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Best Practices

Updated on August 28, 2017

“By changing nothing, nothing changes.”
Tony Robbins

Wait time for nursing services and wait time for personal support services for complex patients in the home are priority indicators for the QIP. In Ontario 93.7% of home care patients receive nursing services within the five day target and 85.4% of home care patients with complex needs receive personal support within five days.

Below are best practices for reducing wait time for these home care services. They are graded according to Type of Evidence. Evidence-informed best practices are based on quality evidence, they can optimize outcomes and should be implemented into practice where possible.

  1. Accreditation Canada.
    Home Care in Canada: Advancing Quality Improvement and Integrated Care.
    Ottawa: Accreditation Canada 2015.
    Retrieved from: https://www.accreditation.ca/sites/default/files/home-care-in-canada-report.pdf

  2. BCNU.
    Provincial Nursing Workload Project Final Report.
    BC Nurses Union 2010.
    Retrieved from: https://www.bcnu.org/Documents/pnwp_report.pdf

  3. Colquhoun HL., Sattler D., Chan C., Walji T., Palumbo R., Chalmers I., Jokhio I., Ivers N. (2017).
    Applying User-Centered Design to Develop an Audit and Feedback Intervention for the Home Care Sector.
    Home Health Care Management and Practice; 29 (3): 148 - 160.

  4. Health Quality Ontario.
    Impressions and Observations 2016/17 Quality Improvement Plans.
    Toronto: Health Quality Ontario 2017.
    Retrieved from: http://www.hqontario.ca/Portals/0/documents/qi/qip/analysis-home-care-2016-17-en.pdf

  5. Health Quality Ontario.
    The Common Quality Agenda 2016 Measuring Up A yearly report on how Ontario’s health system is performing.
    Toronto: Health Quality Ontario 2016.
    Retrieved from: http://www.hqontario.ca/portals/0/Documents/pr/measuring-up-2016-en.pdf

  6. Health Quality Ontario.
    Community Care access Centres: Impressions and Observations 2015/16 Quality Improvement Plans.
    Toronto: Health Quality Ontario 2016.
    Retrieved from: http://www.hqontario.ca/Portals/0/documents/qi/qip/qip-analysis-ccac-2015-en.pdf

  7. Health Quality Ontario.
    Community Care access Centres: Impressions and Observations 2014/15 Quality Improvement Plans.
    Toronto: Health Quality Ontario 2015.
    Retrieved from: http://www.hqontario.ca/portals/0/Documents/qi/qip-analysis-ccac-en.pdf

  8. Ivers N, Jamtvedt G, Flottorp S,.
    Audit and feedback: effects on professional practice and health care outcomes.
    Cochrane Database Syst Rev. 2012;(6).

  9. Office of the Auditor General of Ontario.
    Community Care Access Centres— Financial Operations and Service Delivery.
    Toronto: Auditor General’s Special Report 2015. Queen’s Printer for Ontario 2015.
    Retrieved from: http://www.auditor.on.ca/en/content/specialreports/specialreports/CCACs_en.pdf

Measurement

Updated on August 28, 2017

“While all changes do not lead to improvement, all improvement requires change”
Institute for Healthcare Improvement

How do we know if a change is an improvement? Measurement is a critical step in QI to assess the impact of a change. Quality indicators are used in the QIPs to measure how well something is performing. There are three types of quality indicators used to measure QI efforts:

  • Outcome Indicators: capture clinical outcomes and or system performance,
  • Process Indicators: track the processes that measure whether the system is working as planned, and
  • Balancing Indicators: ensure that changing one part of the system does not cause new problems in another.

Indicator Percentage of home care patients who received their first nursing visit within five days of service authorization
Topic Wait Times
Quality Dimension Timely
Type of Indicator Process
Measure Percentage (%)
Data Source Client Health and Related Information System (CHRIS), Home Care Database (HCD)
Data Collection Instrument Collected by the Ministry of Health and Long-Term Care (MOHLTC), and Health Shared Services Ontario (formerly the Ontario Association of Community Care Access Centres (OACCAC))
How to Calculate

The percentage is calculated as: (Numerator/Denominator) x 100

Numerator: # of home care patients who received their first nursing service visit within five days of the date they were authorized for nursing services by the CCAC

Denominator: # of adult home care patients who received in-home nursing services

Target Higher is better (Provincial Benchmark is 95%)
Range 0 – 100%
HQO Reporting Tool Public Reporting, and Quality Improvement Plans (QIPs)

Indicator Percentage of home care patients with complex needs who received their personal support visit within five days of service authorization
Topic Wait Times
Quality Dimension Timely
Type of Indicator Process
Measure Percentage (%)
Data Source Client Health and Related Information System (CHRIS), Home Care Database (HCD)
Data Collection Instrument Collected by the Ministry of Health and Long-Term Care (MOHLTC), and Health Shared Services Ontario (formerly the Ontario Association of Community Care Access Centres (OACCAC))
How to Calculate

The percentage is calculated as: (Numerator/Denominator) x 100

Numerator: # of complex home care patients who received their first personal support service visit within 5 days of the date they were authorized for personal support services by the CCAC

Denominator: # of adult complex home care patients who received in-home personal support services

Target Higher is better (Provincial Benchmark is 95%)
Range 0 – 100%
HQO Reporting Tool Public Reporting, and Quality Improvement Plans (QIPs)

This data can be presented using Run Charts to track improvement over time. To read more about general measurement in QI refer to Measurement for Quality Improvement or the QI Getting Started Section.

Tools & Resources

Updated on August 28, 2017

Background

Updated on August 28, 2017

Issue

Providing home care to patients in a timely manner is key to ensuring they receive the right care when they need it. The consequences of delayed access to nursing or personal support worker (PSW) services may include increased confusion and stress for patients and caregivers and potential re-hospitalization (HQO 2016). Wait times in home care are measured using two priority indicators. The first indicator measures the time to first visit to any patient from a nurse. The second indicator measures the time to first visit to complex patients from a personal support worker.

In 2013, Ontario created a five-day target for all patients waiting for nursing service, as well as for all complex patients waiting for personal support service. Complex patients are those who need a high level of care, usually because they have one or more health conditions combined with complicating factors such as physical, cognitive or other limitations (CCAC, 2014). The personal support service they receive may include personal service such as bathing, helping with eating and other activities of daily living (ADL), as well as homemaking and cleaning (HQO 2016).

Ontario provides 6.9 million nursing visits and 28.7 million hours of personal support and homemaking to approximately 650,000 people per year (MOHLTC 2016). In 2015/16 93.7% of home care clients received nursing services within five days of discharge to home care and 85.4% of complex patients received personal support within 5 days of admission to home care (Figure 1). The majority of home care clients receive services within the target period.

FIGURE 1: Percentage of home care patients in Ontario whose first nursing visit and personal support is within five days of authorization, 2012/13 to 2015/16

Data source: Home Care Database provided to the Ministry of Health and Long-Term Care by the Ontario Association of Community Care Access Centres

The wait time for service is measured from the date a service is authorized to the date it is first provided. However, before a service is authorized, it must first be applied for by a health care provider, the patient or their caregiver, and a home care coordinator must determine whether the patient is eligible for the service. The time required for the application process and determination of eligibility is not included in the wait time target.

When considered by LHIN (Figure 2) there is quite a bit of variability in timeliness of personal support services for complex patients. Timely nursing services remains fairly constant across LHINs and there may be a ceiling effect being encountered for this indicator.

FIGURE 1: Percentage of home care patients by Local Health Integration Network (LHIN) whose first nursing visit and personal support is within five days of authorization, 2012/13 to 2015/16

Data source: Home Care Database provided to the Ministry of Health and Long-Term Care by the Ontario Association of Community Care Access Centres


Call to Action

Ontario was the First province to provide home care related wait times, and there have not been substantial changes since 2013/14 (HQO2016; WTA 2015). For personal support services the percentage who receive care within five days has slowly increased to 85% over the past three years. The median current performance on this indicator is 85% (range of 74% to 92%). For in-home nursing the percentage has been steady at 93%. The median performance is 94% (range 88% to 96%) which is approaching the provincial benchmark of 95%.

While performance on nursing visits is high which we are looking to maintain, there remains room for improvement for the personal support services. With appropriate supports, many individuals of all ages can remain in their homes, return home more quickly from hospital, or delay or even avoid the need for admission to a hospital or long-term care home (Home and Community Care Expert Panel 2015).

  1. Central Community Care Access Centre.
    Central Community Care Access Centre Strategic Plan (2014-2017) 2014
    Retrieved from: http://healthcareathome.ca/central/en/who/Documents/Strategic%20Plan%202014%202017%20EN.pdf

  2. Health Quality Ontario.
    Impressions and Observations 2016/17 Quality Improvement Plans.
    Toronto: Health Quality Ontario 2017.
    Retrieved from: http://www.hqontario.ca/Portals/0/Documents/qi/qip-analysis-for-improvement-2012-en.pdf

  3. Health Quality Ontario.
    The Common Quality Agenda 2016 Measuring Up A yearly report on how Ontario’s health system is performing.
    Toronto: Health Quality Ontario 2016.
    Retrieved from: http://www.hqontario.ca/portals/0/Documents/pr/measuring-up-2016-en.pdf

  4. Health Quality Ontario.
    Community Care access Centres: Impressions and Observations 2015/16 Quality Improvement Plans.
    Toronto: Health Quality Ontario 2016.
    Retrieved from: http://www.hqontario.ca/Portals/0/documents/qi/qip/qip-analysis-ccac-2015-en.pdf

  5. Home and Community Care Expert Panel.
    (2015) Bringing Care Home.
    Toronto, Ontario: Donner G., Fooks C., McReynolds J., Smith K., Sinha S., Thomson D.
    Retrieved from: http://health.gov.on.ca/en/public/programs/lhin/docs/hcc_report.pdf

  6. Ministry of Health and Long-Term Care.
    Ontario investing an additional $100 million this year in home and community care.
    News release. July 19, 2016.
    Retrieved from https://news.ontario.ca/mohltc/en/2016/07/ontario-investing-an-additional-100-million-this-year-in-home-and-community-care.html

  7. Wait Times Alliance (WTA). (2015).
    Eliminating Code Gridlock in Canada’s Health Care System 2015 Wait Times Alliance Report Card.
    Canada 2015.
    Retrieved from: http://www.waittimealliance.ca/wp-content/uploads/2015/12/EN-FINAL-2015-WTA-Report-Card_REV.pdf