Urology - Chronic Kidney Disease (CKD)

Planning Advisory GroupSummary of Meetings

HNHB LHIN Clinical Services Planning Project

PAG Membership

Rick Badzioch

Dr. Ian Brown

Dr. Euan Carlisle

Jane Cornelius

Terry Dalimonte

Maureen Kitson

Dr. Bill Love

Dr. Frank Scallan

Maureen Shantz

Dr. Bobby Shayegan

PAG Deliverables

Describe the strengths & challenges within the existing health care system in addressing population health care needs

Identify leading factors that may influence the future demand for health care

Develop a high level, HNHB LHIN wide, ideal services delivery model for the PAG population

Identify pre-requisites & challenges of implementation of the ideal service model

Urology & CKD

At the start of the project the PAG concurred that urology and CKD are distinct services with little overlap and need to be reviewed separately.

Meeting 1

•Strengths & challenges within the existing health care system

•Leading factors that may influence the future demand for health care

•Ideal delivery model (high level)

Urology - Strengths & Challenges of Current Health Care System

Strengths

Good distribution of urologists across the LHIN. Access to urologists not an issue

HNHB LHIN Urologists – cohesive group

Readiness of LHIN urologists to develop quality working group to review and improve services in LHIN

Majority of urology related care available in LHIN, only need to transfer outside LHIN for special technology i.e. lithotripsy.

Nurse practitioners in LTCH can increase capacity by performing minor care procedures i.e. changing suprapubic catheters

CCAC – provides continence referrals

Hamilton – training program for physician assistants

Less subspecialty among urologists.

Challenges

Access to interventional urology in Brantford, requires transfer to Hamilton, often needing an overnight stay

Access & support for new technology i.e. lithotripsy, robotic

Aging population with limited access to continence support

Transportation especially with aging population

Agreement & standardization of Nurse Practitioner practice within LTCH across the LHIN

Centralized model may limit recruitment, impacting health human resources in smaller sites.

Need to access urologist on urgent basis makes regionalization of specialty challenging.

Inability to share information across sites (each sites has meditech and PAC system but cannot share information online between sites)

Wait time to operative time

Maintain & replace capital equipment

Lack of level 1 evidence for screening in urology. If evidence supports screening potential for increased demand.

Increase pressure to teach residents.

Access to operating room time

CKD - Strengths & Challenges of Current Health Care System

Strengths

Ready access to specialists

No wait lists (except for transplant)

Immediate access to hemodialysis (hemo)

Hub & spoke service delivery model – satellites across the LHIN

CCAC support for home dialysis

Pre-dialysis clinic care > reduce or delay need for dialysis (medical preventive care – nephrology clinics)

Range of hemo dialysis modalities

LTC access for clients on hemo

MOH PD in LTC Initiative

MOH increased support for transplant services

Challenges

Access to timely surgical, vascular & interventional radiology support - (for peritoneal dialysis catheter insertion/replacement, vascular access/complications, & nephrology tubes)

Access to interventional radiology only in select areas of LHIN

CCAC staff turnover – has resource implications for regional centre to retain for home and LTC support

Regional referral role - pressure to accept transfers from satellites and from other centres for transplant

Access to LTCH for seniors on PD

Costs of different modalities i.e. daily, nocturnal absorbed by regional centres

LTCH capacity to care for individuals on dialysis i.e. staffing model

Lack of dedicated funding to support pre-transplant treatments i.e. plasmapheresis, tissue typing

Management of CKD programs that cross LHIN boundaries i.e. Halton/Burlington

Maintenance of knowledge/skills at non CKD centres to facilitate repatriation (critical mass).

Resources/costs associated with supporting dialysis offsite at other tertiary centres (Hamilton)

Factors Most Likely to Increase or Decrease Demand – common to both

*Aging population

* Increase in comorbidities in aging population & starting

earlier in younger population i.e. type 2 diabetes, obesity

* Social economic profile of the LHIN

* Increase availability of primary care > increase demand

Access to transportation – will increase demand for services close to home

Medical advancements, both in skill & technology (urology, transplant, continual renal therapy, cancer treatment options)

Client/family expectations

Competition for limited health human resources

Note: * Denotes factors identified as having a significant impact

Factors Most Likely to Increase or Decrease Demand – Service SpecificUrology Increase demand

None identified

Unknown – evidence supporting cancer screening

Projected increased oncology demand

Decreased Demand

Increased access to physician assistant or nurse practitioner may increase result in increased productivity

CKDIncreased Demand

Increase in individuals with end stage heart disease

Transplant population – long term use of anti-rejection medication

Diabetes

Decreased Demand

Increase prevention

Best practice standards for hypertension, diabetes

Increase client’s knowledge of health risks and status and success with self management.

Increase access to nephrology clinics/care to prevent or delay need for dialysis

Urology – Components of Ideal Service Delivery Model

Component Services associated with this component Clinical & non-clinical interdependencies

Linkages to community services

Health promotion/disea se prevention

Increased education re on prevention of cancerIncreased education on stone prevention

Global media marketing of health

Link to CCO forpreventionLink to public

Health

Primary & Community Care–Pre & post hospital

Continuity in primary care Primary care capacity to meet population access requirements in all areas of the LHIN Standard care pathsTimely access to urologist, other allied health, diagnostic services in the most appropriate place – (does not need to be done at academic centre) Integrated information systemCoordinated care with community services Access to funded stoma/catheter therapy trainingEarly detection, assessment and followAccess to multidisciplinary team for complex cancer cases \Role of pre-cancer screening identified

Integrated information systemDiagnostic servicesOutreach multidisciplinary teamInterventional radiologyAccess to specialistsAccess to end of life care – identification of what services are needed to provide end of life care

CCAC for follow up careCommunity based continence care – keeps people home Link to rehab services Link to end of life careStoma/catheter support

Urology – Components of Ideal Service Delivery Model

Component Services associated with this component Clinical & non- clinical interdependencies

Linkages to community services

Acute Care – Hub andSpoke ModelTertiary care Community hospitalsCommunity Clinics

Hub (everything plus)Complex cancer servicesMultidisciplinary team Interventional radiologyTimely access to tertiary care bedsAccess to evidence based technologyCommunity HospitalsMost oncology cases, the majority of stones cases, most male and female voiding dysfunction, most infectious diseases, most erectile dysfunction, much of pediatrics, most andrology, basic infertility Access to urology services at multisite hospitals Access to interventional radiologyClinics Simple basic surgical proceduresPrimary & Specialist care servicesEarly urological screening & diagnostics Monitoring and follow upOutreach team

Integrated information systemCross site urology work group to monitor quality of care and outcomes Interventional radiologySupportive specialists i.e. cardiologyEducation across sitesVideoconferencing/w eb based education

CCAC & community careContinence, catheter and stoma care & support

CKD – Components of Ideal Service Delivery Model

Component Services associated with this component Clinical & non-clinical interdependencies

Linkages to community services

Health promotion/disease prevention

Strong, integrated primary prevention system to prevent diabetes, high blood pressures & obesityIncreased coordination & integration of all diabetes education programs

Link to Public Health/Min Health Promotion, CDPM,Diabetes strategyHeart and stroke strategy to reduce cardiac and HTN events

Municipalities – planningOther ministries i.e. education CDPMCHCs

Primary & Community Care- Pre and post acute

Education provided by mixture of health care professionals. Flexible modelsBest practice guidelines for screeningEarly detection of high risk population.Continuity in primary care for assessment, monitoring & follow upStaffing model standards/regulations for community & LTC (Default mech)CCAC maintain home PD & hemo.Access to rehab/LTCH/end of life/basket of services for dialysis clientsPre-emptive transplant careEstablished ongoing communication system between regional centre/LTC/Community sectorDesignated number LTCHs adequately resourced to care for the CKD population

Integrated information systemAccess to other specialists, endocrine, cardiac etcOngoing education for community and LTCPublic health/primary care vaccinations for hepatitisOngoing education to maintain expertise - across health professionals and EMS

Role of community support for brittle diabeticsDiabetes education programs CCAC for home dialysis supportAccess to rehab, LTC Link to rehab services Link to end of life careAccessible transportation Partnership with kidney foundation

CKD – Components of Ideal Service Delivery ModelCompone nt

Services associated with this component interdependencies Linkages to community

Acute Care – Hub &Spoke ModelRegional centres Satellites IHF

Defined by MOH CKD model

Hub/Regional CentreTertiary centre: Transplant & dialysis to other tertiary centresVascular & interventional resources for vascular access. Access to interventional radiology services at the regional centre or formalized linkages to access service in a timely mannerTimely body access – Dedicated OR time for Vascular & PD Primary level 2 & 3 dialysisPre & Post dialysis clinics, nephrology clinicsHome dialysis & trainingAccess to surgeons – all hemo patients surgeon consultNephrology clinics referral based on GFRExpress protocol for admission to regional centre established (with repatriation agreements) Optimize ambulatory services and supports to reduce inpatient staysDedicated resources for plasmapheresisMaximize transplant program along the transplant continuumHome dialysis targets appropriate for the demographic and geographical areaSatellitesLevel 1 – 2 dialysisPost dialysis and nephrology clinicsPredialysis clinics based on critical need (mobile clinics)Selective home dialysis training.

Integrated information systemServices for vascular access – link to vascular PAGInterventional radiologyUrology re PD insertionAccess to resources/specialists to treat peripheral vascular disease Combine treatment clinics (diabetes, nephrology, stroke/HTN)Videoconferencing/ web based conferencing

CCAC – community supportAccess to rehab, LTC End of life care education and support Link to Critical Care Lead to identify dialysis needs at LHIN critical care units.Diabetes clinics

CKD – Components of Ideal Service Delivery ModelComponent Services associated with this component interdependencies Linkages

to community

– Hub andSpoke ModelRegional centres Satellites IHF

Defined by MOH CKD model

IHF - Level 1 dialysisReevaluate the necessity of IHF through expansion of home dialysis

Regional CKD Centre

Meeting 2

•Incorporate PAG colleagues feedback

•Diagram of PAG ideal service delivery Model

•Describe PAG Ideal Model using LHIN Criteria

•Describe prerequisites, enables and challenges to the implementation of the ideal service model

Heath Promotion

•Cancer prevention education•Stone prevention•Global media marketing of health

Primary Care•Assessment and early detection • Consistency in referrals (care paths & regular knowledge sessions)•Follow up care & monitoring•Coordinated & integrated with community providers care (including palliative)

Community Care•Coordinated by CCAC •Continence care•Pre and post acute care education/support for stoma and catheter care•Pallative care (hospice/outreach)•Pain Clinics

Primary & CommunityPre & Post Acute Care

Integrated & Coordinated Care Across the Continuum

Urology Ideal Service Delivery Model

Patient Accesses & Moves Across Levels of

Care Based on Need

Terti

ary CentreComplex Cancer

& other urology cases

Multidisciplinary outreach

Com

mun

ity Hospitals

, Most oncology, stone, voiding infertility, erectile dysfunction

pediatric and basic fertility, andrology cases.

Medical oncology & multi-disciplinary cancer care (oncology, palliative car etc. )

Com

mun

ity Clinics

Simple basic surgical procedures

Assessment, monitor, follow up Diagnosis, Access to Primary Care & Urologist

Outreach team

Heath Promotion

Strong, integrated primary prevention system to prevent diabetes, high blood pressures & obesityIncreased coordination & integration of all diabetes education programs/clinics, nephrology and cardiac/stroke/HTN clinics

Primary CareEducation provided by mixture of health care professionals. Best practice guidelines for screeningEarly detection of high risk population.Continuity in primary care for assessment, monitoring & follow upPre-emptive transplants

Community Care•Staffing standards/regulations for community & LTCH (Default mech)•CCAC maintain home PD & hemo.•Access to rehab/LTCH/Pallative care for dialysis clients

Primary & CommunityPre & Post Acute Care

Integrated & Coordinated Across the Continuum

SatellitesA,B, C

Level 1 & 2 Dialysis

Post dialysis andNephrology clinics

Outreach Pre-dialysisclinics

CKD Regional CentreDefined by MOH CKD Model

Body access – Vascular and PDDedicated OR time for PD

Interventional radiologyDialysis level 2 & 3

Pre & Post dialysis clinics, nephrology clinics

Home dialysis including training

Tertiary Regional Centre RoleRenal Transplant services

Dialysis services to other tertiary centres

IHF?

Home

LTCH

Supporting tertiary Specialties i.e. Cardiac, neuro

CKD Ideal Service Delivery Model

PAG Ideal Model -LHIN Criteria

Domain Criteria Assessment

Strategic Fit Aligns with LHIN priorities for health improvement, health care needs and system transformation

Promotes patient flow and integration across the continuum of careBuilds on existing infrastructure & optimizes use of health human resourcesResponds to health care needs of population i.e. close to home

Population Health

Heath Status – clinical outcomesPrevalenceHealth Promotion and disease prevention

Strong emphasis on integrated prevention across the continuum of care (screening – case finding in early stages)Supports quality outcomes The hub and spoke model can quickly respond to variances in prevalence and incident.

PAG Ideal Model -LHIN Criteria

Domain Criteria Assessment

System Values

Client Focused Promotes prevention, early detection, close to home and in the home Focused on patient safety

Partnership & Community Engagement

Hub and spoke model depends on partnerships between hospitals, community and primary careGreater integration with community which will build confidence between teams

Innovation LHIN model promotes integration ideas and centres, which is innovativeDoes not considered IHF model for urology (stand alone centres i.e. Alberta)Integration of knowledge

Equity Equity of services through hub/spoke modelAccess to advanced technology limited i.e. lithotripsy

Efficiency Integrated information system needed, to reduce duplications of tests i.e. labs, xray (model has potential to gain efficiencies)

PAG Ideal Model -LHIN Criteria

Domain Criteria Assessment

System Performance

AccessQualitySustainabilityIntegration

Modelimproves accesspromotes qualityis feasible. sustainable and does not require substantial new investmentsoptimizes health care professionals and supports training

promotes and depends on integration across the continuum.Promotes integration

Ideal Service Model - Prerequisites, Enables & Challenges to Implementation

Category Prerequisite Enables Challenges

Policy/legislation Changes in legislation/policy re staffing models LTCH- community CCO guidelines for urologyPolicy change re use of creatine vs GFR for nephrology clinics

PD policy in LTCH

Funding policy for CKD Funding policy for CKD in LTCH

Resources Existing infrastructure, formal hub and spoke model for CKD

LTCH – PD Dialysis resources for dietician Transportation Lack of integrated information system – communication with regional centreTransplant resourcesPreemptive transplant resources

Ideal Service Model - Prerequisites, Enables & Challenges to Implementation

Category Prerequisite Enables Challenges

Community readiness

Availability of resources (funds & HR) in communityStandard medical directive/orders for nursing

Community supportLHIN based interactive IT

TransportationLack of supportive housing/assisted livingHome maintenance/adaption

Services eHealth – transfer of information

Partnerships/linkages

Enhanced communication process between acute, LTC and community

Urology – cohesive collaborative groupCKD modelStandardized MD credentialing across the LHIN

Timely affordable transportationReadiness of ancillary resources

Meeting 3

•Discuss Input from PAG Colleagues

•Finalize All Templates for Submission to Committee

PAG Colleague Feedback

Suggested feedback incorporated or strengthened in model:

Greater emphasis on need for vascular support for CKD (Dependency on “plastic” i.e., catheters increases infection rates/sepsis, in-patient admissions and mortality)

Physician PD catheter insertion compensation

Promote more ambulatory care

Strengthen rehab & Pallative care services

Funds need to move with patient

Timely access to short term beds (24-48 hours)

Support centres of excellence

PAGs with Direct Links to UR/CKD

Vascular Surgery

Rehab

Pallative Care

Critical Care

Emergency Services