Care by Design

Background

Between 1999 and 2005, Nova Scotia experienced a 32% reduction in LTCF physician services, and fewer physicians were willing to provide on-call coverage for LTCFs.¹ Before CBD, physician involvement in LTCF resident care was uncoordinated, and residents were responsible for finding their own physicians. Uncoordinated primary care in LTCFs often resulted in transports to the ED for problems that could have been addressed effectively within LTCFs with a coordinated care team. Avoidance of unnecessary ED transports reduces strain on stretched acute care resources, and respects residents with no-transfer wishes. In 2006, the CDHA sponsored the Primary Care of the Elderly (PCOE) Project to review primary care in LTCFs.¹ Retrospective analyses of 2002 to 2005 emergency health services (EHS), hospital, and LTCF charts revealed an annual transport rate from LTCFs to EDs of 75 residents per 100 beds.¹

To study implications of transports to the ED, chart audit data were collected on all LTCF-to-ED transports between November 2004 and April 2005 from 7 LTCFs. Of the 240 transports, 80% of residents were transported for breathing problems or falls. Overall, 35% of residents transported to hospital had advanced care directives stipulating they should not be hospitalized. While comfort care orders can change, it was found that in 50% of all transfer cases the LTCF could not reach the patient’s physician for consultation before transfer. Only 15% of cases had on-site assessment by a family physician before transfer. In 60% of cases there was no family physician contact in the week before transfer, and 33% of transferred patients had no family physician contact in the 4 weeks before transfer. Among transported residents, 60% returned to the LTCF, 39% were admitted to the hospital, and 1% died.¹

One reason transfer rates are high in CDHA LTCFs is that Nova Scotia legislation prohibits LTCFs from providing bloodwork more than 3 times a week, retention sutures, extensive dressings, continuous bladder irrigation, gastrostomy, intermittent oxygen, intravenous antibiotics, or nutrition other than by mouth, gastrostomy, or jejunostomy.² As a result, before CBD, LTCFs called 911 for ambulance transfer to the ED for these services.

Objectives of program

The objectives of CBD include providing comprehensive, skilled, timely, resident-centred care and making appropriate use of specialized health care resources in serving LTCF residents. Care by Design should

• provide better coordinated care;

• provide increased continuity of care;

• reduce ambulance transport rates to the ED;

• reduce rates of polypharmacy; and

• reduce health care costs.

Program description

Recognizing the need for a more coordinated and interdisciplinary model of care based on the findings of the PCOE Project, the CDHA implemented the CBD model, which has 5 components (Figure 1). Under CBD, all residents of an LTCF floor are cared for by the same dedicated family physician, with on-call physician coverage after hours. The 55 CBD physicians are organized into 5 networks across the CDHA, representing a total of 2600 beds. Each physician attends interprofessional team meetings and provides regular, anticipated care on their designated floors once per week. Practice standards include 30-minute physician on-call response time to calls from LTCFs, on-call sign-out communications, on-call telephone support, and standing orders and protocols. This consistent interaction between LTCF residents and dedicated family physicians is designed to improve continuity of care, facilitate communication, and allow for timely, best-practice care on site. Communication is improved with the reduced number of physicians caring for residents, creating greater familiarity for staff and residents. For example, CBD has reduced the number of family physicians providing care in 7 of the CDHA facilities (representing 1312 beds) from 230 to 41 physicians (Table 1). Care by Design physicians were self-selected, leading to a team with interest in geriatric care. Additionally, a comprehensive program of interdisciplinary education and training improves team coordination, communication, and end-of-life care.

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Figure 1.

Implementation of the Care by Design model components

Another component of CBD is a new EHS ECP program, initiated in February 2011. The ECPs are experienced advanced care paramedics, trained and equipped to deliver acute care on site at LTCFs at the request of the CBD physician. The ECP care plan is developed in consultation by telephone or in person with the CBD physician and the EHS oversight physician. The ECPs work alone (rather than the typical paramedic crew of 2) in a non–transport-capable vehicle. The ECPs can administer oxygen; provide suturing, slab splinting, steroid therapy, urinalysis, and 12-lead electrocardiograms; and take blood samples. When ECPs are involved with 911 calls from LTCFs, approximately 70% of patients remain on site.³ When it is deemed that an LTCF resident should be seen in the ED, the ECP and the EHS oversight physician coordinate to ensure timely transport to the ED. This occurs about 24% of the time. Facilitated transfers by ambulance minimize stress for residents and strains on resources. Rarely, it is necessary for the ECP to request an emergency ambulance for immediate transport to the ED (about 6% of the time). The ECP program was established to provide geriatric-appropriate care in several ways. First, ECPs were selected through an application, screening, and interview process designed to find experienced, mature advanced care paramedics well suited for this role. Next, they received specific interdisciplinary classroom and on-site LTCF training. In addition, ECP-specific processes were developed and implemented for care in LTCFs, moving away from a rapid assessment, stabilization, and transport model to a “slow medicine” approach of evaluation, consultation, and providing care on site.

Performance measures are being collected in a systemized way to measure outcomes. For example, an on-call tracking system has been implemented to monitor the number and types of calls being handled by on-call physicians, and collect clinical event and outcome data for residents. These forms are reviewed by the medical director and reports are evaluated by CDHA. In addition, EHS data on ambulance transfers and ECP calls are monitored monthly at the district level and within EHS.

Care by Design includes a standardized CGA of the health status of each resident, completed by the interdisciplinary team and signed off on by the CBD physician. The CGA is a 1-page form, modified and validated for use in LTCFs,⁴ documenting an older patient’s frailty status, including cognition (eg, dementia, delirium), mood, mobility, function, appetite, weight, bowel and bladder function, medical conditions, goals of care, care directives, and medications. This form is sent with residents who are transferred and has been a provincial standard since late 2010.

Costs of the CBD dedicated-physician model are revenue neutral, with the exception of on-call coverage, which costs $875 per day for all 5 networks and is paid by the CDHA. A before-and-after cost analysis of the full program including the ECP is planned.