Fast Track Outpatient Program

Mark Bayley MD, FRCPC Saunderson Family Chair in Brain Injury Research Medical Director, Brain and Spinal Cord program Professor, University of Toronto Disclosure

• Relationships with commercial interests: § Grants/Research Support: None § Speakers Bureau/Honoraria: None § Consulting Fees: None § Other: None Case 1- Mr. Jones

• Mr. Jones- 73 year old man with left hemisphere CVA , right hemiparesis and inattention • Admitted to inpatient rehab on Day 14 post stroke with FIM of 75 needs assistance with all ADL • Progresses well over 40 days but still needing one person minimal assistance with walking with a walker • Team is reticent to discharge him because he is still progressing • Family nervous about discharge • Wait list for starting outpatient Physiotherapy is 5 weeks and OT is 7 weeks

3 Case 2 Ms. Nospeak • 76 year old married woman admitted for left hemisphere CVA, very mild right hemiparesis with significant expressive aphasia while comprehension better • Walking with single point cane with supervision and supervision for most self-care (Alpha FIM 89) • Stroke unit therapists don’t want to discharge as no speech therapy in community recommend inpatient rehab

4 Problems Illustrated By These Cases

• People with stroke who are almost independent in self care (FIM >80) should be able to treat as outpatients • Inpatient length of stay is prolonged by lack of access to outpatient rehab • Different wait lists for each profession mean patients don’t get coordinated outpatient rehab • Speech therapy is special problem for those with aphasia

5 Objectives

By the end of the presentation, participants should be able to: 1. Discuss the rationale for and key elements of a Fast Track Outpatient Stroke Program 2. Describe the benefits of implementation of a Fast Track Outpatient program 3. Name 5-6 considerations for implementation of a fast track program ( i.e. Barriers, Facilitators and Potential implementation strategies)

6 Objective 1

• Discuss the rationale for and key elements of a Fast Track Outpatient Stroke Program

7 Outpatient Rehab

• Outpatient therapy improves short-term functional outcomes • Hospital same as home-based • 30% reduction in bad outcomes, including institutionalization and allows earlier discharge home • Estimated savings is $2 for every $1 spent on outpatient therapies

• From Stroke Rehab Evidence Based Review Recommendation 4.1

• Stroke survivors with ongoing rehabilitation goals should continue to have access to specialized stroke services after leaving hospital (Level A). • This should include in-home community- based rehabilitation services (like ‘‘Early Supported Discharge’’ teams) or facility- based outpatient services (Evidence Level A).

9 Recommendation 4.1 4.1 (Continued)

• Should be provided by a specialized interprofessional team, when needed by patients, within 48h of discharge from an acute hospital or within 72h of discharge from inpatient rehabilitation (Evidence Level C). • Therapy should be provided for a minimum of 45 minutes per day (Evidence Level B) per discipline, 2 to 5 days per week, based on individual patient needs and goals (Evidence Level A) for at least 8 weeks (Evidence Level C). 10 Background – Stroke landscape in Ontario

• In Ontario, stroke is one of 15 diagnoses that falls under Quality-Based Procedures (QBP) – Part of funding is based on volume (adjusted for patient type) • QBP has aggressive targets for acute care length of stay in stroke – 5 days for ischemic stroke – 7 days for ICH • However, in the absence of appropriate discharge destination, difficult for achieve target LOS – Not counting alternate level of care days Rehabilitation after stroke

• 2 usual paths for stroke rehabilitation – Inpatient rehabilitation, followed by outpatient rehabilitation (if necessary) – Direct to outpatient rehabilitation • Inpatient Rehab LOS ranged from 14-48 days depending on function (RPG derived targets) • Outpatient Rehab based on functional needs/ goals – 2 days per week, up to 12 weeks per block of outpatient rehab – Up to 3 blocks of outpatient rehab Rehabilitation after stroke

• Inpatient capacity limited by physical and financial resources • Outpatient capacity limited by financial resources (usually) – 3+ week wait for outpatient rehabilitation • Waits for inpatient rehabilitation create acute care capacity issues • Waits for outpatient rehab create disposition issues (inpatient rehab and acute care) Background:Block System for Rehab

• Developed our rehab program into blocks of rehab of about 4-5 weeks • All members of the team start and complete the block at the same times (PT, OT, SLP, SW) • Patient chooses when they want their next block

14 Background: Toronto Rehab Outpatient

• Realized that most people received 2-3 months of outpatient rehab 2 times per week • Some people wanted to return later or were ready for return to work or driving later • We asked the question: If you only had 3 tokens worth of rehab how would you spend them?

15 UHN/TRI Integration – An opportunity to innovate

• July 2011 – University Health Network and Toronto Rehabilitation integrated their operations • Toronto Western Hospital is a high volume designated stroke centre (was already sending many patients to TRI for stroke rehab) • With the merger, there was an incentive from an institutional perspective to move stroke rehab patients along faster (especially with QBP funding for stroke starting in 2012) Fast Track Program Goal:

To provide intensive short term therapy for individuals with a mild-moderate stroke using an innovative, flexible, and interdisciplinary approach, with the aim of increasing access to inpatient services for stroke patients

Fast-track (FT) outpatient program

• From the UHN/TRI merger savings • Outpatient program to address short-term rehab needs following stroke, and helping patient’s transition from hospital to the community • Interdisciplinary approach to patient care. Resources available include physiatry, physiotherapy, occupational therapy, speech language pathology, and social work • Frequency of therapy depends on patient’s needs, ranging from 1 to 5 times a week, for a maximum period of up to 4 weeks • Goal is to start therapy within 5 days. Mandate is start date within 2 weeks of inpatient discharge Eligibility TRI - 9 South: • Patients from 9 South who can be discharged earlier than their target discharge date. AND • Complex discharges where target discharge date can be met with the support of immediate access to outpatient services. Toronto Western Hospital: • Patients with mild to moderate stroke admitted directly from acute care, who otherwise would have applied for an inpatient bed. Objective 2

• Describe the benefits of implementation of a Fast Track Outpatient program

20 Financial incentives in health care – working against the patient?

• Institutions receive (block) funding from provincial governments to provide services

• However, there is no financial incentive for one institution to invest their resources to offload the burden of another institution – i.e. Rehab hospitals did not (and mostly still do not) have an incentive to invest their resources to offload the acute care system Potential hospital and system benefits of Fast-track

• TRI( Rehab hospital) – discharge patients earlier from inpatient rehab bed • Cost savings for a couple of days for that patient (remember, QBP provides same amount of funding for that patient whether they stayed their whole LOS or went home 2 days early) • Increase inpatient rehab capacity without increasing staffing or the number of physical beds (greater throughput – again, remember there is funding attached to each patient treated from QBP) Potential hospital and system benefits of Fast-track

• TWH – Some patients that may have needed inpatient rehab (to avoid outpatient waitlist and/or get appropriate intensity) could now be discharged home – Avoid ALC days waiting for Inpatient stroke rehab bed

• All acute care hospitals – TRI now able to take stroke patients sooner due to increased capacity, leading to decrease ALC days in the system for those waiting for rehab – 2/3 of inpatient stroke rehab patients at TRI come from hospitals other than TWH/UHN Preliminary analysis:Total Number of Fast Track Admission

173 patients participated in the Fast Track Program (September 2012 – September 2014)

TWH external 32%, n= 55 TRI internal 68%, n=118 Median wait time from discharge to starting therapy = 5 days

Wait Times86% to Begin Fast Track Program

90% 80% 70% 60% 50% 40% 30% 13% 20% 1% 10% 0% within 1 week within 2 weeks 2+ weeks Time from Discharge to Program Start Number of inpatient days saved = 631

60

50

40

30

20 Number of daysNumber savedof

10

0

Month Patients Requiring Further Outpatient Therapy

Services Required Patient Requiring Further Outpatient Therapy

100%

90% 35% 80% 30% 96% 34% 70% 25% 60% 91%

50% 20% 58%

% of Patients%of 40% 47% % of Patients 15% 30% 17% 20% 10% 2% 10% 5% 0% 0% PT OT SLP SW Day Hospital Rumsey Centre Other Cost-effectiveness of an early access, high intensity, outpatient stroke rehabilitation program at Toronto Rehabilitation Institute

Alan Tam1,2, MD Stephen Mac2, MSc Wanrudee Isaranuwatchai1,PhD Mark Bayley1,2, MD

1University Health Network-Toronto Rehabilitation Institute 2Institute for Health Policy, Management and Evaluation, University of Toronto How about costs?

• Does this actually save money? – Beds do not sit empty – Costs to provide the fast-track rehab

Why study cost-effectiveness?

• Clinical efficacy is an important, but not the only, consideration when evaluating healthcare intervention funding

• The cost of the intervention needs to “justify” the effect – When you fund a new intervention, you are taking money away from something else that was providing benefit Why study cost- effectiveness? Few Assumptions Made in modelling

• Assume rehab unit always at capacity (patients would be ALC in acute care on waitlist if not admitted), • Assume patients would have been discharged on target LOS day in absence of FT • Assume all patients directly from TWH to Fast track would have had the length of stay of the mildest possible stroke (RPG 1160)

32 Methods

• Current analysis examined cost-effectiveness from a health- payer perspective (Ministry of Health) using administrative data from the Fast-track database (n=100 for fiscal year 2015-16) • Using regression techniques, incremental cost effectiveness ratio (ICER) estimated – ICER is the ratio of difference in cost between 2 interventions compared to the effect difference • (ICER = ΔC/ΔE) – Costs for a patient from inpatient rehab admission to discharge from fast track were calculated • Costs included physician, therapist, hospital, medication costs – The theoretical cost of inpatient rehab (full LOS) was calculated – The effect in this analysis was the number of projected inpatient rehab days saved Results (April 2015-March 2016)

• 56 patients discharged from inpatient stroke rehab t – 291 days “saved” from the target length of stay for these patients • 44 patients discharged from TWH to Fast-track – If they went to Inpatient stroke rehab, would have a target LOS of at least 14 days • 57% of patients attending fast-track needed further outpatient rehab – 70% of TRI referrals – 40% of TWH referrals • 96% of non-Fast track stroke rehab patients at TRI required further outpatient therapy

Results

• ICER • TRI - $403.87 per inpatient day saved • TWH - $37.16 per inpatient day saved • Willingness to Pay $698 • TRI – 99.2% cost effective • TWH – 100% cost effective • Willingness to Pay $509 • TRI – 85.2% cost effective • TWH – 100% cost effective Objective 3

• Name 5-6 considerations for implementation of a fast track program ( i.e. Barriers, Facilitators and Potential implementation strategies)

36 What do you think the barriers would be at your center?

• Which health care professionals might need to be involved in acute care and how? • Which health care professionals in inpatient rehab?

37 Things not costed that you might have to consider

• Start-up cost – Multiple meetings by various stakeholders • Physical space – Utilized space/gym/equipment that was already in place that was under-utilized – If need to invest in new space/equipment, that would have to be taken into account • Integrated system/funding? – Your administrators/finance people may ask you “What does this cost us (the hospital)” – The savings are not necessarily at the hospital level, but the system level

Barriers to accessing/implementing Fast- track

• Transportation to and from the Fast-track – Stroke patients cannot drive in the early period post-stroke – Rely on family or public transport

• ADL support (if needed) at home – FT population included all RPGs

• ADL support (if needed) at home – FT population included all RPGs Few suggestions for Implementation that you could do today

• Consider developing your Outpatient rehab into clear blocks of therapy • We found that team needed to improve their skills in Setting and negotiating SMART ( Specific Measurable Achievable, Relevant and Time limited) • May need to have single service speech therapy

40 How might we engage hospital leaders?

• Review the rationale and the business case for fast track • If you reduced length of stay for all your patients by fast track by 2 days for 200 patients

41 Conclusions • Waits for inpatient rehabilitation limit acute care capacity • Waits for outpatient rehab create discharge issues (inpatient rehab and acute care • Fast-track is likely a cost-effective method of delivering the high intensity rehabilitation services after acute stroke (compared to inpatient rehabilitation) – Caveat is potential barriers to attendance of program – Some costs shifted from Health Payer (MOH) to Patient (transport, caregiver, etc.)

• Fast-track can be implemented to support early discharge after stroke to drive down length of inpatient rehab stays

Acknowledgements • TRI Stroke Rehab Team • Nathalie Topdjian • Megan Wormald

• UHN Decision Support & Finance • Shahin Ansari • Mikhail Zaitsev • Alan Tam Questions

@DocMarkBayley