West Toronto Local Collaborative Priority Area: Rockcliffe Smythe – Focus on Chronic Diseases and Access to Primary Care
May 26, 2017 Contents 1. Rockcliffe Smythe background and methodology/considerations/limitations of this deep dive analysis
2. Overall Emergency Department and Acute Inpatient Utilization for Selected Chronic Conditions for Rockcliffe-Smythe residents
3. ED and Acute Inpatient Utilization for Individual Selected Chronic Conditions for Rockcliffe-Smythe residents
4. Patient Journey for Residents with ED Visits, Health Links and Home Care Referrals and Use
5. Primary Care Attachment, Access and Continuity for Rockcliffe-Smythe Residents
6. Community providers serving Rockcliffe-Smythe residents (CBI)
7. Appendix
a) Diagnostic codes for the selected chronic conditions 2 West Toronto Sub-Region – Rockcliffe-Smythe Neighbourhood
3 Rockcliffe-Smythe – Background information on chronic conditions identified through previous data review and consultations Previous analyses showed that Rockcliffe-Smythe: Was one of the 4 neighborhoods in the northwest corner with a high prevalence of chronic diseases (Diabetes, Asthma, high blood pressure and COPD) Had high rate of seniors (ages 65+) living alone (36.8%), High Proportion of immigrants (51.0%) High rate of individuals with no knowledge of English or French (6.3%), Second highest marginalization rate in the West sub-regions and a high rate of persons living below low income measure (after-tax) (23.1%), It is a City of Toronto designated Neighborhood Improvement Areas (NIA)
Discussions with working group requested information on ED visits, admissions, primary care attachment data and information on high needs Toronto Community Housing buildings.
Comments from Providers Could tailor a strategy similar to that being done in Mount Dennis
There is a need for communicating the availability of services, particularly for new Canadians and immigrants that don’t speak English or French Encouraging more coordination with preventative efforts linked to the social determinants of health Coordination of services are needed for vulnerable populations, including housing and transportation There should be more engagement of community members and patients in future planning discussions. 4 Methodology and Limitations of Analysis
Several Data Sources were used for this analysis:
1. Toronto Central LHIN utilization data on emergency department visits (NACRS) and acute inpatient discharges (DAD) with a focus on chronic conditions. This data was based on identifying the number of ED visits and discharges for the postal codes in the neighborhood. • 10 chronic conditions (Arthritis, Asthma, CHF, COPD, Diabetes, Hypertension, IHD, Stroke, Mental Health and Addictions) that had been identified by the Ministry as relevant for Health Links. See ICD codes for ED visits and Inpatient hospitalizations in Appendix. For inpatient analysis, MH and addictions were excluded. • Analysis for the chronic conditions focused on adults 20+ as these conditions are more prevalent in adults, with the exception of COPD where we used population 35 years and over. • Data are broken down by age groups and sexwhere possible
2. Attachment and continuity data was also included from Ontario Community Health Profiles Partnership 3. Integrated Decision Support (IDS) data was used to explore the patient journey for Rockcliffe-Smythe residents with ED visits due to chronic conditions who were were Health Links patients, and those with CCAC referrals in 2015/16. 4. Community Business Intelligence (CBI) data was used to identify a small group of top HSPs in the neighborhood. A list of top HSPs that serve 50% of the clients Rockcliffe Smythe neighbourhood is provided (this gives the top 4 to 6 CMHA HSPs and the top 1 or 2 CSS HSPs). However, it should be noted that most HSPs are serving small numbers in each neighbourhood, so this is just a fraction5 of the total HSPs involved in the neighbourhood. Key Highlights and Summary of All Findings Overall, Emergency Department Utilization for Selected Chronic Conditions, FY 2015/16: • Of the total 9,886 ED visits by Rockcliffe-Smythe residents, 1,489 were for the 10 selected chronic conditions for target population of 20 years and older (35+ for COPD). This represented 1,066 unique visitors. High rate of multi-morbidity: • 51 (5%) individuals had more than one chronic condition • 460 (43%) individuals who had a visit for a chronic condition also had a visit for a non-chronic conditions • Arthritis was the most common condition (671 ED visits) followed by mental health (261) and Addictions (140). IHD had the lowest number of visits (34). • The majority of ED visits for the select chronic diseases were severe (CTAS 2 & 3) with Ischemic Heart Disease and Congestive Heart failure having the highest proportion of CTAS 2 • CHF, cancer and stroke had the highest proportion of admitted visits. • Arthritis, addictions, asthma and hypertension had the highest proportion of visits discharged home without supports • Proportion of those reporting having a primary care provider varied from 65% for Addictions related ED visits to 92% for Diabetes related ED visits • Majority of the patients visited St. Joseph’s Health Centre (35%), followed by Humber River Regional Hospital – Church Street Site (18%) and Humber River Hospital – Wilson Site (14%) .
Overall, Acute Inpatient Utilization for Selected Chronic Conditions, FY 2015/16: • Of the 2,049 acute inpatient discharges for Rockcliffe-Smythe residents, 433 were due to the 8 selected chronic conditions as the most responsible diagnosis, representing 336 unique individuals. High rate of multi-morbidity: • 17 (5%) individuals had more than one chronic condition • 79 (24%)individuals who had a discharge for a chronic condition also had a discharge for one or more non-chronic conditions • Cancer had the highest number of discharges (63) followed by Arthritis (53). Hypertension had the lowest (5). • Discharges due to cancer had the longest length of stay (LOS) ( 9.3 days) while asthma had the shortest (2.8 days) • Cancer had the longest ALC LOS with an average stay of 8 days. 6 Key Highlights and Summary of all Findings continued Characteristics for Selected Conditions Arthritis- Age groups 40-64 and 20-39 had highest number of ED visits, mainly males. Highest proportion (28%) of CTAS 4 and 5 among the conditions. Acute inpatient discharges were more among older female adults and seniors. 13% of patients had repeat ED visits while only 1% of those discharged had a repeat admission.
Mental Health – Adults 20-39 years, mainly males, had highest number of ED visit. 55% of visits were CTAS 3. 18% had repeat ED visits
Addictions – ED visits most prevalent among males 20-39 and females 40-64. Only 10% of ED visits were CTAS 4 and 5. Relatively high rate of repeat ED visits (17%).
Cancer – higher number of ED visits in 40-64 and 75+ age group, mainly males. Nearly Two-thirds of visits were CTAS 3. Cancer had the highest number of admissions among the selected conditions, with the same age groups having the highest numbers of discharges.14% of patients with repeat ED had repeat visits and 19% of those admitted having repeat admissions.
Heart Disease- ED visits more prevalent in older females 75+. Majority of ED visits for CHF are for CTAS 2 and 17% of patients had 2 or more visits due to CHF.
Diabetes- Adults 20-64, mainly males , had the highest proportion of ED visits and acute admissions. .Majority of ED visits are CTAS 3. Lower proportion have repeat ED visits (7%).
COPD – Mainly in males 75+. 16% of patients had 2 or more ED visits due to COPD
Patient Journey for those with Chronic Conditions, FY2015-16 • Of the total 6,582 ED visits for Rockcliffe-Smythe residents captured in IDS, 7% (488) were for identified Health Links clients. • As expected there was a higher proportion of Health Links clients among the group with chronic conditions (251 or 23%) compared to the 4% in the group without chronic conditions
7 Key Highlights and Summary of all Findings continued
Access to Primary Care and Continuity for Rockcliffe-Smyth Residents • West Toronto has the lowest number and per capita rate of primary care providers among the 5 sub-regions • Rockcliffe-Smythe has 10 primary care physicians located in the neighborhood, the majority of whom are in fee-for- service practices • The physicians are organized in 6 practices with one being a CHC • Rockcliffe-Smythe was among the top 3 neighborhoods with the lowest levels of primary care continuity (i.e. highest proportion of low continuity) in West Toronto sub-region (together with Mount Dennis and New Toronto) in 2013/14- 14/15.
Distribution of High needs population in Rockcliffe-Smythe • The western part of Rockcliffe-Smythe neighborhood has among the highest concentration of high heathcare cost users in FY2013/14 – FY2014-15. • Nearly all of Rockcliffe-Smythe neighborhood has among the highest concentration of SAMI scores indicating an expected number of primary care visits that is higher than normal .
8 Overall Emergency Department and Acute Inpatient Utilization for Selected Chronic Conditions for Rockcliffe-Smythe residents
National Ambulatory Care Reporting System (NACRS), FY2015-16 Discharge Abstract Database (DAD) –FY2015-16
9 Emergency Department Visits for Rockcliffe-Smythe Residents, 2015/16
• During 2015/16, there were 9,886 visits to the Emergency Department (ED) by residents of Rockliffe-Smythe • 145 visits did not have a valid health card number • 7,772 were for individuals 20 years and over
• For the target population for chronic conditions of 20 years and over (except COPD (35+)): • There were a total of 1,489 visits to the ED with the selected chronic conditions as most responsible diagnosis • This represented a total of 1,066 unique visitors to the ED • 51 (5%) individuals had more than one chronic condition • 460 (43%) individuals who had a visit for a chronic condition also had a visit for a non-chronic condition
10 Source: National Ambulatory Care Reporting System (NACRS), FY2015-16, MOHLTC, IntelliHealth (Extracted: 2017) ED Visits Due to Selected Chronic Conditions in Rockcliffe- Smythe, Ages 20+*, FY2015-16
Arthritis was the Unique 2011 Rate per 1,000 pop most common Chronic Condition ED visits patients Population 20+* 20+ for ED Visits condition Arthritis 671 565 16,985 39.5 followed by MH Mental Health 261 167 16,985 15.4 and addictions. Addictions 140 70 16,985 8.2 COPD 70 54 13,417 5.2 Diabetes 64 55 16,985 3.8 Rates of ED visits for the Stroke 60 55 16,985 3.5 chronic CHF 58 43 16,985 3.4 conditions in Asthma 55 43 16,985 3.2 Rockcliffe- Hypertension 42 36 16,985 2.5 Smythe ranged Cancer 34 30 16,985 2.0 from 39.5 for IHD 34 33 16,985 2.0 Arthritis to 2.0 per 1,000 Total Chronic population 20+ Conditions 1,489 1,066* 16,985 87.7 for Ischemic Note*: Some unique individuals presented to the ED for multiple chronic conditions. Heart
11 Source: National Ambulatory Care Reporting System (NACRS), FY2015-16, MOHLTC, IntelliHealth (Extracted: 2017) ED Visits for Adults 20+* due to Chronic Conditions for Rockcliffe-Smythe Residents, FY2015/16
Note:*COPD was reported for Ages 35+
Of the chronic conditions that were focused on, most individuals presented at the ED with Arthritis (565), followed by Mental Health conditions (167) as most responsible diagnosis Addictions (70) and Diabetes (55), Stroke (55) and COPD (54) were other diagnoses for visits by unique individuals to the ED. 12 Source: National Ambulatory Care Reporting System (NACRS), FY2015-16, MOHLTC, IntelliHealth (Extracted: 2017) Acuity and Discharge Disposition of ED Visits Due To Selected Chronic Conditions, Adults 20+*, FY2015/16
• The majority of ED visits for the select chronic diseases were severe (CTAS 2 &3) with Ischemic Heart Disease and Congestive Heart failure having the highest proportion of CTAS 2 • Arthritis which had the highest number of ED visits had the least proportion of CTAS 2.
• CHF, cancer and Stroke had the highest proportion of admitted visits. • Arthritis, addictions, asthma and hypertension had the highest proportion of visits discharged home without supports.
Note:*COPD was reported for Ages 35+ CTAS 2 – Emergent/Potentially Life-threatening; CTAS 3 - Urgent /Potentially Serious 13 Source: National Ambulatory Care Reporting System (NACRS), FY2015-16, MOHLTC, IntelliHealth (Extracted: 2017) Primary Care Provider and Time/Day of Week for ED Visits, FY2015/16
• Proportion of those reporting having a primary care provider varied from 65% for Addictions related ED visits to 92% for Diabetes related ED visits
Day of Total Day of Week Total Day of Week Total Time of Day Total Time of Day • For all conditions, most Week (All Conditions) (Mental Health) Time of Day (All Conditions) (Mental Health) ED visits occurred between the morning and Sunday 204 (14%) 28 (11%) Morning (6:00am - afternoon (6 am and 11:59am) 450 (30%) 46 (18%) Monday 235 (16%) 40 (15%) 6pm), with lower ED visits on Saturdays and Afternoon (12:00pm Tuesday 239 (16%) 48 (18%) Sundays - 5:59pm) 499 (33%) 88 (34%) • For mental health ED Wednesday 211 (14%) 34 (13%) Evening (6pm - visits, most ED visits Thursday 217 (15%) 42 (16%) 11:59pm) 366 (25%) 76 (29%) occurred in the afternoon and evening, with higher Friday 214 (14%) 37 (14%) Late night (12:00am - number of visits on 5:59am) 177 (12%) 51 (20%) Tuesdays Saturday 172 (12%) 32 (12%) Grand Total 1,492 (100%) 261 (100%) Grand Total 1,492 (100%) 261 (100%)
Note:*COPD was reported for Ages 35+ 14 Source: National Ambulatory Care Reporting System (NACRS), FY2015-16, MOHLTC, IntelliHealth (Extracted: 2017) Hospital EDs Used by Rockcliffe-Smythe Residents with Chronic Conditions, Ages 20*
• Majority of patients visited St. Joseph’s Health Centre (35%) , followed by Humber River Regional Hospital – Church Street Site (18%) and Humber River Hospital – Wilson Site (14%)
Note:*COPD was reported for Ages 35+ 15 Source: National Ambulatory Care Reporting System (NACRS), FY2015-16, MOHLTC, IntelliHealth (Extracted: 2017) Acute Inpatient Discharges for Chronic Conditions for Rockcliffe-Smythe Residents, 2015/16
• During 2015/16, there were 2,049 acute inpatient discharges for residents of Rockliffe-Smythe • 42 discharges did not have a valid health card number • 1,645 were for individuals 20 years and over
• For the target population for chronic diseases of 20 years and over (except COPD (35+): • There were a total of 433 discharges with the selected chronic conditions as the most responsible diagnosis • This represented a total of 336 unique individuals • 17 (5%) individuals had more than one chronic condition • 79 (24%) individuals who had a discharge for a chronic condition also had one or more non-chronic condition
16 Acute Inpatient Discharges due to Selected Chronic Conditions for Rockcliffe-Smythe Residents, Ages 20+*, FY2015-16
There were a total of 433 acute inpatient No of No of Rate of discharges for the Chronic Discharges Discharges Total Unique 2011 Population discharges per selected Condition (Males) (Females) Discharges Individuals 20+* 1,000 pop 20+ conditions. Cancer 61 63 124 101 16,985 7.3 Rates of discharges for the Arthritis 37 53 90 87 16,985 5.3 chronic ranged from 7.3 for IHD 45 15 60 48 16,985 3.5 cancer to 0.3 per 1,000 population CHF 25 21 46 33 16,985 2.7 20+ for Hypertension Stroke 17 19 36 34 16,985 2.1
COPD* 24 10 34 23 13,417 2.5 **Of the 336 unique individuals, Diabetes 12 13 25 23 16,985 1.5 5% had an admission for Asthma <5 10 13 12 16,985 0.8 more than one chronic condition Hypertension <5 <5 5 <5 16,985 0.3 Total Discharges 226 207 433 336** 16,985 25.5
Note:*COPD was reported for Ages 35+ 17 Source: Discharge Abstract Database (DAD), FY2015-16, MOHLTC, IntelliHealth (Extracted: 2017) Length of Stay (LOS) for the Selected Chronic Conditions (Acute and ALC) for Rockcliffe Smythe Residents, FY 2015/16
Discharges due to Total Total Acute Avg Acute ALC Avg ALC Cancer had the Total No of LOS LOS # of ALC LOS LOS longest length of Row Labels Discharges (days) (days) discharges (days) (days) stay (9.3 days) Cancer 124 1150 9.3 9 72 8 while Asthma had Arthritis 86 383 4.5 <5 27 6.8 the shortest (2.8 IHD 60 231 3.9 days) CHF 46 390 8.5 <5 <5 <5 Stroke 36 316 8.8 8 62 7.8 Cancer had the COPD 34 209 6.1 <5 8 8 longest ALC LOS Diabetes 24 187 7.8 with an average stay of 8 days Asthma 8 22 2.8 Hypertension 5 22 4.4 Asthma, diabetes, hypertension and IHD did not ALC days.
Note:*COPD was reported for Ages 35+ 18 Source: Discharge Abstract Database (DAD), FY2015-16, MOHLTC, IntelliHealth (Extracted: 2017) ED and Acute Inpatient Utilization for Individual Selected Chronic Conditions for Rockcliffe-Smythe residents
National Ambulatory Care Reporting System (NACRS), FY2015-16 Discharge Abstract Database (DAD) –FY2015-16
19 Arthritis – ED Visits and Acute Inpatient Discharges for Rockcliffe-Smythe Residents, Age 20+, FY 2015-16
• Females in the 40-64 age group had the highest number of ED visits due to Arthritis, followed by the 20-39 group (mainly males) • ED visits for arthritis were of relatively lower acuity compared to those of other conditions; with 64% for CTAS 3 and 27% for CTAS 4 • Rate of ED visits with Arthritis as the most responsible diagnosis were at 39.5/1,000 population 20+ • 13% of patients had two or more repeat ED visits for Arthritis. • Only 1% of individuals with arthritis had 2 or more discharges.
Sources: National Ambulatory Care Reporting System (NACRS), FY2015-16, MOHLTC, IntelliHealth (Extracted: 2017) 20 Discharge Abstract Database (DAD), FY2015-16, MOHLTC, IntelliHealth (Extracted: 2017) Mental Health – ED Visits for Rockcliffe-Smythe Residents, Age 20+, FY 2015-16
• The age group with the highest number of ED visits due to Mental Health was the 20-39 (mostly males) followed by the 40-64 (mostly females) age group. • Most ED visits due to Mental Health were CTAS 3 (55%), followed by CTAS 2 (26%). A considerable proportion were CTAS 4 (15%) • Rate of ED visits due to Mental Health per 1,000 population 20+ was 1.5 • Mental health had a relatively high repeat ED visit rate with 18% of patients having two or more ED visits.
Please note: Admissions for Mental Health were not included in this analysis
21 Sources: National Ambulatory Care Reporting System (NACRS), FY2015-16, MOHLTC, IntelliHealth (Extracted: 2017) Discharge Abstract Database (DAD), FY2015-16, MOHLTC, IntelliHealth (Extracted: 2017) Addictions – ED Visits for Rockcliffe-Smythe Residents, Age 20+, FY 2015-16
• The age group with the highest number of ED visits due to addictions 20-39 group (mainly females) followed by the 40-64 age group (mostly females) • Most ED visits due to addictions were CTAS 3 (51%) and CTAS 2 (39%). • The rate of ED visits due to addictions was 8.2/1,000 population 20+ • 17% of patients had two or more repeat ED visits for addictions.
Please note: Admissions for Addictions were not included in this analysis
Sources: National Ambulatory Care Reporting System (NACRS), FY2015-16, MOHLTC, IntelliHealth (Extracted: 2017) 22 Discharge Abstract Database (DAD), FY2015-16, MOHLTC, IntelliHealth (Extracted: 2017) Chronic Obstructive Pulmonary Disease (COPD) – ED Visits and Acute Inpatient Discharges for Rockcliffe-Smythe Residents, Age 35+, FY 2015-16
COPD Acute Inpatient Discharges (n=34) The highest proportion of ED visits and acute 25 inpatient discharges due to COPD were among 20 20 seniors 75 years and over (mainly males).
15 Males accounted for 57% of ED visits and over 10 70% of the inpatient discharges 10 Most ED visits for COPD were CTAS 2 and 3 5 <5 16% of patients had 2 or more ED visits due to 0 COPD Noof Acute Inpatient Discharges 40-64 65-74 75+ 4% of patients had 2 or more acute discharges Sources: National Ambulatory Care Reporting System (NACRS), FY2015-16, MOHLTC, IntelliHealth (Extracted: 2017) 23 Discharge Abstract Database (DAD), FY2015-16, MOHLTC, IntelliHealth (Extracted: 2017) Diabetes – ED Visits and Acute Inpatient Discharges for Rockcliffe Smythe-Residents, Age 20+, FY 2015/16
ED visits and acute inpatient discharges due to Diabetes were mostly among adults 40-64 years. For ED visits, males had a higher proportion (59%) while for acute discharges, the proportions were nearly the same. The majority of ED visits for CHF were for CTAS 3 (56%) and 2 (34%). 7% of patients had more than 2 ED visits due to Diabetes 9% patients had 2 or more acute discharges.
Sources: National Ambulatory Care Reporting System (NACRS), FY2015-16, MOHLTC, IntelliHealth (Extracted: 2017) 24 Discharge Abstract Database (DAD), FY2015-16, MOHLTC, IntelliHealth (Extracted: 2017) Stroke – ED Visits and Acute Inpatient Discharges for Rockcliffe-Smythe Residents, Age 20+, FY 2015-16
• ED visits due to Stroke were highest in the 40+ and mostly females 65+ age groups. Among the seniors, there was a higher proportion of females than males. • Most ED visits due to Stroke were CTAS 3 (48%) and CTAS 2 (38%) • Rate of ED visits due to Stroke was at 3.5/1,000 population 20+. • 9% of patients had two or more repeat ED visits due to Stroke. • Among those admitted, 6% of individuals had 2 or more acute discharges 25 Congestive Heart Failure (CHF) – ED Visits and Acute Inpatient Discharges for Rockcliffe-Smythe Residents, Age 20+, FY 2015-16
CHF Acute Inpatient Discharges (n=46) ED visits and acute inpatient discharges due to CHF 35 were mostly among seniors 75 years and over. 30 For ED visits, females had a higher proportion (57%) 25 while for acute discharges, males had the higher 20 proportion (54%) 15 The majority of ED visits for CHF were for CTAS 2 10 (59%) and 3 (34%) 5 17% of patients had 2 or more ED visits due to CHF. No of Acute Inpatient No Acute of Discharges 0 40-64 65-74 75+ 18% patients had 2 or more acute discharges Age Group
Sources: National Ambulatory Care Reporting System (NACRS), FY2015-16, MOHLTC, IntelliHealth (Extracted: 2017) 26 Discharge Abstract Database (DAD), FY2015-16, MOHLTC, IntelliHealth (Extracted: 2017) Hypertension – ED Visits and Acute Inpatient Discharges for Rockcliffe-Smythe Residents, Age 20+, FY 2015-16
• ED visits due to Hypertension were mostly prevalent among adults 65-74 years with the majority being among females. • Most ED visits due to Hypertension were CTAS 3 (57%) followed by CTAS 2 (36%) • 14% of patients had two or more ED visits due to diabetes • There were only 5 discharges due to hypertension in 2015/16 for Rockcliffe-Smythe residents.
Sources: National Ambulatory Care Reporting System (NACRS), FY2015-16, MOHLTC, IntelliHealth (Extracted: 2017) 27 Discharge Abstract Database (DAD), FY2015-16, MOHLTC, IntelliHealth (Extracted: 2017) Ischemic Heart Disease (IHD) – ED Visits and Acute Inpatient Discharges for Rockcliffe-Smythe Residents, FY 2015-16 Age 20+
• ED visits due to IHD were mostly among males 40-64. The proportion of males decreased with increasing age. In the 75+ group, the majority of visits were for females. • Highest acuity among the selected conditions; most ED visits due to IHD were CTAS 2 (71%) and CTAS 3 (21%). • Rate of ED visits due to IHD were at 2.0/1,000 population 20 and overy. • Rate of repeat ED visits was low among IHD patients with only 3% of patients having two or more repeat ED visits for IHD. • Among those admitted, 17% of individuals had 2 or more acute discharges Still investigating why there were higher inpatient admissions than ED visits. 28 Asthma – ED Visits and Acute Inpatient Discharges for Rockcliffe- Smythe Residents, Age 20+, FY 2015-16
• ED visits due to Asthma were mostly among the 40-64 and 20-39 groups. The majority of ED visits were for females • Nearly half of the visits were for CTAS 3 (49%) and 40% were for CTAS 2 • Asthma had the highest rate of repeat ED visits, with 23% of patients having two or more ED visits due to Asthma. • There were only 13 discharges for asthma with the majority being for females. 8% of individuals had 2 or more acute discharges
Sources: National Ambulatory Care Reporting System (NACRS), FY2015-16, MOHLTC, IntelliHealth (Extracted: 2017) 29 Discharge Abstract Database (DAD), FY2015-16, MOHLTC, IntelliHealth (Extracted: 2017) Cancer – ED Visits and Acute Inpatient Discharges for Rockcliffe-Smythe Residents, Age 20+, FY 2015-16
• ED visits due to cancer as the were among males 75 and older. • Relatively higher acuity compared to other conditions with 65% being CTAS 3 and 24% CTAS 2. • Rate of ED visits due to cancer were at 2.0/1,000 population 20 and over. • 14% of patients had two or more repeat ED visits for cancer. • Cancer led to the highest number of admissions among the selected chronic conditions. Readmission was relatively high among those with cancer; 19% of individuals had 2 or more acute discharges Still investigating why there were higher inpatient admissions than ED visits. 30 Sources: National Ambulatory Care Reporting System (NACRS), FY2015-16, MOHLTC, IntelliHealth (Extracted: 2017) Discharge Abstract Database (DAD), FY2015-16, MOHLTC, IntelliHealth (Extracted: 2017) Patient Journey for Rockcliffe Smythe Residents with ED Visits
Integrated Decision Support (IDS) Database, FY2015-16 • ED Visits by Complexity, Chronic conditions and Health Link status • ED visits by Chronic Conditions, Frequency of ED Use and Use of CCAC (Home Care) Services.
31 Definitions of Measures Used in IDS Chronic Conditions IDS includes a flag for a set of 6 selected chronic conditions based on whether the primary ICD10 Diagnosis Category Code for either DAD (Inpatient) or NACRS (ED visits) falls within the following criteria: • Diabetes (E10 - E14), Stroke (I60 - I69), COPD ('J40' - 'J44‘), Asthma (J45), Congestive heart failure (150), and Ischemic Heart Disease (I20 - I25) • Please note: this list of conditions excludes several conditions that were included in the earlier analyses
Health Links Status • Status is set to 'Identified‘ at the patient level for those LHIN identifiers included in the 4+ cohort circulated to the LHIN offices in December 2015. This replaces any previous cohort flagged in the field. The 4+ analysis reviewed all conditions and high cost interventions in all DAD and NACRS intervention and diagnosis fields for the 24 month time frame FY 13/14 Q2 –FY 15/16 (inclusively) as included in the MoHLTC definitions. See methodology documented in the knowledge base, Health Links folder
Is ED Frequent Visitor – Patient • Is Yes when the patient has visited the ED four or more times in the past 12 months
CCAC Home Care Status – NACRS • Admitted to CCAC (A): means this patient is admitted to CCAC from a Home Care Referral at the time of the NACRS registration (ED visit) • Known to CCAC (K): not CURRENTLY admitted, but this patient has had a CCAC Home Care Referral Start, Referral End or Admission within one year prior to the current NACRS (ED) registration • Unknown to CCAC (U): means the patient has not been admitted or referred for Home Care to the CCAC as defined by the two above criteria. A patient would be "Unknown to CCAC" if they had had a Referral more than one year prior to the NACRS (ED) registration Is CCAC Home Care Referral From NACRS (ED) Visit – NACRS • A CCAC Home Care Referral was generated during the NACRS visit, or the day pre or two days post. Linked data is available regarding the CCAC referral. A Reliability Score is a assigned to the link based on number of points of matching da32ta between the NACRS visit and the CCAC Referral information. Limitations of IDS Data
IDS Database has only 6 LHINs currently submitting data: • Erie St Clair LHIN • South West LHIN • Waterloo Wellington LHIN • Hamilton Niagara Haldimand Brant LHIN • Mississauga Halton LHIN • Toronto Central LHIN
• Toronto Central LHIN patients who go to hospitals outside of Toronto Central LHIN that belong to a LHIN that does not submit to IDS will not be included in this data. This leads to an underestimate of the volumes for Toronto Central LHIN residents especially for neighborhoods near the LHIN border.
• In FY 2015/16, there were a total of 9,886 ED visits for Rockcliffe-Smythe residents based on IntelliHealth data. In IDS, the total visits for Rockcliffe-Smythe is 6,582, which is 67% of total visits. The balance of visits would likely be due to patients who went to hospitals in other LHINs particularly Central LHIN (Humber River Regional hospital) and Central West (William Osler).
33 Rockcliffe-Smythe Residents Using ED, by Chronic Conditions and Health Links Status, FY 2015/16
Total Unscheduled ED Visits by Chronic Conditions Status and Acuity (CTAS), FY 2015/16 Chronic Non Chronic Total # % # % # % CTAS 1 17 1.6% 33 0.6% 50 0.8% CTAS 2 356 32.6% 905 16.5% 1,261 19.2% CTAS 3 547 50.0% 2989 54.5% 3,536 53.7% CTAS 4 152 13.9% 1355 24.7% 1,507 22.9% CTAS 5 21 1.9% 199 3.6% 220 3.3% Unknown and blank 0.0% 8 0.1% 8 0.1% Total ED Visits 1,093 100.0% 5,489 100.0% 6,582 100%
Unscheduled ED Visits by Chronic Condition Status and Health Link Status, FY 2015/16 Chronic Non Chronic Total # % # % # % Total identified HL Clients 251 23% 237 4% 488 7%
Total N/A HL Clients 842 77% 5,252 96% 6,094 93% Total Unscheduled ED Visits 1,093 100% 5,489 100% 6,582 100%
• Of the total 6,582 ED visits for Rockcliffe-Smythe residents in IDS, 17% (1,093) were due to the selected chronic conditions. • ED Visits due to the selected chronic conditions had higher acuity compared to those for non-chronic conditions (84.2% vs 71.6% being for CTAS 1-3 respectively). • Of the total ED visits, 7% (488) were for identified Health Links clients. As expected there was a higher proportion of health links clients among the group with chronic conditions (251 or 23%) compared to the 4% in the group without chronic conditions. 34 Source: Integrated Decision Support (IDS), FY2015-16, MOHLTC, IntelliHealth (Extracted: 2017) Rockcliffe-Smythe Residents Using ED, by Frequency of ED Visits, Chronic Conditions and Health Link Status, FY 2015/16 Not Frequent ED Not Frequent ED Frequent ED Visitor Frequent ED Visitor Total Visitor Visitor Total # % # % # % # % # % # % Admitted to Chronic CCAC 339 6% 77 13% 416 6% 920 15% 173 29% 1,093 17% Known to CCAC 222 4% 37 6% 259 4% Non-Chronic Unknown to 5,064 85% 425 71% 5,489 83% CCAC 5,423 91% 484 81% 5,907 90% Grand Total 5,984 100% 598 100% 6,582 100% Subtotal 5,984 100% 598 100% 6,582 100% Chronic Non-Chronic Total # % # % # % Admitted to CCAC 178 16% 238 4% 416 6% Known to CCAC 107 10% 152 3% 259 4% Unknown to CCAC 808 74% 5,099 93% 5,907 90% Total 1,093 100% 5,489 100% 6,582 100%
• Of the total 6,582 ED visits in FY 15/16, 9% (598) were for patients who frequently used the ED (i.e. had between 4 or more ED visits in the last year): • Among the 5,984 visits for non frequent users • The majority 91% (5,423) were unknown to CCAC • 339 (6%) were admitted to CCAC from a Home Care Referral at the time of the ED registration • 222 were known to CCAC (i.e. not CURRENTLY admitted, but this patient has had a CCAC Home Care Referral Start, Referral End or Admission within one year) prior to the current ED registration), and of those only 3 got a referral to home care at the time of the visit • Majority of the non-frequent ED visitors were non-chronic patients(85%) while 15% were chronic condition patients • Among the 598 visits for Frequent users: • A higher proportion 77 (13%) were admitted to CCAC from a Home Care Referral at the time of the ED registration • 37 were known to CCAC (i.e. not CURRENTLY admitted, but this patient has had a CCAC Home Care Referral Start, Referral End or Admission within one year) • 81% were unknown to CCAC. • Majority of the frequent ED visitors 83% were non-chronic condition patients while 17% were chronic condition patients • Of the total chronic patients, majority 74% were unknown to CCAC, 16% were admitted to CCAC and 10% were known to CCAC. As expected, a lower proportion were admitted to CCAC (6%) and 4% were known to CCAC among the non-chronic patients when compared to the chronic patients group. 35 Source: Integrated Decision Support (IDS), FY2015-16, MOHLTC, IntelliHealth (Extracted: 2017) Access to and Continuity of Primary Care for Rockcliffe-Smythe Residents
36 Access to Primary Care for Rockcliffe-Smythe Residents, 2017
Physician to Rockcliffe-Smythe Clinics and Physicians Number of Population Ratio % of Total # of Physicians PEM type Clinics Physicians (per 100,000 pop.) EDENBRIDGE'S FAMILY DOCTORS 1 FHG West Toronto 199 12% 81 DOCTOR BUTT-YAU CHIU'S OFFICE 1 ACCESS ALLIANCE MULTICULTURAL Mid-West Toronto 521 37% 151 CHC HEALTH AND COMMUNITY SERVICES - North Toronto 231 17% 106 ACCESS POINT ON JANE 1 FFS or DOCTOR PAUL MATTHEW'S OFFICE 1 Mid-East Toronto 221 16% 135 NON-PEM WHITE'S MEDICAL CLINIC 3 East Toronto 251 18% 89 Group JANE PARK DOCTOR'S OFFICE 3 TOTAL 1,359 100% 108 Total 10 Physicians in Rockcliffe Smythe and West Toronto Sub-Region, by PEM Type, March 2017 West West Toronto - Toronto- West Toronto Sub- • Overall among the 5 Sub-regions, West PEM type Rockcliffe-Smythe secondar primary Region Total y Toronto has the lowest number and per practice practice capita rate of Primary Care Providers # % # # # % FHG 2 20.0% 38 0 38 19.1% • Rockcliffe-Smythe has 10 primary care CHC 1 10.0% 25 2 27 13.6% physicians, the majority of whom are in FFS or NON- fee for service practices PEM Group 7 70.0% 43 0 43 21.6% CCM 0 0.0% 10 0 10 5.0% • The physicians are organized in 6 FHO 0 0.0% 43 1 44 22.1% practices with one being a CHC STJ 0 0.0% 16 3 19 9.5% Blank 0 0.0% 12 6 18 9.0% Total 10 100.0% 187 12 199 100.0%
PEM = Physician Enrolment Model 37 Source: Toronto Central LHIN Physician Census Database, March 2017; 2015 Population Estimates , MOHLTC Health Analytics Branch, 2017 Continuity of Primary Care for West Toronto Neighbourhoods, FY 2013/14 - FY 2014/15
% Low Continuity Amongst Enrolled & Non-Enrolled, Both sexes, Ages 19+ 30.0 24.3 24.6 24.8 25.0 22.1 22.9 20.7 21.0 19.6 19.9 19.9 20.3 20.5 20.5 20.0 17.6
15.0
10.0
% % Low with Continuity 5.0
0.0
Rockcliffe-Smythe was among the top 3 neighborhoods with the lowest levels of primary care continuity (i.e. highest proportion of low continuity) in West Toronto sub-region (together with Mount Dennis and New Toronto).
One quarter of adults 19 years and older have low continuity of care in Rockcliffe-Smythe.
38 Data source: Ontario Community Health Profile Partnership Website Concentration of Residents with the Highest Expected Health Care Utilization* (high health care users) by Census Tract, Toronto Central LHIN, FY2013/14 – FY2014-15
The western part of Rockcliffe- Smythe (#111) has among the highest concentration of high health care users.
See list of neighborhoods on slide 41
Source: ICES Project No. 2017 0900 810 001, Note*: Expected health care utilization was calculated using the Johns Hopkins Adjusted Diagnosis Groups (ADG) Resource Utilization Bands (RUBs), which uses patient diagnosis in administrative data to assign patients to quintiles of expected health care utilization. The higher the proportion of RUBs 4 and 5, the higher the concentration of high health care users who are located in a given geographic area. Data is based on patient data from April 1, 2013 to March 31, 2015. 39 Expected Primary Care Visits Demand Using the Standardized ACG Morbidity Index (SAMI)* by Census Tract, Toronto Central LHIN, FY 2013-2014
Nearly all of Rockcliffe-Smythe (#111) has among the highest concentration of SAMI scores indicating an expected number of primary care visits that is higher than normal.
See list of neighborhoods on slide 41
Source: ICES Project No. 2017 0900 810 001, Note*: The SAMI represents the mean ACG (using Johns Hopkins’ Adjusted Diagnosis Groups (ADGs)) weight standardized to the number of primary care visits. For example, a SAMI of 1.85 can be interpreted as an expected number of primary care visits that is 85% higher than in the general Ontario population and a SAMI of 0.88 can be interpreted as a 12% lower expected number of primary care visits than in the general Ontario population. 40 List of Neighbourhoods in Toronto Central LHIN Neighb ID Neighbourhood Name Neighb ID Neighbourhood Name 9Edenbridge-Humber Valley 80Palmerston-Little Italy 15Kingsway South 81Trinity-Bellwoods 16Stonegate-Queensway 82Niagara 17Mimico 83Dufferin Grove 18New Toronto 84Little Portugal 32Englemount-Lawrence 85South Parkdale 39Bedford Park-Nortown 86Roncesvalles 41Bridle Path-Sunnybrook-York Mills 87High Park-Swansea 43Victoria Village 88High Park North 44Flemingdon Park 89Runnymede-Bloor West Village 54O'Connor-Parkview 90Junction Area 55Thorncliffe Park 91Weston-Pellam Park 56Leaside-Bennington 92Corso Italia-Davenport 57Broadview North 93Dovercourt-Wallace Emerson-Junction 58Old East York 94Wychwood 59Danforth-East York 95Annex 60Woodbine-Lumsden 96Casa Loma 61Taylor-Massey 97Yonge-St.Clair 62East End-Danforth 98Rosedale-Moore Park 63The Beaches 99Mount Pleasant East 64Woodbine Corridor 100Yonge-Eglinton 65Greenwood-Coxwell 101Forest Hill South 66Danforth 102Forest Hill North 67Playter Estates-Danforth 103Lawrence Park South 68North Riverdale 104Mount Pleasant West 69Blake-Jones 105Lawrence Park North 70South Riverdale 106Humewood-Cedarvale 71Cabbagetown-South St. James Town 107Oakwood Village 72Regent Park 109Caledonia-Fairbank 73Moss Park 110Keelesdale-Eglinton West 74North St. James Town 111Rockcliffe-Smythe 75Church-Yonge Corridor 114Lambton Baby Point 76Bay Street Corridor 115Mount Dennis 77Waterfront Communities-The Island 120Clairlea-Birchmount 78Kensington-Chinatown 121Oakridge 41 79University 122Birchcliffe-Cliffside CMHA and CSS Providers Providing Services in Rockcliff Smythe
Community Business Intelligence ( CBI) database – 2016/17
42 Top CMHA and CSS Providers that Serve at least 50% of Clients in Rockcliffe Smythe, 2016/17
CMHA Providers St. Joseph's Health Centre 22% LOFT Community Services 15%
University Health Network 10%
Reconnect Mental Health Services 8% + 31 other HSPs
CSS Providers
Humber Community Seniors' Services Inc. 44%
St. Clair West Services for Seniors 34% + 16 other HSPs
Rockcliffe Smythe is served by at least 35 CMHA and 18 CSS HSPs. 43 Source: Community Business Intelligence (CBI) database 2016/17 Toronto Central LHIN West Sub Region – Health Service Providers by Neighborhood
Neighborhood Community Health Hospitals Long Term Care Community Support Service Community Mental Health and Shelter Family Health Team Centre Addiction Rockcliffe-Symthe Four Villages Community Health Centre- Dundas Site -Access Alliance Multicultural Health and Community Services-Jane site Edenbridge- Humber Valley High Park North -Four Villages Community Health Centre-Bloor site
High Park- Swansea -St. Joseph’s Urban Family -St. Joseph Health Centre -Copernicus Lodge -West Toronto Support Services Health Team for Senior Citizens and the Disabled Inc. Junction Area -Runnymede Healthcare -Cross Toronto Community Centre Development Corporation, Fresh Start
Kingsway South Lambton- Baby Point Mimico -Garden Court, -Storefront Humber -Family Association for Mental Health -SVDP- Elisa Sharparral Limited Everywhere House -Jean Tweed Treatment Centre Mount Dennis -West Park Family Health -West Park Healthcare -West Park Long Term -Humber Community Seniors’ Team Care Centre Service Centre New Toronto -Lakeshore Area Multi- -Lakeshore Lodge Services Project Roncesvalles Parkdale Community -Parkdale Golden Age -Breakaway Addictions Services Health Centre- Satellite Foundation -Habitat Services, Mental Health Program for Services of Metropolitan Toronto Inc. -Regeneration House Inc. Runnymede- Bloor West South Parkdale -Parkdale Community -White Eagle Residence -Working for Change -COTA Health- Health Centre -Norwood Nursing Home Bailey House limited - -Parkdale Activity- Recreation Centre Lakeside Long Term Care Centre -Elm Grove Living Centre Inc.
Stonegate-Queensway -Stonegate Community -Ivan Franko Home Association No Assigned Neighborhood ** -Etobicoke Services for Seniors
Note** Some HSP have main offices in another LHIN, these HSPs are placed into the closest sub region but are not assigned to a neighborhood Please note that some HSPs provide services to other neighborhoods as well as provide different services in different neighborhood Please note: Islington City Centre West has not been included in this profile as the majority is located in Mississauga Halton LHIN. Also, Edenbridge-Humber Valley has a small portion that lies44 in Central LHIN. Source: Toronto Central LHIN Health Service Provider List, March 2017 Appendix
45 Day of Week/Time of Day for ED Visits for Rockcliffe-Smythe residents with Chronic Conditions, Overall and Mental Health, FY 2015-16
Time/Day of Week for All Chronic Wednesda Total Time Percent Sunday Monday Tuesday Thursday Friday Saturday Conditions y of Day (%)
Morning (6:00 - 11:59) 4% 5% 5% 4% 4% 5% 4% 450 30% Afternoon (12:00 - 17:59) 5% 6% 6% 5% 5% 4% 4% 499 33%
Evening/Earky Night (18:00 - 23:59) 3% 3% 3% 4% 4% 4% 3% 366 25% Late Night (0:00 - 5:59) 2% 2% 3% 1% 1% 1% 1% 177 12% Total Day of Week 204 235 239 211 217 214 172 1492
14% 16% 16% 14% 15% 14% 12% 100%
Time/Day of Week for Mental Wednesda Total Time Percent Sunday Monday Tuesday Thursday Friday Saturday Health ED visits y of Day (%)
Morning (6:00 - 11:59) 2% 2% 5% 3% 3% 2% 2% 51 20% Afternoon (12:00 - 17:59) 2% 3% 3% 2% 3% 3% 3% 46 18%
Evening/Earky Night (18:00 - 23:59) 3% 6% 7% 3% 6% 3% 5% 88 34% Late Night (0:00 - 5:59) 4% 5% 3% 5% 4% 5% 3% 76 29% Total Day of Week 28 40 48 34 42 37 32 261 100%
11% 15% 18% 13% 16% 14% 12% 100% • Overall for all chronic conditions, most ED visits occured between 6AM and 6PM and there were considerately lower ED visits on Saturdays • For Mental health, most ED visits occur in the afternoon and overnight; there are considerably higher number of visits on Tuesdays
Source: National Ambulatory Care Reporting System (NACRS), FY2015-16, MOHLTC, IntelliHealth (Extracted: 2017) 46 ICD Diagnostic Codes and Methodology for ED Visits for 10 Selected Chronic Conditions
• The list of chronic conditions was adopted from that included in IntelliHealth based on a 'chronic condition' grouper data item. This was developed for the Report: Chronic Conditions − Emergency Visits by LHIN v3, last updated Wednesday, March 22, 2017 2:13:11 PM EDT (JoAnn Heale)
• Data Inclusions: • − Ontario residents • − ED visits − unscheduled visits to hospital emergency departments or urgent care centres (AM case type = EMG) • − ICD10 codes: the following ICD−10 codes reported for the main problem diagnosis (MPDx) for the hospitalization: • 1. Arthritis − ICD−10 codes beginning with: M00−M03, M05−M19, M22−M25, M32−M36, M45−M47, M48−M482, M488−M489, M65−M68, M70−M71, M75−M77, M79, M99. These codes are consistent with those previously defined by the Arthritis Community Research & Evaluation Unit (1). The range of codes capture soft tissue derangements, joint disorders etc. as well as arthropathies (osteoarthritis, rheumatoid arthritis). [(1). University Health Network, March 2006. Arthritis and related conditions within Ontario Emergency Departments]. • 2. Asthma − ICD−10 codes beginning with J45 • 3. Cancer (Malignant neoplasms) − ICD−10 codes beginning with C00−C97 • 4. CHF − ICD−10 codes beginning with I50 • 5. COPD − ICD−10 codes beginning with J40−J44 • 6. Diabetes − ICD−10 codes beginning with E10−E14 • 7. Hypertension − ICD−10 codes beginning with I10−I15 (Lead cause group 038) • 8. IHD − ICD−10 codes beginning with I20−I25 • 9. Stroke − ICD−10 codes beginning with: I60−I61, I63−I64, H34.1, G46.4−G46.7, G45 • 10. Mental Health and Addictions – ICD -10 codes beginning with F00-F99 • Mental Health F20 –F48, F00-F09, F50-F99 • Addictions ICD10 codes beginning with F10 –F19
• Please note: Depression − ICD−10 codes beginning with F32−F33 (see Section 2 for ED visits with a depression MPDx). Depression was not included as a chronic condition in this grouper because depression is not included in the Health Link profiles (as of May 2014).
• Not applicable − ICD−10 codes that don't match the above diagnoses are blank. This group is included in all tables so that the total count in every table represents total ED visits. 47 ICD Diagnostic Codes and Methodology for Acute Hospitalizations for Selected Chronic Conditions
• The list of chronic conditions was adopted from that included in IntelliHealth based on a 'chronic condition' grouper data item. This was developed for the Report: Hospitalizations − Chronic conditions − Health Link v3, last modified Monday, May 26, 2014 8:39:12 AM EDT. Reported prepared by Health Analytics Branch, MOHLTC (JoAnn Heale)
• Data Inclusions: • − Ontario residents • − Acute care hospitals (Hospital type = AT, AP) • − ICD10 codes: the following ICD−10 codes reported for the most responsible diagnosis (MRDx) for the hospitalization: • 1. Arthritis − ICD−10 codes beginning with: M00−M03, M05−M19, M22−M25, M32−M36, M45−M47, M48−M482, M488−M489, M65−M68, M70−M71, M75−M77, M79, M99. These codes are consistent with those previously defined by the Arthritis Community Research & Evaluation Unit (1). The range of codes capture soft tissue derangements, joint disorders etc. as well as arthropathies (osteoarthritis, rheumatoid arthritis). [(1). University Health Network, March 2006. Arthritis and related conditions within Ontario Emergency Departments]. • 2. Asthma − ICD−10 codes beginning with J45 • 3. Cancer (Malignant neoplasms) − ICD−10 codes beginning with C00−C97 • 4. Congestive heart failure (CHF)− ICD−10 codes beginning with I50 • 5. Chronic obstructive pulmonary disease (COPD) − ICD−10 codes beginning with J40−J44 • 6. Diabetes − ICD−10 codes beginning with E10−E14 • 7. Hypertension − ICD−10 codes beginning with I10−I15 (Lead cause group 038) • 8. Ischemic heart disease (IHD) − ICD−10 codes beginning with I20−I25 • 9. Stroke − ICD−10 codes beginning with: I60−I61, I63−I64, H34.1, G46.4−G46.7, G45
• Not applicable − ICD−10 codes that don't match the above diagnoses are blank. This group is included in all tables so that the total count in every table represents total Inpatient discharges.
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