait more than 5 days for a nursing clinic appointment
2) Consultation with nursing clinic providers to evaluate process for scheduling first visits, and reasons for delay
Risk level assessed and response plan developed 100% completed by September 2015
We have recently opened new nursing clinics in our area and are providing nursing care to a larger number of patients in a clinic setting.

Client-centred To improve client experience
Percent of home care clients who responded “Good”, “Very Good”, or “Excellent” on a five-point scale to any of the following client
93.9% experience survey questions
• Overall rating of CCAC services
• Overall rating of management/handling of care by
Care Coordinator
• Overall rating of service provided by service provider
Equitable To reduce variation in service for long stay patients with similar needs
Standard Services for Long Stay
Patients: Percent of active long stay patients whose personal support (PSW) services are within established service guidelines
80.5%
93.9%
2015/16 Quality Improvement Plan for CCAC
"Improvement Targets and Initiatives"
Maintain current performance.
Our performance in overall satisfaction continues to be very high. This year, we do not have specific change ideas targetted at shifting overall satisfaction scores.
Instead, as part of our strategic plan, we are developing a patient engagement program to inform our improvement activities and service design.
This will include testing different methods for engaging patients.
90.0% Changes in service plan occur during natural reassessment schedules. Target
1)Implementation of Needs Risk
Indicator to establish standard
PSW service levels for all new patients at contact assessment acknowledges known exceptions to the standard.
1) Generate a needs risk indicator (NRI) for all new Percentage of new patients referred from patients at contact assessment, to guide service plan
2) Implementation at contact assessment hospital whose weekly PSW service units aligns to NRI based service guidelines for the first 2 weeks of service.
98% of new patients from hospital receive personal support services within guidelines by
March 2016.
Current service standard guidelines are based on comprehensive needs assessment at the first home visit. The NRI guides the initial service plan for patients who receive service upon discharge from hospital in advance of home visit. Baseline of 92% of all new patients from hospital receive standard service levels.
2)Continue roll out of standardized PSW service guidelines for long stay patients as part of scheduled reassessment and service plan adjustment
1) Reassess patient needs at scheduled reassessment date and adjust PSW service level to align to needs based guidelines
Percentage of patients on service prior to
August 2014 whose PSW service units align to guidelines.
90% of patients on service prior to
August 2014 will have PSW service
Implementation of needs based PSW service level guidelines started in August
2014. This change idea within needs based pertains to continued roll guidelines by
March 2016 out through routine reassessments. Target allows for exceptions to the guideline to meet the needs of individual patients.