Panel – Integration of Health Organizations and Services in Canada Centre for Health System Design and Management Octob

1. Panel – Integration of Health Organizations and Services in Canada Centre for Health System Design and Management October 15th

2. Agenda • Relevance and role of caregivers • Community support services as part of integrated system • Nursing Care Delivery Models and Staff Mix

3. Caregiving in Canada

4. Title • Page 4 • www.von.ca • www.caregiver-connect.ca Context of Caregiving SUPPLY OF FAMILY CARE DECREASING DEMAND FOR CARE INCREASING Aging population and living longer with disability or health condition Increased participation of women in the labour market Preference to be cared for at home/live independently Changing family structures Capacity of system to meet growing demand for care Geographic mobility Increasing need to balance several responsibilities • Health care system reform • early discharge from hospital • cost containment Pressures on health, social, and economicwell-being of Canadians

5. An Integrated Approach to Home and Community Care

6. An Integrated Approach: An AHS-VON Partnership • Page 6 • www.von.ca VON’s Integrated Approach SMILE Community Support Home Care Stay@Home Caregiver Connect SMART Home Support Nurse Practitioner Programs Technology Pilots Caregiver Respite and Education Home At Last Partnerships

7. What is the impact? 91% of in-home and 100% of group participants maintained or improved function during the program. SMART Programs improves: Overall health and energy level Strength, coordination, balance, and flexibility Lung and heart function Mobility and independence SMART Programs prevents: Social isolation Bone loss Falls Title • Page 7 • www.von.ca • www.caregiver-connect.ca VON SMART

8. What is SMILE? SMILE and other CSS initiatives provide an integrated web of care designed to support the frail elderly at critical health “tipping” points” - where health status can change rapidly and chance of full recover is limited. It is Person and caregiver centered Leverages existing services Multi-pronged interventions at the right time and by the right person Sustainable changes to the system Reflective of community input

9. What is the Evidence? Providing home care and support to the frail elderly  LTCH bed use by 30% Cuts to homemaking services to the frail elderly cost the health care system an average of $3500/person due to  hospital and LTCH utilization Studies and locally observed results suggest that relatively small investments in assisting the frail elderly with ADL can  the number who present in the ER and admissions to hospital beds

10. What is the impact? “Created a domino effect of success” 36%  in clients waiting for LTCH placement 482 clients of SMILE voluntarily removed themselves from the LTCH waiting list In one year the wait time for LTCH beds  by 50% ER visits have  Base cost of SMILE is $56-$62/week/ client, significantly less than care in LTCH or ALC bed

12. Performance Indicators: 0% clients waiting for service 93% maintained in the community 61% using more than one community support service Almost 25% reported the patient’s discharge date was moved up as a result of the availability of HAL.  by a total of 1794 hours or an average of 13.8 hours per client/referral. Title • Page 12 • www.von.ca • www.caregiver-connect.ca

13. Nursing Care Delivery Models and Skill Mix

14. Nurse Staffing and Hospital Mortality Rates Dr. Ann Tourangeau

15. Mortality Rate Results (75 ON H)

16. Nurse Staffing Results

17. Findings: 2006 Study Explained 45% of variance in risk and case mix adjusted hospital mortality rates Lower hospital mortality rates associated with: HIGHER proportion of RNs in staff mix (similar to Estabrooks et al. 2005 Alberta study) HIGHER % of baccalaureate educated nurses (similar to Estabrooks et al. 2005 Alberta study) HIGHER nurse-reported adequacy of staffing & resources HIGHER use of care maps HIGHER nurse-reported quality of care on unit

18. Conclusions The wide range in risk and case mix adjusted 30-day hospital mortality rates found indicates that after controlling for the impact of patients’ own characteristics and the mix of patients within and across hospitals, some hospitals have structures and processes of care that more effectively prevent unnecessary patient death – these structures and processes of care reflect nursing care

19. Conclusions For acute medical patients, higher % of RN staffing and higher % of baccalaureate educated RNs promote fewer unnecessary deaths In 2006 study, a 10% increase in RNs was associated with 6 fewer deaths per 1000 discharges In 2006 study, a 10% increase in baccalaureate educated nurses was associated with 9 fewer deaths per 1000 discharges

20. Conclusions 10% increase in routine use of care maps / algorithms by nurses associated with 10 fewer deaths per 1000 discharges 10% increase in nurse-reported adequacy of staffing & resources was associated with 17 fewer deaths per 1000 discharges

21. May 4, 2010 Linda O’Brien-Pallas, PhD, RN Gail Tomblin Murphy, PhD, RN Judith Shamian, PhD, RN Nursing Health Services Research Unit

22. Average turnover rate is close to 20% per year in Canada, with the highest level in medical, surgical, combined medical-surgical and ICUs. For every 10 nurse vacancies the cost is 250K. The highest turnover costs are attributed to temporary replacements and decrease in initial productivity of new hires. Takes a new hire on average almost 8 weeks minimum to reach 100% role implementation; strategies need to be in place to support the transition. Given the high cost associated with temporary replacement, leaders ought to reassess the cost-benefit efficiency of employing temporary replacement staff over retention strategies. Any reproduction requires permission from TOS co-PIs 22

23. Turnover is a system issue and is associated with decrease in job satisfaction, increase in likelihood of medical errors, overtime and environmental complexity. Better leadership is associated with better mental health, higher job satisfaction but decreased physical health status in nurses. Nurse leaders should ensure appropriate staffing resources that consider the needs of patients, and role responsibilities and health of nurses. Any reproduction requires permission from TOS co-PIs 23

24. Better leadership is associated with higher productivity on the unit Evidence shows non-supportive working environments and poor relationships with nurse managers and other team members are contributing factors in nurses’ decision to leave. Role ambiguity and conflict on the units are associated with higher turnover rate for nurses. When nurses encounter competing demands or are unclear about their expectations, job stress and deterioration in mental health result. Any reproduction requires permission from TOS co-PIs 24

25. 7. Errors in patient care are related to higher levels of turnover and role ambiguity for nurses on the unit. Medical errors are 38% more likely to occur for each additional 10% increase in the turnover rate. 8. Units with higher proportion of overtime find it difficult to attract more experienced nurses; but these experienced nurses are crucial to supporting patient safety. 9. Higher proportion of full time nurses is associated with lower nursing turnover. Any reproduction requires permission from TOS co-PIs 25

26. Dr. Judith ShamianPresident and CEO Judith.Shamian@von.ca