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Rockcliffe-Smythe Residents

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Rockcliffe-Smythe Residents 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
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