Review of the Increasing Pressures of an Aging Population on the Health Care System in the City of Timmins and the Cochrane District

June 2004

Table of Contents EXECUTIVE SUMMARY .................................................................................................v SOMMAIRE .................................................................................................................... xiv BACKGROUND & INTRODUCTION ..............................................................................1 1.0 1.1 1.2 1.3 1.4

FACTORS AFFECTING UTILIZATION PATTERNS .............................3 Demographics ....................................................................................................3 Determinants of Health ......................................................................................6 Health Status Profile ..........................................................................................9 Primary Care Services......................................................................................13

2.0 2.1

COMMUNITY SUPPORT SERVICES ......................................................15 Community Support Services Available in Timmins and the Cochrane District .......................................................................................15

3.0

COMMUNITY CARE ACCESS CENTRE – COMMUNITY SERVICES .......................................................................17 Home Care Services in the Cochrane District .................................................17 Assessment of CCAC Home Care Clients.......................................................19

3.1 3.2 4.0 4.1

COMMUNITY CARE ACCESS CENTRE – LONG-TERM CARE PLACEMENTS ....................................................23 Placement Coordination Statistics ...................................................................23

5.0 5.1

LTC INSTITUTIONAL FACILITIES ........................................................27 Comparison to the Provincial LTC Bed Ratio.................................................27

6.0 6.1 6.2 6.3

ALTERNATE HOUSING OPTIONS..........................................................30 Retirement Facilities ........................................................................................30 Supportive Housing .........................................................................................31 Social Housing for Seniors ..............................................................................32

7.0 7.1 7.2 7.3 7.4 7.5 7.6 7.7

HOSPITAL UTILIZATION DATA ............................................................35 Emergency Department Visits .........................................................................35 TDH Profile of Admissions and Length of Stay (LOS) ..................................37 Hospital Resource Utilization (CCC Beds) .....................................................38 Admission Patterns to Complex Continuing Care (CCC) Beds ......................40 CCC Bed Discharge Patterns ...........................................................................41 Alternate Level of Care....................................................................................43 Profile of ALC Patients at Timmins and District Hospital ..............................45

8.0

COMMUNITY RESPONSE TO THE PRESSURES ON THE LTC CONTINUUM ......................................................................48 Strategic Solutions ...........................................................................................48 Additional Proposals to Enhance the Districts Long-Term Care Continuum..52

8.1 8.2

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List of Tables Table 1: Table 2: Table 3: Table 4: Table 5: Table 6: Table 7: Table 8: Table 9: Table 10: Table 11: Table 12: Table 13: Table 14: Table 15: Table 16: Table 17: Table 18 Table 19: Table 20: Table 21: Table 22: Table 23: Table 24: Table 25:

Population Change in Selected Districts, North Region and Ontario, 1996 and 2001...............................................................................3 Proportion of Population Age 65 Years and Over, ACMS Districts, Ontario, 2001 .....................................................................................................3 Age Distribution and Senior’s Population Change, ACMS Communities, Ontario and Canada, 2001..................................................................................4 Population Projection, Total and Age 65 and Over, Cochrane District and Ontario.........................................................................................................4 Life Expectancy (from birth), Porcupine, ACMS, Ontario and Canada, 1996....................................................................................................................5 Languages First Learned and Still Understood, ACMS Districts and Ontario, 2001...............................................................................................5 Aboriginal Population, ACMS Districts and Ontario, 2001 ..............................6 Unemployment Rates (%), ACMS Districts and Ontario, 2001........................7 Proportion of the Population by Level of Education Achieved, Population Aged 20 Years and Over, ACMS Districts and Ontario, 2001........7 Persons over 65 years, Living Alone, ACMS Districts and Ontario, 2001 .......8 Profile of Earnings from Full-Time Employment, ACMS Districts and Ontario, 2001...............................................................................................8 Median Income Levels for Seniors 65 and Over, Timmins, Cochrane District and Ontario, 2001 .................................................................9 Selected Standardized Mortality Ratios (SMRs), ACMS Districts, 1995 to 1999 ....................................................................................................10 Selected Standardized Morbidity Ratios (SMRs), ACMS Districts, 1997 to 2001 ....................................................................................................10 Hospitalizations Due to Accidental Falls, Timmins, Cochrane District and Ontario, 1997 to 2001 ...............................................................................11 Projected Cases of Dementia for Persons 65 years and over, ACMS Districts................................................................................................11 Cancer Incidence, Selected Cancers, Cochrane District and Ontario, 1994-1998 ........................................................................................................12 Service Units/Hours: 10A Homemaking/Personal Care/Attendant Respite....17 Cochrane District CCAC Service Utilization, 2000/01 to 2003/04.................19 Distribution of Clients by Disease Categories, Cochrane District CCAC, February 2003 to February 2004......................................................................20 Average Monthly Placement Caseloads, ACMS CCACs, 2000 to 2003 and January to April 2004................................................................................23 Average Monthly Waiting List for Cochrane CCAC , 2000 to 2003 and January to April 2004................................................................................23 Admissions to ACMS LTC Facilities, 2000 to 2004.......................................24 Number of Persons Waiting for a LTC Bed and Present Location, ACMS Districts, February 2004 ......................................................................24 Average Wait Time for Placement within Golden Manor, Timmins, by Gender.........................................................................................................25

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Table 26 : Waiting Times for ACMS Area Long-Term Care Facility/Placements, February 2004 ..................................................................................................25 Table 27: Individuals Accepted and Waitlisted for Basic and Preferred Accommodation, ACMS Long-Term Care Facilities, February 2004 .........................................26 Table 28: LTC Facilities in the Cochrane District, April 2004........................................27 Table 29: Long-Term Care Beds per 1,000 Population Over 75 Years of Age, Cochrane District .............................................................................................29 Table 30: Inventory of Retirement Homes in the Cochrane District, 2004 .....................30 Table 31: Summary of Benchmarks for 65+ for Cochrane District.................................32 Table 32: Social Housing Units for Seniors 60 Years +, 2004 ........................................32 Table 33: Timmins and District Hospital Bed Complement by Classification................35 Table 34: Emergency Department Visits, Population Age-Standardized Rates, ACMS Districts and Ontario, 2002/03.............................................................35 Table 35: Emergency Department Visits by Main Cause, ACMS Hospitals and Ontario, 2002/03 .......................................................................................36 Table 36: Emergency Department Visits Due to “Factors Influencing Health Status”, ACMS Hospitals, 2002/03 ...............................................................................37 Table 37: Network 13 Case Mix Index for Network 13 Facilities, 1999/00, 2000/01, and 2001/02......................................................................................................39 Table 38: Network 13 Average Length of Stay for Complex Continuing Care, 1999/00 to 2001/02 ..........................................................................................40 Table 39: Client Location prior to Admission to CCC Beds, 1999/00 to 2001/02..........40 Table 40: Discharge Patterns of Network 13 Facilities, 1999/00 to 2001/02 ..................42 Table 41: Network 13 ALC Bed Equivalency, 1998-2002..............................................44 Table 42: Timmins and District Hospital, Alternate Care Needs (Days) in the CCC Unit . 1999/00 to 2003/04 ..........................................................................................44 Table 43: Timmins and District Hospital, ALC Patients (Acute Care), 1999/00 to 2003/04 ........................................................................................................45 Table 44: Timmins and District Hospital, Percentage of ALC Patients (Acute Care) Age 65+, 1999/00 to 2003/04 ..........................................................................45 Table 45: Timmins and District Hospital, ALC Patients by Gender, 1999/00 to 2003/04 ..........................................................................................46 Table 46: Timmins and District Hospital, Total ALC Incidents by Level of Care Needed from October 8, 2003 to March 31, 2004 ...........................................46

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List of Figures Figure 1: Cochrane District CCAC Clients by Age and Gender,....................................20 Figure 2: Timmins and District Hospital RUGS Report, 2000 to 2003 (1st Quarter) ....................................................................................................39

Appendices A. B. C.

Community Support Services Definitions .......................................................53 Description of Placement Waiting List Categories..........................................71 Definition of Supportive Housing....................................................................74

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EXECUTIVE SUMMARY Background Information On Wednesday, May 26th, 2004, the Timmins & District Hospital mobilized all internal and external resources to deal with a bed shortage crisis, which resulted in the hospital having no acute medical, surgical or ICU inpatient beds available. On June 1st, 2004, the Ministry of Health and Long-Term Care issued a Category 1-A Crisis Designation for the Timmins and District Hospital. The designation means that patients at Timmins and District Hospital awaiting placement to long term care facilities will be given top priority within the Cochrane District. The designation will be in effect from June 1st until July 31st, 2004, at which time the designation may be extended, depending on local circumstances. The ACMS District Health Council received a request from the Chair of Network 13 to assist the community in understanding the factors that contributed the current crisis. Over a four-week period staff collected data from each sector of the long-term care continuum in an effort to understand the multiple factors that contributed to the current situation. Pressures, associated with patients being identified as needing an alternative level of care (ALC), have intensified over the past year. The mounting challenges led to Deputy Ministry Phil Hassen touring the Northwest. Shortly thereafter, an internal committee of the North Region Branch of the Ministry of Health and Long-Term Care was established to look at ALC pressures. Interim bed allocations across a number of northern communities followed thereafter as a means of alleviating pressures in the short-term. The North Region Branch of the Ministry also began negotiating with the northern District Health Councils the outline of a project that would deliver a ‘blueprint’ or plan for an integrated and coordinated long-term care system – both community and institutionally based – in the North over the next four years (2004-2008).

Overview of the Health Care System in the Cochrane District Factors Affecting Utilization Patterns Demographics The population of Northeastern Ontario declined by 4.4 percent between 1996 and 2001. During the same five-year period the population of Ontario grew by 6.1 percent. The Cochrane District experienced an even higher decline of 8.6 percent. The percentage of seniors aged 65 years and over in the Cochrane District increased in proportion to the total population at levels similar to that of the province (12.2 versus 12.9 percent). The City of Timmins experienced a 3.2 percent increase in its seniors’ population between 1996 and 2001 (increase of 155 seniors). The Aboriginal population in the Cochrane District is significantly higher than that of the province (9.8 versus 1.7 percent), and is considerably younger. Population projections to 2026 indicate that the ACMS planning area will experience substantially smaller growth (1.5 percent) than is anticipated for the province as a whole (31.4 percent). Additionally, the life expectancy of residents in the ACMS planning area is about 2 years less than the provincial rate (76.6 versus 78.6 years). Review of the Increasing Pressures of an Aging Population on the Health Care System in the City of Timmins and the Cochrane District – June 2004

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Determinants of Health Determinants of health have an impact on health status and the demand for health care services. Compared to provincial rates, the Cochrane District has a higher level of unemployment. Meaningful employment has been identified as a key determinant of health. The unemployed are at greater risk of developing mental health problems and an overall lower health status. The Cochrane District has a lower level of education in two categories - less than a high school education, and those with a university degree. Studies have demonstrated a relationship between lower levels of education, general health problems, and increased hospital utilization. Research has identified a strong link between income and health status. In general, low income correlates with lower levels of health status and higher rates of hospitalization. The profile of income or earnings from full-time employment for the overall population across the Cochrane District indicates that residents of the district earn on average 8 percent less than the provincial rate. Information specific to income levels of seniors (age 65+) reveals that average and median incomes for seniors living in the City of Timmins and/or the Cochrane District are lower than the provincial rates. Median income for females over the age of 65 is below the threshold for lowincome cut-off. Income levels also have an impact on the ability of seniors to consider privately funded alternatives for housing. Seniors living alone may be at a higher risk for premature placement if they do not have sufficient levels of support by informal caregivers (family and friends). Census data reveal that the Cochrane District has a higher ratio of persons aged 65 years and over living alone when compared to the provincial rate (31 versus 26.8 percent). The exodus of the younger segment of the northern population also has a corresponding impact on the availability of family members to provide support for aging parents and relatives. Health Status Risk Factors The health status of Northern Ontario residents is in general, poorer than that of Ontario residents. Risk factor prevalence provides some insight into why northerners have an overall lower health status. Smoking, high blood pressure, obesity and binge drinking all occur at levels that exceed provincial rates. Low rates of consumption of fruit and vegetables and low rates of physical activity also contribute to poorer health status. Mortality and Morbidity The Cochrane District experiences higher rates of mortality and morbidity. Over the five-year period, 1995 to 1999, mortality rates were 24 percent higher than the provincial experience. A review of selected diseases including cancer, circulatory, respiratory, injury and poisoning reveals mortality rates that exceed the provincial experience. Hospitalization rates (morbidity) for the same diseases all exceed provincial levels. Age-related diseases such as dementia are also projected to increase substantially over the next decade. Dementia cases are projected to increase by 40 percent across Ontario and 37 percent across the Cochrane District. Access to Primary Care Access to comprehensive primary care services is a growing concern to all Ontarians. In spite of numerous practice opportunities, there remain substantial numbers of physician and nurse Review of the Increasing Pressures of an Aging Population on the Health Care System in the City of Timmins and the Cochrane District – June 2004

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practitioner vacancies in many communities. Although physician to population ratios in the Cochrane District are comparable to the province, access to specialist services are considerably lower. Hospital emergency rooms are more commonly used by residents of the Cochrane District as compared to the provincial experience. In 2002/03 residents of the Cochrane District used hospital emergency rooms at levels that were 166 percent higher than provincial rates. This picture may point to inadequate access to other services. Examination of the leading reasons for visits to the emergency room reveals that a significant volume of visits, across the ACMS area, are for health issues that could be provided in an alternative setting. Emergency department data also provides insight into access to a family physician within the Cochrane District. Individuals indicating they have a family physician ranges from a low of 69.5 percent (Kapuskasing) to a high of 99.8 percent (Smooth Rock Falls and Bingham Memorial hospitals). The Timmins and District Hospital reported that 72.8 percent of ER visits noted having a family physician. Practice patterns of physicians in the north – most of whom share their time between private practice and hospital coverage – results in residents having access which is not always timely, which in turn may account for the high reliance on hospital based services. Alternate means of enhancing access to primary care services, such as Family Health Networks and multi-disciplinary clinics may decrease the reliance on hospitals for the provision of primary care services.

Community Support Services A review of community support services funded by the Ministry of Health and Long-Term Care highlights a number of gaps or inequities in the funding received in the Cochrane District relative to other northern districts. Key areas of concern relate to the provision of adult day services for the frail elderly or more specifically the inequity in the distribution of these services within the district from a population basis. Also identified as lacking are transportation services that facilitate access to primary care services and other community based supportive services. Ensuring that involuntary caregivers have access to adequate levels of support to care for the aging population is paramount.

Community Care Access Centre (CCAC) – Community Services In 2001/02, CCACs that were projecting deficits were mandated by the MOHLTC to balance their budgets. Cost recovery plans were developed and resulted in service level reductions for homemaking, personal care, attendant care, and respite services. The need for personal care was required for clients to remain eligible for CCAC services. The most noticeable cuts in units of service over the years were for homemaking services, which declined 17 percent since 2000/01. Nursing services also declined over a three-year period; there was a 6.2 percent gain in the last fiscal year, which resulted in service levels returning to 2001/02 rates. Compounding the impacts of the reductions to homemaking services was the reality that, in 1999, funding for the delivery of home help/homemaking services on a fee for service basis delivered by a community agency other than the CCAC - was transferred into the Cochrane District CCAC’s budget, at the request of the MOHLTC. A number of other districts and regions Review of the Increasing Pressures of an Aging Population on the Health Care System in the City of Timmins and the Cochrane District – June 2004

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of the province challenged the policy and ultimately were permitted to continue to offer the service. Hence, these areas now have access to the CCAC’s personal support/homemaking service and additional community support services on a co-payment basis. A review of CCAC assessment data was undertaken to provide insight into the profile of CCAC clients. The data reveal that the majority of clients are aged 75+; are females (72 percent of the caseload); are living alone (49 percent); and, that 27 percent are living with their spouses. From this clientele profile, one is drawn to the following conclusions: Female clients in the district are more likely to be living below the low income threshold therefore access to affordable housing will be of a greater concern; The proportion of CCAC clients living alone1 is 18 percent higher than the proportion of seniors living alone in the district (31 percent). Seniors that live alone without adequate levels of support are at a higher risk for premature placement within a long-term care setting; and, A quarter of CCAC clients rely heavily on informal caregivers (spouses). Spouses require supportive services to allow them to continue with their caregiving responsibilities. Supportive services such as access to respite, education, peer support, are limited within the Cochrane District. An overview of the client assessments undertaken by the CCAC over a one-year period (February 2003 to February 2004) reveals that the majority of individuals assessed by the CCAC were healthier in comparison to their provincial counterparts. Specifically, the assessment indicated that: Most clients (80 percent) had a ‘lesser degree of cognitive impairment’ which means that their skills for daily decision-making were high; Most clients (82 percent) received the highest score associated with their level of independence (rated based on activities of daily living and self-reliance); and, More than 75 percent of clients scored low for medical complexity and health instability. Additionally, these assessments revealed that a number of identified areas of concern – such as support levels, prevention measures, home care support, medication management, etc., could be managed through an enhancement of community-based services such as homecare, and personal care. Community-based supportive services for the aging population are vital to maintaining seniors living at home independently. It is well documented that providing supportive care to individuals living at home provides improvements in the quality of care and results in substantial financial efficiencies. It is worthy of mention however that in recent years, research conducted by Marcus Hollander expressed concern with a mindset that views home care as a substitute for acute care. While the provision of home care support can in some instances facilitate the discharge of patients from an acute setting back into the community, Hollander emphasized that cuts to home support and housekeeping services (as a means of reducing admissions) would result in an increased demand for acute health care services in future years. In his opinion, home care supports need to be focused on preventing admissions and not on facilitating discharges for the population with chronic health care needs. 1

Note that CCAC clients living alone will include clients less than 65 years of age.

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Alternate Housing Options The most conspicuous gap within the long-term care continuum within the Cochrane District is the absence of supportive housing2 for the frail elderly. This option would ensure that seniors, who find themselves needing an increasing level of support, but are still too independent or high functioning to warrant placement within a long-term care facility, have the ability to live independently much longer. The level of support would increase as the individual aged and their self-sufficiency diminished to the point where admission to a long-term care facility would become preferable. Without Ministry benchmarks, it is difficult to quantify the level of supportive housing needs within a community such as Timmins or the entire district3. Using benchmarks derived from the literature, one can estimate that a community the size of Timmins would have somewhere in the range of 152 to 355 individuals that would be ideal candidates for supportive housing. The low end of the range refers to individuals whose supportive needs would be considered high and the high end of the range refers to individuals with low supportive needs. Another important consideration is the inequity in the distribution and supply of private retirement facilities across the district. The City of Timmins is home to all but one of the retirement facilities. Moonbeam is home to a small private facility. All facilities indicate extremely low vacancy rates. Despite the high demand for the current supply of units, a recent attempt to add to the City’s supply of retirement living suites failed4. There is some indication that affordability is a key barrier for the senior population considering private retirement facilities. Conversely, low-income levels of district residents hinder the sustainability of some private for profit ventures. The Cochrane District Social Services Administration Board has advised that there is a sizeable waiting list for affordable social housing for seniors across the entire Cochrane District (i.e. close to 400 seniors are on a waiting list for 1,131 units).

Community Care Access Centre – Long-Term Care Facilities’ Placement Coordination A review of placement coordination statistics documented by the Cochrane District CCAC over the past five years, reveals a relatively stable caseload until 2003, at which point the caseload increased by 40.4 percent. Over this same period, the CCAC reported an average monthly waiting list increase of 72.6 percent. A more in-depth analysis of the placement coordination statistics revealed that:

2

3 4

Supportive Housing, also called Supportive Living, is rent geared to income housing that provides services that support independent living. For example, access to Personal Support Workers 24/7, congregate dining and medication management. The ACMS District Health Council study of supportive housing needs is currently underway for the Cochrane District. It is beyond our ability to comment on the viability of this private venture.

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In comparison to other districts in the ACMS planning area, the annual turnover rate of residents in the Cochrane District is considerably lower. A lower rate of turnover means that facilities admit a lower percentage of new residents on an annual basis. For the 2002/03 fiscal period, the turnover rate decreased by 4 percent. This translates into a reduction in bed availability of about 25 beds. The reduction in bed availability jumps to about 43 beds if one considers the change in turnover rates between the 2001/02 and 2002/03 fiscal periods. 2003/2004 is the fourth consecutive year that the Government of Ontario made the influenza vaccine available, free of charge, to all Ontarians over 6 months of age through its Universal Influenza Immunization Program (UIIP). Improved immunization of residents and staff of long-term care facilities may in part account for the increased longevity of residents, and the decrease in turnover rates.

Long-Term Care Institutional Facilities The Cochrane District has 635 long-term care beds5 scattered among 10 facilities located in seven communities dispersed within a land area of 141,244 square kilometres. The Cochrane District is considered above the provincial average based on the provincial benchmark of one hundred (100) long-term care beds per 1,000 population over the age of 75. Using 2001 population figures, Cochrane District has a bed ratio of 155 and the City of Timmins has a bed ratio of 141 with the provincial average being 100. A number of communities within the district have bed ratios in excess of 195. Benchmarks are based on a bed to population ratio and fail to account for a number of important factors such as a lack of community based supports or alternate affordable housing options. These factors influence and can provide rationale for the extreme demand for long-term care facilities within the district. A review of the level of care needs of residents (CMIs – Case Mix Index) occupying long-term care facilities within the Cochrane District indicates that, on average, these residents are relatively healthier than residents in other provincial long-term care facilities. Healthier residents housed within an environment which provides a high level of care will, naturally, live longer. Longer life spans will in turn affect the turnover rate within the facility, which in turn influences access to the current supply of long-term care beds. While one could question the appropriateness of placing residents within these long-term care facilities, it is important to note that an individual whose health care needs are relatively low can still satisfy Ministry criteria for placement within a long-term care bed. The lowest priority ranking is a Category 3 – defined as a person who does not meet the requirement for placement in any other category – which does allow access to long-term care beds for seniors who have no alternative housing options due to a lack of caregiver support, low-income levels, homelessness, etc. Once an individual becomes a resident, they usually continue to live there for the remainder of their life.

5

Includes 10 temporary/interim beds at the Timmins and District Hospital.

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The distance between facilities poses unique challenges to the placement of residents across the vast catchment area of the Cochrane District. The CCAC must balance bed availability from a system’s perspective while keeping in mind the human aspect of ensuring that residents are placed in close proximity to family and friends. At times, loved ones are placed at a considerable distances from their community, especially residents from the James Bay Coast. Work continues to gain approval for the development of LTC beds for the James Bay Coast so that elders from these communities can live close to home and within their cultural environment. In a previous report6, the ACMS District Health Council has supported the development of beds along the Coast. The demand for some facilities far exceeds that of others. The Golden Manor in Timmins is the facility of first choice for 70 percent of clients awaiting placement within the district. There is an inequity in the ratio of beds to population within the district. The City of Timmins accounts for 51 percent of the total district population, and accounts for 46.5 percent of the long-term bed complement for the entire district.7 Equity in bed to population ratios for the communities in the Cochrane District would necessitate a 28-bed increase to the current complement for the City of Timmins.

Hospital Utilization Data Admissions and Length of Stay In preparation for this review, the Timmins and District Hospital provided data pertaining to inpatients admissions. The information indicated that patients over the age of 65 occupy approximately 55 percent of in-patient beds. While length of stay for patients 65+ remained constant over the last two fiscal years, the adjusted length of stay of patients over the age of 65 has increased by 1.23 days. This increase relates to a 4.7 percent increase in the LOS of patients over the age of 80 as the number of patients 65+ has decreased. It is interesting to note that admissions to the hospital from long-term care facilities in Timmins have decreased by 28 percent in the last two fiscal years. Emergency Department An analysis of emergency room data revealed a rate of ER visits that well exceeds the provincial rate (166 percent higher). Health status factors account for almost twice as many visits (15.2 percent) in the ACMS planning area when compared to the provincial rate (8.19 percent). A number of these ‘health factors’ are issues that could be addressed in an alternate setting. Timely access to primary care likely accounts, in part, for the high reliance on the emergency department. Worthy of mention is that emergency department visits increased by 8 percent in the last two fiscal years yet ER visits from seniors 65+ decreased by 3 percent.

6 7

Algoma, Cochrane, Manitoulin and Sudbury District Health Council, Annual District Service Plan For LongTerm Care Community Services 2003/2004, March 2003 Temporary (10) beds excluded.

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Complex Continuing Care In general, an analysis of the RUG-III CMI of most Network 13 complex continuing care units revealed that the level of resource needs of patients occupying these beds is less than the provincial average. However, three facilities within the Network 13 cluster of hospitals stand out as having CMIs that are higher than the provincial rate. These include Timmins and District Hospital (19 percent higher), Anson General Hospital (4 percent higher), and Kirkland and District Hospital (6 percent higher). High and low CMI rates must be considered within the context of alternate health care services available within a community as the absence of more appropriate services may affect the decision to enter a hospital for the provision of care. Conversely, the range of health care services within a community may influence the hospital’s ability to discharge back to the community to a more appropriate level of care. Alternate Level of Care (ALC) Pressures Establishing a clear understanding of the ALC challenges faced by the Timmins and District Hospital over the years is complicated by reporting mechanisms. ALC patient days within the acute care setting are considered separately from ALC patient days within the complex continuing care setting. Additionally, the Timmins and District Hospital began to classify patients awaiting rehabilitation as being ALC, hence the 49 percent spike in ALC patients in 2001/02. The number of ALC days within the acute care setting has been steadily increasing across the entire cluster of Network 13 hospitals. In addition to these figures, the Timmins and District Hospital estimated that, in 2003/04, ALC days within its CCC unit equalled about 17 beds. Historical data provides insight into the most commonly cited reasons for an ‘incident’ being classified as an ALC. These ‘reasons’ were grouped into main themes: requiring rehabilitation; absence of caregiver supports; and, awaiting long-term care placement. A detailed assessment of ALC clients over the last 6-month period (October 2003 to May of 2004) reveals that 242 patients account for 355 ALC incidents. Seniors (65+) account for more than three quarters (¾) of the ALC patients over the last five fiscal periods. Of all ALC incidents reported during this period, 17 percent did NOT have a family physician and 83 percent were over the age of 65. The most pressing level of care needs identified included long-term care placements (37 percent), palliative care (10 percent), and rehabilitation (50 percent). Lack of home care services accounted for less than 2 percent of ALC incidents. Drawing from the Hollander research, this reinforces the theory that home care needs to be focused on preventing admissions and not on facilitating hospital discharges.

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Response to the Pressures on the Long-Term Care Continuum This report brings together numerous data sets in an attempt to draw a more complete picture of the factors that led to the recent alternate level of care crisis at the Timmins and District Hospital. This analysis reveals that the issue is complex and is due to many factors including: • geography; • demographics; • health status; • limited access to primary care alternatives; • underdeveloped community supports and services; • lack of a designated rehabilitation program at the Timmins and District Hospital; and • no additional LTC beds in the community given current provincial policy associated with the development of 20,000 new long term care beds across the province. Drawing from the findings of this discussion paper, the community has focused its efforts on five strategic areas. These are not to be considered an exclusive listing of the district’s long-term care needs. Such an exercise requires much more time and consultation than the current timelines allow. A series of DHC studies will delve further into these needs over the coming year from a district perspective (needs assessment of key community support services; supportive housing study, and a ‘blueprint’ for an integrated and coordinated long-term care system). Based on the work to date, the strategies to respond to the LTC pressures include: 1. 2. 3. 4. 5.

Coordination of Services for Specific Population Groups (palliative and geriatric) Community Support Services Supportive Housing Long-Term Care Beds Development of a Local/District Rehabilitation Program

It is imperative that the approach to building up the long-term care continuum in Timmins and the Cochrane District include enhancements to community supports and services. Without an investment in the community, residents will continue to clog up the hospital’s acute beds. Residents require access to a full range of supports and services to enable them to live independently in their homes. This is the current policy of the province but it requires additional resources.

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SOMMAIRE Contexte Le mercredi 26 mai 2004, l’Hôpital de Timmins et du district a mobilisé toutes ses ressources internes et externes afin de faire face à une crise qui l’a laissé sans lits pour les soins médicaux actifs, la chirurgie et les soins intensifs. Le 1er juin 2004, le ministère de la Santé et des Soins de longue durée a placé l’hôpital dans la catégorie 1A (classification de crise). Les patients de ce dernier en attente d’un placement dans un établissement de soins de longue durée sont donc considérés comme hautement prioritaires dans le district de Cochrane. Cette classification portera sur la période comprise entre le 1er juin et le 31 juillet 2004, date à laquelle elle pourra être prolongée, selon les circonstances. Le Conseil régional de santé d’Algoma-Cochrane-Manitoulin-Sudbury a reçu une demande émanant de la présidence du Réseau 13 afin d’aider la collectivité à comprendre les facteurs qui ont contribué à l’émergence de la crise actuelle. Pendant quatre semaines, le personnel a recueilli des données auprès de chaque secteur du continuum des soins de longue durée afin de remplir cette mission. Au cours de la dernière année, les pressions associées aux patients ayant besoin d’un autre niveau de soins (ANS) se sont intensifiées. Les défis croissants ont amené le sous-ministre Phil Hassen à effectuer une visite de la région du Nord-Ouest. Peu après, un comité interne de la direction de la région du Nord du ministère de la Santé et des Soins de longue durée a été formé afin d’examiner les pressions liées aux ANS. Dans plusieurs communautés du Nord, des lits ont été attribués provisoirement en vue d’atténuer les pressions à court terme. La direction de la région du Nord du ministère a aussi entamé des négociations avec les conseils régionaux de santé du Nord concernant les grandes lignes d’un projet qui déboucherait sur un « modèle » ou un plan, pour les quatre prochaines années (2004-2008), visant un système intégré et coordonné de soins de longue durée – au sein de la communauté et des établissements – dans le Nord.

Vue d’ensemble du système de soins de santé du district de Cochrane Facteurs touchant les profils d’utilisation des services de santé Données démographiques Entre 1996 et 2001, la population du Nord-Est de la province a chuté de 4,4 pour cent tandis que celle de l’Ontario a augmenté de 6,1 pour cent. Le district de Cochrane a enregistré une diminution plus importante encore : 8,6 pour cent. Dans ce district, le pourcentage de personnes âgées de 65 ans et plus a connu par rapport à l’ensemble de la population une augmentation similaire à celle de la province (12,2 pour cent contre 12,9 pour cent). Entre 1996 et 2001, dans la ville de Timmins, le nombre de personnes âgées s’est accru de 3,2 pour cent (+155 personnes). Proportionnellement, la population autochtone du district de Cochrane est beaucoup plus importante que celle de la province (9,8 pour cent contre 1,7 pour cent) et compte une proportion considérablement plus élevée de jeunes. Selon les projections démographiques pour 2026, la région de planification d’Algoma-Cochrane-Manitoulin-Sudbury connaîtra une croissance Review of the Increasing Pressures of an Aging Population on the Health Care System in the City of Timmins and the Cochrane District – June 2004

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démographique largement inférieure (1,5 pour cent) à celle de l’ensemble de la province (31,4 pour cent). Aussi, les personnes résidant dans cette région ont une espérance de vie inférieure de deux ans à la moyenne provinciale (76,6 ans contre 78,6 ans). Déterminants de la santé Les déterminants de la santé influencent l’état de santé et la demande en services de soins. Le district de Cochrane possède un taux de chômage supérieur à la moyenne provinciale. Il a été établi que le fait d’avoir un emploi valable constituait un déterminant essentiel de la santé. Les personnes sans emploi risquent davantage de souffrir de problèmes de santé mentale et d’être moins bien portantes. Le district de Cochrane présente un niveau de scolarité plus faible dans deux catégories – le plus haut pourcentage de personnes ayant moins qu’un diplôme d’études secondaires et le plus bas pourcentage de personnes ayant un diplôme universitaire. Des études ont démontré un lien entre un niveau de scolarité faible, des problèmes de santé générale et un nombre d’hospitalisations plus élevé. Selon les recherches, revenu et santé sont intimement liés. En règle générale, il existe un lien étroit entre un faible revenu d’une part et un mauvais état de santé et un plus grand nombre d’hospitalisations d’autre part. D’après le profil du revenu ou des gains liés à un emploi à plein temps pour l’ensemble de la population du district de Cochrane, les personnes vivant dans ce district disposent d’un revenu inférieur d’environ 8 pour cent à la moyenne provinciale. Selon les renseignements spécifiques aux niveaux de revenu des 65 ans et plus, les revenus moyen et médian des personnes âgées vivant dans la ville de Timmins ou dans le district de Cochrane sont inférieurs aux moyennes provinciales. Le revenu médian des femmes de plus de 65 ans se situe sous le seuil de faibles revenus. Les niveaux de revenu influent également sur la capacité des personnes âgées à envisager le recours à des solutions de logement dans le secteur privé. Les personnes âgées vivant seules sont davantage exposées au risque de placement prématuré si elles ne bénéficient pas d’un niveau de soutien suffisant de la part de soignants naturels (famille et amis). Selon les données de recensement, dans le district de Cochrane, la proportion de personnes âgées de 65 ans et plus vivant seules est plus élevée que dans la province (31 pour cent contre 26,8 pour cent). Au sein de la population du Nord, l’exode des jeunes a également eu une influence sur la disponibilité des membres de la famille pour aider les parents et les proches vieillissants. Facteurs de risque pour l’état de santé La santé des résidents du Nord de l’Ontario est, en général, moins bonne que celle du reste de la population de la province. La prévalence des facteurs de risque donne certaines indications sur les raisons de ce phénomène. Le nombre de fumeurs, de personnes souffrant d’hypertension, d’obésité et ayant une consommation excessive d’alcool dépasse les moyennes provinciales. La faible consommation de fruits et de légumes et le manque d’exercice physique contribuent également à la moins bonne santé de la population.

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Mortalité et morbidité Le district de Cochrane présente des taux de mortalité et de morbidité plus élevés. De 1995 à 1999, le taux de mortalité était supérieur de 24 pour cent au taux provincial. Une étude portant sur des maladies telles que le cancer, les maladies du système circulatoire, les maladies respiratoires, les blessures et les intoxications, révèle des taux de mortalité dépassant les taux provinciaux. Les taux d’hospitalisation (morbidité) pour les mêmes maladies dépassent tous les niveaux provinciaux. Selon les prévisions, le nombre de maladies liées à l’âge, telles que la démence, connaîtra une hausse importante au cours de la prochaine décennie. Les cas de démence augmenteront vraisemblablement de 40 pour cent pour l’ensemble de l’Ontario et de 37 pour cent pour le district de Cochrane. Accès aux soins primaires L’accès à des services complets de soins primaires préoccupe de plus en plus les Ontariennes et Ontariens. Malgré de nombreuses possibilités d’exercer, beaucoup de postes de médecin et d’infirmières et infirmiers praticiens restent vacants dans un grand nombre de collectivités. Bien que le rapport du nombre de médecins à la population dans le district de Cochrane soit comparable à celui de la province, l’accès aux services de spécialistes y est largement inférieur. Les résidents du district de Cochrane fréquentent davantage les services d’urgence des hôpitaux que le reste de la population de la province. En 2002-2003, ils ont eu recours à ces services dans des proportions dépassant de 166 pour cent les taux provinciaux. Ce phénomène peut éventuellement être révélateur d’un accès inadéquat aux autres services. Un examen des principales raisons des consultations aux urgences révèle que pour l’ensemble de la région d’Algoma-Cochrane-Manitoulin-Sudbury, un volume considérable de consultations porte sur des questions de santé qui pourraient être résolues dans un autre cadre. Les données des services d’urgence fournissent des renseignements sur l’accès à un médecin de famille dans le district de Cochrane. L’éventail de personnes indiquant avoir un médecin de famille se situe entre un minimum de 69,5 pour cent (Kapuskasing) et un maximum de 99,8 pour cent (l’hôpital Smooth Rock Falls et l’hôpital Bingham Memorial). Selon l’Hôpital de Timmins et du district, 72,8 pour cent des personnes ayant consulté les urgences affirmaient avoir un médecin de famille. En raison des habitudes de pratique des médecins du Nord qui, pour la plupart, partagent leur temps entre l’exercice privé et le travail en milieu hospitalier, les résidents n’ont pas toujours accès à ces soins en temps opportun, ce qui peut expliquer pourquoi ils comptent beaucoup sur les services hospitaliers. D’autres moyens d’améliorer l’accès aux services de soins primaires, tels que les réseaux Santé familiale et les polycliniques, pourraient réduire la dépendance à l’égard des hôpitaux pour ce qui est de la prestation de services en la matière.

Services de soutien communautaires Un examen des services de soutien communautaires subventionnés par le ministère de la Santé et des Soins de longue durée met en lumière un certain nombre de lacunes ou d’inégalités au niveau du financement reçu dans le district de Cochrane par rapport aux autres districts du Nord. Les principaux sujets de préoccupation portent sur la prestation de services de jour auprès des personnes âgées fragiles ou, plus spécialement sur l’inégalité au niveau de la répartition de ces services au sein même du district sur le plan de la population. Cet examen souligne également le Review of the Increasing Pressures of an Aging Population on the Health Care System in the City of Timmins and the Cochrane District – June 2004

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manque de moyens de transport facilitant l’accès aux services de soins primaires et à d’autres services de soutien communautaires. Il est primordial de veiller à ce que les soignants non bénévoles aient accès à des niveaux de soutien adéquats afin de prendre soin de la population âgée.

Centre d’accès aux soins communautaires – Services communautaires En 2001-2002, le ministère de la Santé et des Soins de longue durée a chargé les centres d’accès aux soins communautaires qui prévoyaient des déficits d’équilibrer leur budget. Des plans de recouvrement des coûts ont été élaborés, entraînant une réduction des niveaux de service pour les services d’aide familiale, les soins personnels, les services d' auxiliaires et les soins de relève. Pour rester admissibles aux services des centres d’accès aux soins communautaires, les clients devaient avoir besoin de soins personnels. Les réductions les plus flagrantes au niveau des unités de service portaient sur les services d' aide familiale, qui ont chuté de 17 pour cent depuis 20002001. Les services de soins infirmiers ont connu une baisse pendant une période de trois ans. Ils ont enregistré une hausse de 6,2 pour cent au cours du dernier exercice financier, ce qui les a ramenés aux niveaux atteints en 2001-2002. À l’impact des réductions touchant les services d' aide familiale s’ajoute le fait qu’en 1999, le financement de la prestation de services d’aide familiale selon la formule de rémunération à l’acte - fournis par un organisme communautaire autre que le centre d’accès aux soins communautaires – a été transféré au budget du Centre d’accès aux soins communautaires du district de Cochrane, à la demande du ministère de la Santé et des Soins de longue durée. Un certain nombre d’autres districts et régions de la province ont contesté cette politique et ont finalement été autorisés à continuer à offrir ces services. Ainsi, ces régions ont désormais accès aux services d’aide familiale/de soutien personnel du Centre d’accès aux soins communautaires et aux autres services de soutien communautaires selon la formule du partage des frais. Un examen des données d’évaluation du Centre d’accès aux soins communautaires a été entrepris afin de dessiner le profil de ses clients. Selon ces données, la majorité des clients sont âgés de 75 ans et plus, sont des femmes (72 pour cent des dossiers traités) et vivent seuls (49 pour cent) ou avec leur conjoint ou conjointe (27 pour cent). À partir de ce profil de la clientèle, il est possible de formuler les conclusions suivantes : les clientes résidant dans le district sont plus susceptibles de vivre sous le seuil de faibles revenus et, donc, l’accès à un logement à un coût abordable constituera pour elles une importante préoccupation; la proportion des clients des centres d’accès aux soins communautaires vivant seuls1 est supérieure de 18 pour cent à la proportion de personnes âgées vivant seules dans le district (31 pour cent). Les personnes âgées vivant seules sans disposer d’un niveau de soutien adéquat sont davantage exposées au risque d’un placement prématuré dans un établissement de soins de longue durée; un quart des clients des centres d’accès aux soins communautaires dépendent fortement de soignants naturels (conjoint ou conjointe). Le conjoint ou la conjointe a besoin de 1

Remarque : les clients des centres d’accès aux soins communautaires vivant seuls engloberont les clients de moins de 65 ans.

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services de soutien afin de pouvoir continuer à assumer ses responsabilités. Ces services, tels que l’accès à des services de relève, à une formation ou au soutien des pairs, sont limités dans le district de Cochrane. Un survol des évaluations de la clientèle entreprises par le Centre d’accès aux soins communautaires sur une période d’un an (de février 2003 à février 2004) indique que les personnes évaluées par le Centre étaient, pour la plupart, en meilleure santé que leurs homologues de la province. Plus précisément, l’évaluation a indiqué les faits suivants : la plupart des clients (80 pour cent) avaient un « niveau de déficience intellectuelle inférieur », ce qui signifie qu’ils avaient de très bonnes aptitudes à prendre les décisions quotidiennes; la plupart des clients (82 pour cent) ont obtenu les résultats les plus élevés pour ce qui est de leur niveau d’indépendance (déterminé en fonction de leurs activités quotidiennes et de leur autonomie); plus de 75 pour cent des clients ont obtenu un faible résultat au niveau de la complexité médicale et de l’instabilité de leur état de santé. D’autre part, ces évaluations ont révélé qu’un certain nombre des préoccupations soulevées – par exemple celles concernant les niveaux de soutien, les mesures de prévention, les soins à domicile et la gestion de la pharmacothérapie – pouvaient être dissipées grâce à une amélioration des services communautaires comme les soins à domicile et les soins personnels. Il est bien établi que le fait de proposer des soins de soutien à domicile permet d’améliorer la qualité des soins et est financièrement avantageux. Cependant, il est intéressant de remarquer que, dans des recherches menées ces dernières années, Marcus Hollander s’est inquiété du fait que les soins à domicile étaient considérés comme un substitut aux soins de courte durée. Bien que la prestation de services de soutien à domicile puisse dans certains cas faciliter la sortie des patients des services de soins actifs et leur retour dans la collectivité, Hollander a souligné que les réductions touchant les services de soutien à domicile et les services d’aide ménagère (comme moyen de réduire les admissions) engendreraient une augmentation de la demande en services de soins actifs dans les années à venir. Selon lui, l’objectif principal des services de soins à domicile doit être de limiter les admissions et non de faciliter la sortie des personnes ayant des besoins chroniques en matière de soins de santé.

Autres solutions de logement Dans le district de Cochrane, la lacune la plus évidente dans le continuum des soins de longue durée est l’absence de logements avec services de soutien2 pour les personnes âgées fragiles. Cette solution permettrait aux personnes âgées qui ont de plus en plus besoin de soutien mais qui sont encore suffisamment valides ou trop autonomes pour justifier un placement dans un établissement de soins de longue durée, de pouvoir vivre de manière indépendante plus longtemps. Le niveau de soutien augmenterait avec l’âge de la personne et la diminution de son 2

Un logement avec services de soutien est un logement dont le loyer est calculé en fonction du revenu et qui propose des services permettant de vivre de manière indépendante. Par exemple, accès à des préposés aux services de soutien à la personne (24 heures sur 24, sept jours sur sept), repas communautaires et gestion de la pharmacothérapie.

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autonomie jusqu’au moment où son admission au sein d’un établissement de soins de longue durée deviendrait préférable. En l’absence de repères ministériels, il est difficile d’évaluer l’ampleur des besoins en matière de logements avec services de soutien pour une collectivité telle que Timmins ou l’ensemble du district3. En utilisant des repères puisés dans la documentation, il est possible d’estimer qu’une collectivité de la taille de Timmins devrait compter de 152 à 355 candidats idéaux à un logement avec services de soutien. À un bout de l’échelle figureraient les personnes ayant d’importants besoins en services de soutien et à l’autre bout les personnes en ayant peu. Une autre préoccupation importante concerne l’inégalité de la répartition et de l’offre en matière de maisons de retraite privées dans le district. La ville de Timmins accueille toutes les maisons de retraite à l’exception d’un petit établissement privé, situé à Moonbeam. Tous les établissements font état d’un taux d’inoccupation extrêmement bas. C’est en dépit d’une forte demande par rapport à l’offre actuelle qu’a échoué une tentative récente destinée à accroître le nombre d’unités de logement pour retraités proposées par la ville4. Certains indices laissent penser que l’aspect financier constitue un obstacle essentiel qui empêche les personnes âgées d’envisager le placement en maison de retraire privée. Inversement, les faibles niveaux de revenu des résidents du district compromettent la durabilité de certaines entreprises privées à but lucratif. Le Conseil d’administration des services sociaux du district de Cochrane a indiqué qu’il existait une très longue liste d’attente pour les personnes âgées souhaitant obtenir un logement social à un prix abordable dans l’ensemble du district (près de 400 personnes âgées figurent sur une liste d’attente pour 1 131 logements).

Centre d’accès aux soins communautaires – services de coordination des placements dans les établissements de soins de longue durée Un examen des statistiques des Services de coordination des placements, compilées par le Centre d’accès aux soins communautaires du district de Cochrane au cours des cinq dernières années, indique que le nombre de dossiers à traiter est resté relativement stable jusqu’en 2003, moment à partir duquel il a enregistré une hausse de 40,4 pour cent. Au cours de cette même période, le Centre d’accès aux soins communautaires a fait état d’une augmentation de 72,6 pour cent au niveau de la liste d’attente mensuelle moyenne. Une analyse plus détaillée des statistiques des Services de coordination des placements a révélé les faits suivants : le taux de renouvellement annuel des pensionnaires dans le district de Cochrane est largement inférieur à celui des autres districts de la région de planification d’AlgomaCochrane-Manitoulin-Sudbury. Lorsque le taux de renouvellement est faible, les établissements admettent un pourcentage annuel moins élevé de nouveaux pensionnaires; pour l’exercice 2002-2003, le taux de renouvellement a diminué de 4 pour cent, ce qui correspond à 25 lits en moins. Cette diminution atteint les 43 lits si l’on tient compte du 3 4

L’étude du Conseil régional de santé d’Algoma-Cochrane-Manitoulin-Sudbury portant sur les besoins en matière de logements avec services de soutien est actuellement en cours pour le district de Cochrane. Il ne nous appartient pas de formuler des observations sur la viabilité de cette entreprise privée.

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changement intervenu au niveau des taux de renouvellement entre les exercices 2001-2002 et 2002-2003; en 2003-2004, pour la quatrième année de suite, le gouvernement de l’Ontario a gratuitement mis le vaccin contre la grippe à la disposition de l’ensemble des Ontariennes et Ontariens de plus de six mois, par l’intermédiaire de son Programme universel de vaccination antigrippale. La meilleure immunisation des pensionnaires et du personnel des établissements de soins de longue durée joue peut-être un rôle dans l’augmentation de la longévité des pensionnaires et dans la diminution des taux de renouvellement.

Établissements publics de soins de longue durée Le district de Cochrane compte 635 lits de soins de longue durée5 répartis entre 10 établissements, situés dans 7 collectivités dispersées sur un territoire d’une superficie de 141 244 kilomètres carrés. Il est considéré comme étant au-dessus de la référence provinciale, qui est de 100 lits de soins de longue durée pour 1 000 personnes de plus de 75 ans. Si l’on se réfère aux chiffres de la population pour 2001, le ratio de lits est de 155 pour le district de Cochrane et de 141 pour la ville de Timmins, tandis que la moyenne provinciale est de 100. Un certain nombre de collectivités du district ont un ratio de lits dépassant 195. Les repères sont définis en fonction de la proportion de lits par rapport à la population et ne rendent pas compte d’un certain nombre de facteurs importants tels que l’absence de soutiens communautaires ou de solutions de rechange abordables en matière de logement. Ces facteurs influencent et peuvent expliquer la très forte demande au niveau des établissements de soins de longue durée dans le district. Un examen du niveau des besoins en soins des pensionnaires (indice des groupes clients) d’établissements de soins de longue durée du district de Cochrane indique qu’en moyenne, ces pensionnaires se portent relativement mieux que ceux des autres établissements de soins de longue durée de la province. Des pensionnaires en meilleure santé qui évoluent dans un environnement proposant un niveau élevé de soins vivront, naturellement, plus longtemps. L’accroissement de la longévité influera à son tour sur le taux de renouvellement de l’établissement, ce qui se répercutera sur la disponibilité des lits de soins de longue durée. Bien qu’il soit possible de remettre en question l’opportunité du placement dans ces établissements de soins de longue durée, il est important de remarquer qu’une personne dont les besoins en soins de santé sont relativement faibles peut néanmoins satisfaire aux critères du ministère pour un placement dans un tel établissement. Le classement le moins prioritaire est la catégorie 3 (personne qui ne satisfait pas aux exigences pour un placement dans une autre catégorie), qui permet à des personnes âgées n’ayant pas de solution de rechange en matière de logement parce qu’elles ne peuvent pas compter sur le soutien d’un aidant, qu’elles ont un faible niveau de revenu, qu’elles sont sans abri, etc., d’obtenir une place dans un établissement de soins de longue durée. À partir du moment où une personne entre dans ce type d’établissement, elle y reste généralement jusqu’à la fin de sa vie.

5

Inclut 10 lits temporaires/provisoires à l’Hôpital de Timmins et du district.

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La distance entre les établissements constitue un obstacle particulier au placement des résidents dans la vaste région couverte par le district de Cochrane. Le Centre d’accès aux soins communautaires doit équilibrer la disponibilité des lits du point de vue du système sans pour autant oublier l’aspect humain, qui consiste à s’assurer que les résidents sont placés à proximité de leur famille et de leurs amis. Parfois, les êtres chers sont placés à une distance considérable de leur collectivité, en particulier les personnes originaires de la côte de la baie James. Les efforts se poursuivent afin de faire approuver la création de lits de soins de longue durée pour la côte de la baie James de façon à éviter que les personnes âgées de ces collectivités soient placées trop loin de leur famille et de leur milieu culturel. Dans un rapport précédent6, le Conseil régional de santé d’Algoma-Cochrane-Manitoulin-Sudbury a soutenu la création de lits le long de la côte. Certains établissements sont largement plus demandés que d’autres. Le Golden Manor de Timmins constitue le premier choix de 70 pour cent des clients en attente d’un placement dans le district. Dans ce district, il existe une inégalité au niveau de la proportion des lits par rapport à la population. La ville de Timmins représente 51 pour cent de la population totale du district et compte 46,5 pour cent des lits de soins de longue durée pour l’ensemble du district7. Pour rétablir l’égalité, il serait nécessaire d’ajouter 28 lits à ceux déjà disponibles pour la ville de Timmins.

Données relatives aux hospitalisations Admissions et durée du séjour En préparation à cet examen, l’Hôpital de Timmins et du district a fourni des données relatives aux hospitalisations. Selon ces renseignements, les patients de plus de 65 ans occupent environ 55 pour cent des lits pour les hospitalisés. Bien que la durée du séjour de cette catégorie de patients soit restée constante au cours des deux dernières années fiscales, elle a augmenté de 1,23 jour selon les données rajustées. Cette augmentation correspond à une hausse de 4,7 pour cent de la durée de séjour des patients de plus de 80 ans étant donné que le nombre de patients de 65 ans et plus a diminué. Il est intéressant de remarquer qu’à Timmins le nombre d’hospitalisations de patients en provenance d’établissements de soins de longue durée a diminué de 28 pour cent au cours des deux derniers exercices. Services d’urgence Une analyse des données relatives aux services d’urgence indique un taux de consultation dépassant de loin le taux provincial (de 166 pour cent). Les facteurs d’état de santé sont à l’origine de presque deux fois plus de consultations (15,2 pour cent) dans la région de planification d’Algoma-Cochrane-Manitoulin-Sudbury par rapport au taux provincial (8,19 pour cent). Un certain nombre de ces « facteurs d’état de santé » concernent des problèmes qui pourraient être traités dans un autre cadre. L’accès en temps opportun aux soins primaires joue vraisemblablement un rôle partiel dans la forte dépendance à l’égard des services d’urgence. Il doit également être mentionné que les consultations aux urgences ont enregistré une hausse de 8 pour cent au cours des deux derniers exercices tandis que les consultations pour les personnes de 65 ans et plus ont diminué de 3 pour cent. 6 7

Conseil régional de santé d' Algoma-Cochrane-Manitoulin-Sudbury, Plan annuel de services de district – services communautaires de soins de longue durée 2003/2004, mars 2003. Les lits temporaires (10) sont exclus.

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Soins continus complexes De manière générale, une analyse de l’indice des groupes clients RUG III de la plupart des unités de soins continus complexes du Réseau 13 a révélé que les besoins en ressources des patients occupant ces lits sont inférieurs à la moyenne provinciale. Toutefois, trois établissements du groupement d’hôpitaux du Réseau 13 se distinguent par des indices des groupes clients supérieurs au taux provincial. Il s’agit de l’Hôpital de Timmins et du district (+ 19 pour cent), de l’Hôpital général Anson (+ 4 pour cent) et de l’Hôpital de Kirkland et du district (+ 6 pour cent). Les valeurs élevées et basses des indices des groupes clients doivent être examinées dans le contexte des services disponibles dispensant d’autres niveaux de soins au sein d’une collectivité dans la mesure où l’absence de services plus adéquats peut influencer la décision de se tourner vers l’hôpital pour recevoir des soins. Inversement, l’éventail de services de soins de santé disponibles dans une collectivité peut influencer la capacité de l’hôpital à réorienter des patients afin que ceux-ci reçoivent un niveau de soins plus approprié. Problèmes liés aux autres niveaux de soins Les mécanismes de reddition des comptes ne facilitent pas la tâche lorsqu’il s’agit d’obtenir une vision claire des difficultés auxquelles a été confronté l’Hôpital de Timmins et du district pendant des années en ce qui concerne les autres niveaux de soins. Les jours-patients consacrés à d’autres niveaux de soins dans le service de soins actifs sont comptabilisés séparément de ceux du service de soins continus complexes. De plus, l’Hôpital de Timmins et du district a commencé à classer ses patients en attente de réadaptation dans la catégorie des autres niveaux de soins, d’où la pointe de 48 pour cent au niveau de ces patients en 2001-2002. Le nombre de jours consacrés à d’autres niveaux de soins dans un service de soins actifs a enregistré une hausse constante dans l’ensemble des hôpitaux du Réseau 13. Outre ces chiffres, l’Hôpital de Timmins et du district a estimé qu’en 2003-2004, les jours consacrés à d’autres niveaux de soins dans son unité de soins complexes continus équivalaient à 17 lits. Les données historiques fournissent des indications sur les raisons les plus fréquemment citées pour qu’un « cas » soit classé dans la catégorie « autres niveaux de soins ». Ces « raisons » ont été regroupées sous de grands thèmes : nécessite une réadaptation; ne bénéficie pas du soutien d’un soignant; en attente d’un placement dans un établissement de soins de longue durée. Selon une évaluation approfondie des patients nécessitant d’autres niveaux de soins portant sur les six derniers mois (d’octobre 2003 à mai 2004), 242 patients représentent 355 cas nécessitant d’autres niveaux de soins. Les personnes âgées (65 ans et plus) représentent plus des trois quarts des patients nécessitant d’autres niveaux de soins pour les cinq derniers exercices. Sur l’ensemble des cas signalés au cours de cette période, 17 pour cent n’avaient PAS DE médecin de famille et 83 pour cent avaient plus de 65 ans. Les besoins en soins les plus pressants étaient les placements dans des établissements de soins de longue durée (37 pour cent), les soins palliatifs (10 pour cent) et la réadaptation (50 pour cent). Le manque de services de soins à domicile représentait moins de 2 pour cent des cas nécessitant d’autres niveaux de soins. D’après les recherches effectuées par Hollander, ce qui précède Review of the Increasing Pressures of an Aging Population on the Health Care System in the City of Timmins and the Cochrane District – June 2004

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renforce la théorie selon laquelle les soins à domicile doivent viser à prévenir les admissions plutôt qu’à faciliter les congés d’hôpitaux.

Réaction aux problèmes touchant le continuum des soins de longue durée Ce rapport rassemble de nombreuses données afin de dresser le portrait le plus complet possible des facteurs qui sont à l’origine de la crise touchant les autres niveaux de soins qui a récemment frappé l’Hôpital de Timmins et du district. Cette analyse révèle qu’il s’agit d’un problème complexe, résultant de nombreux facteurs tels que : • la situation géographique; • les données démographiques; • l’état de santé des résidents; • l’accès limité à des solutions de rechange au niveau des soins primaires; • le manque de développement des soutiens et services communautaires; • l’absence d’un programme de réadaptation attitré à l’Hôpital de Timmins et du district; • le fait qu’aucun ajout de lits de soins de longue durée dans la collectivité ne soit envisagé en raison des politiques provinciales actuelles prévoyant la mise en place de 20 000 lits de ce type dans la province. Compte tenu des conclusions de ce document de travail, la collectivité a concentré ses efforts sur cinq domaines stratégiques. Ceux-ci ne doivent pas être considérés comme une liste exhaustive des besoins du district en matière de soins de longue durée. Un tel exercice exige beaucoup plus de temps et une plus vaste consultation que ne nous le permettent les échéances actuelles. Une série d’études du Conseil régional de santé examinera ces besoins plus en détail au cours de l’année à venir à l’échelle du district (évaluation des besoins des principaux services communautaires de soutien; étude portant sur les logements avec services de soutien; et « plan directeur » pour un système de soins de longue durée intégré et coordonné). Élaborées en fonction des travaux réalisés à ce jour, les stratégies visant à répondre aux contraintes des soins de longue durée comportent notamment : 1. la coordination de services destinés à des segments de population spécifiques (soins palliatifs et gériatriques); 2. des services communautaires de soutien; 3. des logements avec services de soutien; 4. des lits de soins de longue durée; 5. l’élaboration d’un programme de réadaptation à l’échelle du district ou à l’échelon local. L’approche adoptée en vue de bâtir le continuum des soins de longue durée à Timmins et dans le district de Cochrane doit impérativement prévoir l’amélioration des services et soutiens communautaires. Sans un investissement dans la collectivité, les résidents continueront à engorger les lits de soins actifs des hôpitaux. Ils doivent avoir accès à un éventail complet de soutiens et de services afin de pouvoir vivre chez eux de manière indépendante. Telle est la politique actuelle de la province. Cependant sa mise en œuvre nécessitera des ressources supplémentaires.

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BACKGROUND & INTRODUCTION To understand the genesis of the current Alternative Level of Care (ALC) crisis in the Cochrane District, one must first understand the structure of the continuum of care that exists to serve longterm care patients. The continuum normally spans from community-based support services that enable residents to live independently in their homes, to long-term care facilities and retirement homes that offer personal and nursing care. Acute care services are also part of that continuum in that hospitals treat acute episodes requiring round-the-clock medical and nursing care. Over the last few years, the level of community-based services has dwindled in the Cochrane District. For example, as a result of being legislatively mandated to balance its budget, the Cochrane District Community Care Access Centre reduced personal care and homemaking service levels. This, coupled with the lack of supportive housing complexes and the waiting lists for affordable seniors housing, resulted in not enough options available to support residents in their homes. Instead, Cochrane residents have chosen to be placed in long-term care facilities even though they are healthier based on objective assessment scales and require a lighter level of care, when compared to the provincial average. In addition, Cochrane residents in long-term care facilities live longer than their provincial counterparts, a fact that impacts upon the rate at which long-term care facilities can accept new residents (i.e. turnover rate). The acute care sector is also impacted by these factors. Hospital in-patients who no longer require acute care but who are dependent on personal and nursing supports cannot find appropriate alternatives. Most are placed on a waiting list for a long-term care facility. However, due to the low turnover rate, placement is sometimes delayed and the district hospitals cannot fill these beds with acute patients, thereby creating a patient flow crisis for the system. On Wednesday, May 26, 2004, the Timmins and District Hospital (TDH) declared an internal crisis affecting the availability of its in-patient beds as a means of mobilizing all internal and external resources to deal with an under-capacity situation, which resulted in the hospital having no acute medical, surgical or ICU (intensive care unit) inpatient beds available for new admissions. In addition, admitted patients waiting for beds were occupying many Emergency Department stretchers, thereby reducing the hospital’s capacity to deal with emergency cases. The internal crisis is the direct result of more than 60 alternate level of care (ALC) patients occupying the hospital’s acute beds. These patients do not require intensive around-the-clock care; rather, they have been identified as having alternate level of care needs that should be transferred to alternate settings according to their less acute needs. Multiple factors impact the timely transfer of these clients to an alternate setting, such as the availability of long-term care beds and access to appropriate community support services that would allow individuals to convalesce safely in their own homes. On June 1st, 2004, the Ministry of Health and Long-Term Care issued a Category 1-A Crisis Designation for the Timmins and District Hospital. The designation means that hospital inpatients awaiting transfer to nursing homes will be given top priority for transfers to facilities within the Cochrane District. Designation will be in effect from June 1 until July 31st, 2004, at which time the designation may be extended depending on local circumstances.

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TDH administrators, local health care stakeholders, District Health Council planning staff, and Ministry of Health and Long-Term Care representatives are working together to develop shortterm solutions to address the current crisis while simultaneously working towards the implementation of longer term solutions that will ensure that the health care resources are reflective of the needs of the community. The ALC pressure faced by the hospital is indicative of a larger community-based problem. The various factors that collectively contributed to the current crisis at the Timmins and District Hospital must be understood so that the solutions that are developed and implemented truly reflect the community’s needs. This review is organized into sections that will help the reader visualize how gaps within one sector of the health care system result in pressures being placed on other services along the continuum of care. The review is divided into the following sections: 1. 2. 3. 4. 5. 6. 7. 8. 9.

Factors Affecting Utilization Patterns Community Support Services Community Care Access Centre – Community Services Community Care Access Centre – Long-Term Care Placements Long-Term Care Institutional Facilities Alternate Housing Options Hospital Utilization Data Proposals to Improve the Utilization of Health Care Resources Overview of the Health Care System

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1.0 FACTORS AFFECTING UTILIZATION PATTERNS 1.1

Demographics Population

Between 1996 and 2001, the population of Ontario increased by 6 percent (Table 1). Comparatively, the North experienced a population decline of 4 percent. Over the same period, the District of Cochrane’s population declined by 8.6 percent. The City of Timmins also experienced a population decline of 8 percent over the five-year period. Table 1:

Population Change in Selected Districts, North Region and Ontario, 1996 and 2001

JURISDICTION Cochrane District Sudbury District Timiskaming District Northeast North Ontario

2001 85,247 22,894 34,442 604,778 839,549 11,410,046

1996 93,240 23,831 37,807 632,622 876,739 10,753,576

% CHANGE - 8.6 -3.9 - 8.9 - 4.4 - 4.2 + 6.1

Source: Statistics Canada, 2001 Census.

Table 2 documents the aging population in the ACMS area as compared to the provincial experience. Most of the ACMS area is marginally older than the population of Ontario as demonstrated by the proportion of residents aged 65 years and older. The population of the District of Cochrane is aging at levels approaching the provincial experience. Table 2:

Proportion of Population Age 65 Years and Over, ACMS Districts, Ontario, 2001

JURISDICTION Algoma District Cochrane District Manitoulin District Sudbury District Greater Sudbury ACMS Ontario

PROPORTION OF POPULATION AGE 65+ 16.5 12.2 16.6 13.3 13.9 14.3 12.9

Source: Statistics Canada, 2001 Census.

PROPORTION OF POPULATION AGE 75+ 5.8 4.9 6.8 4.8 5.8 5.8 5.7

Individual communities within the ACMS planning area also display a higher than average proportion of seniors. The City of Timmins had one of the lowest percentage increases in the population aged 65 years and over, when compared to other ACMS communities, provincial and national trends (Table 3). Review of the Increasing Pressures of an Aging Population on the Health Care System in the City of Timmins and the Cochrane District – June 2004

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Table 3: Age Distribution and Senior’s Population Change, Selected ACMS Communities, Ontario and Canada, 2001 % OF POP. 0-19 YEARS 21 25 28 26 26 25 26 26

COMMUNITY Elliot Lake Sault Ste. Marie Timmins Kapuskasing Hearst Greater Sudbury Ontario Canada

AGE COHORT % OF POP. % OF POP. 20-64 YEARS 65+ YEARS 54 59 61 59 62 61 61 61

% CHANGE IN 65+, 1996 TO 2001

25 17 12 15 11 14 13 13

29.7 10.3 3.2 4.1 6.5 10.9 10.3 10.2

Source: Statistics Canada, 2001 Census.

Population Projections The Ontario Ministry of Finance prepares population projections for the province. The most recent projection available is based on population change between 1991 and 1996 with estimates of mortality, fertility and migration applied. The projection for the Cochrane District indicates that the population will grow only 1.6 percent between 1999 and 2026 (Table 4). This compares to an estimated population growth for the province of 31 percent over the same time period. The population aged 65 years and older is projected to more than double between 1999 and 2026 for both Cochrane District and the province. Table 4:

Population Projection, Total and Age 65 and Over, Cochrane District and Ontario

JURISDICTION Cochrane District Ontario

TOTAL POPULATION 2026 % CHANGE 93,570 95,082 1.6% 11,513,811 15,124,397 31.4% 1999

POPULATION AGED 65+ 1999 2026 % CHANGE 10,236 20,715 102% 1,441,350 3,040,750 111%

Source: Ontario Ministry of Health and Long-Term Care, Provincial Health Planning Database.

Life Expectancy Overall life expectancy (from birth) for residents across the ACMS area and for residents of the Porcupine Health Unit area is lower than the provincial and national experience (Table 5). Life expectancy for males in the Porcupine Health Unit area is 2.6 years less than the provincial experience. Female life expectancy for the same area is 1.6 years less than the provincial experience.

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Table 5:

Life Expectancy (from birth), Porcupine, ACMS, Ontario and Canada, 1996.

JURISDICTION Porcupine Health Unit Area ACMS DHC Ontario Canada

FEMALES 79.7 79.6 81.3 81.2

MALES 73.3 73.8 75.9 75.4

Source: Statistics Canada, Health Indicators.

Languages Mother tongue is defined as the first language learned as a child and still understood. Mother tongue is the measure by which the Ontario Office of Francophone Affairs determines French Language Services (FLS) status. The Act places responsibility on services funded by the Provincial Government to provide French language capacity. Table 6 profiles Mother tongue in the ACMS planning area. In the Cochrane District, almost 50 percent of the population reported French as the language first learned and still understood. The profile of language in the ACMS area is markedly different from that of the province. Table 6: Languages First Learned and Still Understood, ACMS Districts and Ontario, 2001 JURISDICTION Algoma District Cochrane District Manitoulin District Sudbury District Greater Sudbury Ontario

LANGUAGE FIRST LEARNED AND STILL UNDERSTOOD ENGLISH FRENCH ENGLISH & OTHER ONLY ONLY FRENCH LANGUAGE 81 8 1 10 45 47 2 6 84 2 0 14 63 32 2 3 62 28 1 8 71 4 0 25

Source: Statistics Canada, 2001 Census.

Aboriginal Profile First Nations peoples are found throughout the ACMS area and are a distinctive component of Northern Ontario and the ACMS planning jurisdiction. There are 29 First Nations in the ACMS area. Table 7 documents the proportion of the aboriginal population in the ACMS area as defined in the 2001 Census. These data capture both reserve and off-reserve aboriginals. The 2001 Census used the terminology, “Aboriginal identity population” to define the aboriginal population.8 8

This is a grouping of the total population into non-Aboriginal or Aboriginal population, with Aboriginal persons further divided into Aboriginal groups, based on their responses to three questions on the 2001 Census form. Included in the Aboriginal population are those persons who reported identifying with at least one Aboriginal group, that is, "North American Indian", "Métis" or "Inuit (Eskimo)", and/or who reported being a Treaty Indian or a Registered Indian, as defined by the Indian Act of Canada, and/or who reported they were members of an Indian Band or First Nation. Statistics Canada, Census 2001.

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The population defining itself as “aboriginal identity” constitutes over 9.8 percent of the total population in the Cochrane District. This reality is markedly different from the overall provincial experience. Table 7:

Aboriginal Population, ACMS Districts and Ontario, 2001

AREA

TOTAL POPULATION OF ABORIGINAL IDENTITY

Algoma District Cochrane District Manitoulin District Sudbury District Greater Sudbury Total ACMS Ontario

10,810 8,275 4,640 2,500 7,065 33,290 188,315

PERCENT OF TOTAL POPULATION OF ABORIGINAL IDENTITY 9.2 9.8 37.1 11.0 4.6 8.5 1.7

Source: Statistics Canada, 2001 Census.

1.2

Determinants of Health

Northern regions of the province report poorer health status among their constituents. In the Health Services Restructuring Commission’s Change and Transition report (April 1998), it was stated that “Standardized Mortality Ratios (SMRs) are high in all of the northern regions, potentially reflecting premature mortality due to poorer health status, which may lead to an increased need for LTC services.” There are a number of ‘determinants of health’, which have an impact on health status and subsequently on the demand for health care services. These include employment status, education, and personal and family income. Unemployment Meaningful employment is a key determinant of health. Studies have shown that the unemployed are at greater risk of developing mental health problems and that general ill health is often associated with unemployment.9 Unemployment rates across the ACMS DHC’s planning area were substantively higher than the provincial experience in 2001. Double-digit unemployment rates were the norm for Algoma, Cochrane, Manitoulin and Sudbury Districts in 2001. Table 8 documents the unemployment rates for males, females and combined totals for 2001.

9

Health Services Restructuring Commission, GTA/905 Report, November 1997.

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Table 8:

Unemployment Rates (%), ACMS Districts and Ontario, 2001

JURISDICTION Algoma District Cochrane District Manitoulin District Sudbury District Greater Sudbury Ontario

MALE RATE 10.9 13.3 11.3 13.6 9.9 5.8

FEMALE RATE 9.7 9.2 9.7 10.9 8.4 6.5

TOTAL RATE 10.3 11.5 10.5 12.5 9.1 6.1

Source: Statistics Canada, 2001 Census.

Education Studies demonstrate a relationship between lower levels of education and the following conditions: unskilled jobs, high unemployment, and a greater prevalence of disability and health problems.10 The level of education is very similar across the ACMS DHC planning area as shown in Table 9. Compared to Ontario as a whole, the population of the planning area presents higher proportions of the population with less than a grade 9 education and lower proportions of the population as university graduates. Recent analysis of the relationship between socio-economic status and the burden of cardiovascular disease indicates that level of education completed (certificate, diploma, degree) is more closely associated with health status. Those individuals with a university degree, for example, are more likely to experience less cardiovascular disease than those with lower levels of achievement.11 Table 9:

Proportion of the Population by Level of Education Achieved, Population Aged 20 Years and Over, ACMS Districts and Ontario, 2001

JURISDICTION Algoma District Cochrane District Manitoulin District Sudbury District Greater Sudbury ACMS Ontario

LESS THAN HIGH SCHOOL 11 15 13 15 11 12 9

HIGH SCHOOL GRADUATES 15 14 13 15 14 14 14

COLLEGE GRADUATES 16 16 17 14 18 17 17

UNIVERSITY GRADUATES 11 8 10 6 12 10 19

Source: Statistics Canada, 2001 Census.

Seniors Living Alone Seniors that live alone may be at a higher risk for premature placement within a long-term care setting if they do not have sufficient support from their family caregivers. Census data in Table 10 indicates that seniors living within the Cochrane District are more likely to be living alone, than their provincial counterparts. 10 11

Health Services Restructuring Commission, GTA/905 Report, (Toronto: November 1997). Cardiovascular disease and socio-economic status. Central West Health Planning and Information Network, September 2002.

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Table 10: PERSONS OVER 65 YRS LIVING ALONE

Persons Over 65 Years, Living Alone, ACMS Districts and Ontario, 2001

COCHRANE DISTRICT

MANITOULIN DISTRICT

5,500

2,990

635

885

6,300

16,310

369,550

29.8%

31.0%

32.3%

29.5%

31.3%

30.6%

26.8%

Number Percentage

SUDBURY DISTRICT

GREATER SUDBURY

ACMS PLANNING AREA

ALGOMA DISTRICT

ONTARIO

Source: Statistics Canada, 2001 Census.

Income Income has been demonstrated to have an inverse relationship with hospital utilization. That is, the lower the income, the higher the hospital utilization.12 Table 11 documents earnings for males, females and combined totals for those who worked fulltime in 2001. The information presented demonstrates that residents of the ACMS area reported earnings substantively lower than the provincial experience. Cochrane District residents reported earnings from full-time employment being 8 percent less than the provincial experience. Within the ACMS planning area, residents of the Cochrane District reported the highest earnings from full-time employment. The information presented is not conclusive evidence that residents of the ACMS area are disadvantaged from an income perspective to the extent that it may affect their health. Nevertheless, based on current knowledge and understanding of the links between income and health, the lower levels of earnings of ACMS residents may be a factor in understanding higher levels of morbidity and mortality in the population. Table 11:

Profile of Earnings from Full-Time Employment, ACMS Districts and Ontario, 2001

Jurisdiction Algoma District Cochrane District Manitoulin District Sudbury District Greater Sudbury Ontario

ACTUAL EARNINGS Total Male Female $41,124 $47,267 $31,754 $43,894 $50,533 $32,988 $32,357 $34,686 $29,509 $40,290 $46,901 $27,476 $43,278 $49,830 $34,451 $47,247 $53,923 $37,720

% DIFFERENCE IN EARNINGS FROM ONTARIO Total Male Female 15% 14% 19% 8% 7% 14% 46% 55% 28% 17% 15% 37% 9% 8% 9%

Source: Statistics Canada, 2001 Census

Table 12 provides insight into the median income levels of seniors living within the City of Timmins and the Cochrane District relative to that of the province. 12

Health Services Restructuring Commission, GTA/905 Report, November 1997.

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Table 12: Median Income Levels for Seniors 65 and Over, Timmins, Cochrane District and Ontario, 2001 Ontario Average 2000 total income $ Median 2000 total income $ Cochrane District Average 2000 total income $ Median 2000 total income $ City of Timmins Average 2000 total income $ Median 2000 total income $

AGE GROUPS (65+) Total - Sex Male 26,747 33,947 18,192 24,164 Age Groups (65+) Total - Sex Male 20,586 24,093 16,067 20,082 Age Groups (65+) Total - Sex Male 21,597 25,469 16,521 21,076

Source: Statistics Canada, 2001 Census

Female 21,073 15,564 Female 17,587 13,716 Female 18,566 14,386

There is some indication that affordability will influence the utilization patterns of health care resources for seniors living within the district. In 2001, Statistics Canada defined the low income cut off for an urban area the size of the City of Timmins as being $16,048. As outlined above, the median income of seniors within Timmins for the same period was $16,521; the median income of the female cohort was 12 percent lower at $14,386.

1.3

Health Status Profile Mortality and Morbidity Ratios

The Algoma, Cochrane, Manitoulin and Sudbury districts, as in other northern Ontario jurisdictions, demonstrate higher than average morbidity and mortality, with reduced years of life from various cancers, respiratory illnesses, cardiovascular disease, accidents and suicide. This reality has major implications for the planning and delivery of health services. For example, higher rates of mortality and morbidity in preventable diseases such as many respiratory diseases point to the need for health promotion and disease prevention initiatives. Hospitalizations are a surrogate measure of the extent of disease and disability in the population. Higher mortality in the population relates directly to higher costs for hospitalization and treatment. Increased morbidity reduces the number of years available for productive work and family life. Tables 13 and 14 profile mortality and morbidity (hospitalization) for the ACMS area.

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Table 13: Selected Standardized Mortality Ratios (SMRs), ACMS Districts, 1995 to 1999 DISEASE CATEGORY Neoplasms (cancer) Circulatory Diseases Respiratory Diseases Injury and Poisoning

ALGOMA DISTRICT 1.1* 1.173* 1.097 1.161*

COCHRANE DISTRICT 1.201* 1.147* 1.292* 1.677*

Suicide

1.122

2.026*

MANITOULIN DISTRICT 1.154 1.124 1.348* 2.614* Too few to report

SUDBURY DISTRICT 1.124 1.145 1.286* 1.966*

GREATER SUDBURY 1.126* 1.258* 1.246* 1.478*

2.174*

1.791*

Source: Northern Health Information Partnership, Mortality Interface v. 2.2 Note: Only those figures highlighted with an asterisk are statistically significantly different than the provincial experience.

Table 14:

Selected Standardized Morbidity Ratios (SMRs), ACMS Districts, 1997 to 2001

DISEASE CATEGORY Neoplasms (cancer) Circulatory Diseases Respiratory Diseases Injury and Poisoning Mental Disorders

ALGOMA DISTRICT 1.25* 1.448* 1.392* 1.374* 1.808*

COCHRANE DISTRICT 1.439* 1.861* 2.012* 1.443* 2.593*

MANITOULIN DISTRICT 1.017 2.199* 2.356* 2.592* 1.856*

SUDBURY DISTRICT 1.268* 1.638* 1.511* 1.443* 1.334*

GREATER SUDBURY 1.276* 1.361* 1.24* 1.304* 1.624*

Source: Northern Health Information Partnership, Mortality Interface v. 2.2 Note: Only those figures highlighted with an asterisk are statistically significantly different than the provincial experience.

By definition, hospitalizations do not capture all illness in a population. Thus, hospital morbidity is an incomplete measure of the burden of illness. Nevertheless, residents of the ACMS area experienced levels of hospitalization that exceed the provincial experience. Injuries In October 1999, the Northern Health Information Partnership prepared a document entitled the Northern Ontario Injuries and Poisoning Report that highlighted the nature of injuries and poisonings in the North. This report noted several findings that are significant to the ACMS DHC planning area: The Northern rates for injuries were consistently higher than the rates for Ontario. The male death Injury/Poisoning rate was 8.3/10,000 for Northeastern Ontario between 1990 and 1995. This compares to the provincial rate of 5.3/10,000. Hospitalization rates show the same pattern as mortality rates, with injuries and poisonings being much more common in Northern Ontario than in the province. The Northern rate for hospitalizations between the years of 1993 and 1997 was 20.4 per 1,000 for males and 17.8 per 1,000 for females. The provincial rates were 15.4 per 1,000, and 13.8 per 1,000 for males and females respectively. Throughout this time period, all of the Northern districts (including ACMS) had a higher injury and poisoning discharge rate than the provincial average for both sexes. Potential years of life lost (PYLL) due to motor vehicle crashes have a provincial average of 4.77 years per 1,000 population for males and 2.05 years for females. In Northeastern Ontario, males lost 7.44 years while females lost 3.71 years per 1,000.

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Falls Overall, residents of the District of Cochrane were hospitalized for accidental falls at levels that are 15 percent higher than the provincial experience (SMR = 1.153) over the five years 1997/98 to 2001/02 (Table 15). Residents of Timmins were hospitalized for accidental falls at a rate of 3.5 per 1,000, a level that is statistically significantly different than the rate for residents of the entire District. Table 15:

Hospitalizations Due to Accidental Falls, Timmins, Cochrane District and Ontario, 1997 to 2001

JURISICATION Cochrane District Timmins rest of Cochrane District

CASE STANDARD 95% CI 95% CI TOTAL RATE/1000 LOWER UPPER 1,757 3.880 3.699 4.060 793 3.502 3.260 3.745 964 4.284 4.014 4.555

95% CI 95% CI SMR LOWER UPPER 1.153 1.099 1.207

Source: Northern Health Information Partnership, Morbidity Interface, March 2004

In Ontario, 64 percent of hospitalizations due to accidental falls over the five-year period, 1997 to 2001, were of persons aged 65 years and over. In Cochrane District, 54 percent of hospitalizations due to accidental falls over the same period, were of persons aged 65 years and over. In Timmins, 59 percent of hospitalizations due to accidental falls over the same five-year period were of persons aged 65 years and over. Cases of Dementia Cochrane District is projected to have 1,102 persons with Dementia by 2010. This represents a 30 percent increase in dementia cases over the next decade (Table 16). Table 16:

Projected Cases of Dementia for Persons 65 Years and Over, ACMS Districts

DISTRICT Algoma District Cochrane District Manitoulin District Greater Sudbury Sudbury District

# OF PERSONS OVER 65 YEARS WITH DEMENTIA 2000

1,483 817 169 1,639 232

2010

2,089 1,102 221 2,305 367

2020

2,636 1,440 273 2,978 519

2028 3,095 1,849 309 3,769 658

Source: Geriatric Psychiatry Unit, Dementia Projections for the Counties, Regional Municipalities, and Districts of Ontario, Robert W. Hopkins, Ph.D. and Julia F. Hopkins, January 2002.

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Cancer There are over 200 different types of malignant cancers. Cancer is the second leading cause of death across the province. Cancer incidence, the reporting of new cancer cases every year, is an indicator of the overall burden of cancer in the population. Table 17 documents cancer incidence for selected cancers by sex for the five-year period 1994 to 1998. For all malignant cancers the experience of residents of Cochrane District is comparable to the provincial experience. However lung cancer incidence for both males and females in the Cochrane District is particularly notable with rates significantly exceeding the provincial experience. It is also notable that the incidence of breast cancer in women and prostate cancer in men is lower for Cochrane District residents as compared to the province. Table 17:

Cancer Incidence, Selected Cancers, Cochrane District and Ontario, 1994-1998 COCHRANE

CANCER TYPE All malignant cancers - males All malignant cancers - females Lung - males Lung - females Breast - females Prostate - males Colorectal - males Colorectal - females

CASES 992 871 216 138 200 204 129 124

ASIR 482.6 365.7 104.8 58.3 83.1 102.6 63.1 52.4

ONTARIO ASIR 465.6 352.4 76.8 41.4 101.8 122.1 62.3 43.4

STATISTICAL SIGNIFICANCE nss nss ss ss ss ss nss nss

Source: Northern Health Information Partnership, Mapping Program, Cancer Incidence Notes: ASIR – Age standardized incidence rate per 100,000 population Statistical Significance – Not shown are the confidence intervals upon which statistical significance was determined nss – not statistically significantly different from province; ss – statistically significantly different from province.

Cardiovascular Disease In Northern Ontario, cardiovascular disease is the third leading cause of premature death (72,886 years) after injuries and poisoning, and cancer. However, cardiovascular disease is the leading cause of death in Northern Ontario, currently accounting for 39 percent of all deaths. Ischemic cardiovascular disease accounts for the greatest percentage of these deaths (63 percent), of which half are attributable to heart attacks. Stroke and other cardiovascular disease account for 18 percent and 19 percent of death respectively. Residents of Cochrane District experience mortality rates that exceed the provincial experience due to circulatory diseases. For the five-year period, 1995-99, Cochrane residents died of circulatory diseases at levels almost 15 percent higher than the provincial experience, (SMR = 1.147, statistically significantly higher than provincial experience).13

13

Northern Health Information Partnership, Mortality Interface.

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Solid evidence connecting smoking and cardiovascular disease has existed for more than 20 years. In the Porcupine Health Unit area (Cochrane), more residents identify themselves as daily smokers (26.2 percent) when compared to the provincial rate (16.7 percent) as reported by the Canadian Community Health Survey in 2003.14 Obesity (as measured by a body mass index of 30.0 or greater) is related to both diabetes and high blood cholesterol, and is also more prevalent in the Porcupine Health Unit area (22.7 percent) compared to the province (14.8 percent).15 How the population spends its leisure time is also an important overall indicator of health status and risk for concerns like obesity. Across Ontario almost 50 percent of the population reports being physically “inactive”. Residents in the Porcupine Health Unit area report rates of physical inactivity at levels that are consistent with the province (48 percent).16 Diabetes is another serious health concern that is often a precursor to cardiovascular disease. Diabetes affects residents of the Porcupine Health Unit area disproportionately compared to the provincial experience. In 2003, 8 percent of residents reported having diabetes as compared to a provincial rate of 4.6 percent.17

1.4

Primary Care Services

Information from the Institute of Clinical Evaluative Sciences for 2001/02 indicates that the Cochrane District had 67.7 full-time equivalent family physicians, excluding those who work as “quasi-specialists”. This translates into 7.7 family doctors per 10,000 population and compares to a rate of 7.2 family doctors per 10,000 population across Ontario.18 In 2002/03, hospitals across Ontario were required to submit an information abstract on all visits to hospital emergency departments. Summary data for the 2002/03 fiscal year are now available. One of the data variables that hospitals were required to ask all patients visiting the emergency department was whether or not they had a family doctor. There has been, to-date, no validation of the accuracy of this particular data variable, however, analysis reveals that in 2002/03, 87 percent of people visiting hospital emergency departments across the ACMS area indicated they had a family doctor. The provincial rate was 88 percent. At the Timmins and District Hospital, only 73 percent of patients presenting to the emergency department reported having a family doctor.19 According to Statistics Canada in 2003, 85 percent of the population in the Porcupine Health Unit area reported having a regular medical doctor. Almost 12 percent reported searching for a regular medical doctor. Another 3 percent indicated they were not searching for a medical doctor. These rates compares to provincial rates of 92 percent with a regular medical doctor, 3.6 percent searching and 4.6 percent not looking.20 14 15 16 17 18 19 20

Statistics Canada, Health Indicators, 2003. Ibid. Ibid. Ibid. Institute of Clinical Evaluative Sciences, Unpublished data, June 2004. Ontario Ministry of Health and Long-Term Care, Provincial Health Planning Database. Statistics Canada, The Daily, June 15, 2003.

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In addition to physicians the following primary health care services and/or organizations are present in the Timmins area: Porcupine Health Unit – one Nurse Practitioner for sexual health program Timmins and District Hospital – one Nurse Practitioner for hospitalist program East-End Health Network – multidisciplinary team of members working collaboratively Misiway Milopemahtsewin Community Health Centre – an aboriginal community health centre

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2.0 COMMUNITY SUPPORT SERVICES 2.1

Community Support Services Available in Timmins and the Cochrane District

The following is a detailed listing of community support services available in the Cochrane District. The service units are organized according to the Ministry’s Planning, Funding & Accountability Policies & Procedures Manual for Long-Term Care Community Services (more complete definitions are found in Appendix A). The ACMS DHC is currently involved in the development of a detailed needs assessment of community support services across its planning jurisdiction. Once complete, this needs assessment will assist stakeholders to understand the gaps in service and needs of the population for these services. 1A Adult day (Alzheimer and Dementia) City of Timmins operates an Adult Day program that serves frail elderly and Alzheimer’s clients. Timmins has one-third of spaces available in the District but is home to one-half of the population. There appears to be a reluctance by clients to attend the Day Program located at the Golden Manor (as noted in the Service Plan for the program and key informant interviews done by DHC staff). The program is not being used to its maximum. 02 Meals on Wheels (Canadian Red Cross serves Timmins and Cochrane District) Timmins and the District appears to be well served relative to other districts 03 Diners Club (Wheels to Meals) (in Timmins service provided by the Finnish Seniors Home) Limited service available in Timmins; limited services available in all districts. 04 Transportation (City of Timmins) The demand for the service seems to exceed capacity of the program (as per Service Plan and Key informant interviews). Transportation (and assistance with transportation) to access medical appointments and errands is essential for independent living, especially for seniors without informal caregivers. 05c Home Maintenance (in Timmins service provided by the City of Timmins) The service is available on a fee for service and limited basis. 06 Friendly Visiting (in Timmins, service provided by the Canadian Red Cross) The service is available, and units of service are comparable to other districts. 07 Security Checks The service is available, and units of service are comparable to other districts. Review of the Increasing Pressures of an Aging Population on the Health Care System in the City of Timmins and the Cochrane District – June 2004

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8a & 8b Caregiver Support (funding to the Alzheimer’s Society) Levels of service in the Cochrane District are below levels in the ACMS district and below the average levels in the Northern Shores and Northwestern Ontario District Health Council areas. 8C & 8G Respite There are no services at the Community Support Services level in the Cochrane District and there is no way to compare the levels of respite care at this point in time with other districts. It should be noted that CCAC provides respite as part of their services. 9B Homehelp/Homemaking This service (homemaking) is no longer provided in the Cochrane District by a non-profit service provider; limited service is available through the CCAC (see section on CCAC for more detail) but only to those requiring personal care assistance. The Cochrane District is the only district with no service being provided in Northern Ontario. Algoma also has very limited 9B services available. 09G Independence Training (for Adults with Physical Disabilities) Service is not available locally. This service is available in Sudbury to people outside of Manitoulin-Sudbury District. 11A Supportive Housing for Elderly At present, there are no services that receive funding for supporting housing for the elderly population in the Cochrane District. This is the only district that does not receive funding for the provision of the service. See the Supportive Housing section under Alternative Housing Options in this document for more details. 12A Supportive Housing for Adults with Physical Disabilities (in Timmins, service provided by Access Better Living). Access Better Living has a 15 unit Supportive Housing Complex in Timmins (available to all residents from the Cochrane District). See the Supportive Housing section under Alternative Housing Options in this document for more details. 12B Homemaking/Personal Supp/Attendant/Respite- Physically Disabled Outreach Presently Access Better Living provides this service in Timmins. The Canadian Red Cross (Community Services) has submitted a proposal to the MOH to provide services in Kapuskasing, Iroquois Falls and Cochrane. 12D Supportive Living Services - ABI Supportive Housing These services are located in Thunder Bay and Sudbury. 12E Supportive Living Service - ABI Outreach At present there are no services of this nature in the Cochrane District; the district is underserved relative to northern Ontario. A proposal has been submitted by the Ontario March of Dimes to provide this service across the ACMS district, but no funding has been approved to date.

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3.0 COMMUNITY CARE ACCESS CENTRE – COMMUNITY SERVICES Community Care Access Centres (CCACs) are local agencies that provide information to the members of the public about care options and help them access government-funded home and community services and long-term care facilities. There are 42 CCACs throughout Ontario. CCACs work with residents, and their families, to: identify their care needs and explore the options best suited to those needs and personal situation; determine their eligibility for government-funded services; and, help register them on the appropriate waiting lists.

3.1

Home Care Services in the Cochrane District

Home care services provided by the CCACs in the ACMS area include home help/homemaking, personal care, attendant and respite services. Service volumes over the last four years are shown in Table 18. Table 18:

Service Units/Hours: 10A Homemaking/Personal Care/Attendant Respite, ACMS Districts

Algoma CCAC Cochrane District CCAC Manitoulin-Sudbury CCAC

1990/00 208,963 202,151

2000/01 210,110 201,488

2001/02 156,756 183,962

(25.4%) (8.7%)

2002/03 147,141 167,919

(6.1%) (8.7%)

334,117

364,224

268,694

(26.2%)

274,620

(2.2%)

Unlike some districts and regions of the province, publicly-funded home help/homemaking services in the Cochrane District are entirely delivered by the CCAC; this is different in the Sudbury District. As required by a policy introduced in 1998/99, The Canadian Red Cross in both the Cochrane and Algoma Districts transferred its funding for 9B home help/homemaking and respite programs to CCACs. A number of agencies in other parts of the province challenged the policy and the Ministry ultimately permitted some of them to continue to provide home support programs, with agencies and clients sharing in the cost of the labour to provide the service. For example, in the Sudbury District, Aide aux Séniors Sudbury Est and Chapleau Health Services continue to offer a home help service. At the beginning of 2001/2002, all three CCACs in the ACMS planning area were projecting deficits due to increasing costs and service demands. With no increases to their budgets, CCACs were requested to submit cost recovery plans to the Ministry. As a result, cuts were made to homemaking/personal care/attendant/respite services and the need for personal care was imposed as an eligibility requirement for any of these services. The most noticeable cuts were made to housekeeping services. Given that the CCAC is the only agency providing home help/homemaking services in the Cochrane District, residents of the district were greatly affected by this reduction in service. Given the differences in home support from district to district, the ACMS DHC, in its 2003/04 LTC Annual District Service Plan, encouraged the Ministry to Review of the Increasing Pressures of an Aging Population on the Health Care System in the City of Timmins and the Cochrane District – June 2004

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implement a consistent approach to the delivery of these services across the ACMS planning area. In recent years, research conducted by Marcus Hollander in British Columbia (August 2003) stated that cuts to home support and housekeeping services would result in increased demand for health care services in future years. This would appear to be the case in the Cochrane District as we see a significant increase in the waiting list for long-term care beds approximately 18 months to 2 years post-CCAC service cuts (Table 18). Hollander Report Summary Marcus Hollander, in his paper Unfinished Business: The Case for Chronic Home Care Services (August 2003), studied the cost effectiveness of home care and found that, on average, it was significantly less costly to care for individuals at home with supports than caring for them in a Long Term Care Facility. Further he notes that: • Chronic Home Care is a key component in maintaining an overall efficient and effective health care system. • At present, the current approach to home care as short term care (as a substitute for acute care in hospital) actually contributes to increasing health care costs; a focus on long term home care acts more as a preventative measure and reduces costs in the long term. • In B.C., Hollander tracked people who were cut from the lowest level of home care (i.e. those receiving housecleaning only) and found that those cuts cost the health care system some $3,500 more in the third year after the cuts. Costs were incurred through hospital and LTCF use. • Actual savings were achieved in British Columbia by holding down future construction of long term care facilities and making investments in home care. • Hollander argues that home care can also be an effective substitution for acute care but needs to be an integrated part of the health care continuum. • Current care needs for those with chronic long term care needs are fragmented and less effective than they could be; a focus on continuing care is needed. • The present system of long term home care needs to be “topped up” to increase the efficiency of the health care system and improve the quality of care. Full report available at www.hollanderanalytical.com/downloads/unfinished_business.pdf The service utilization patterns for CCAC services in the Cochrane District from 2000/2001 to the end of March 31, 2004, show a decline in service units for most service categories (Table 19).

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Table 19: Service Provision Homemaking Case Management Placement Coordination Nursing Physiotherapy Occupational Therapy Social Work Speech Dietetic Service

Cochrane District CCAC Service Utilization, 2000/01 to 2003/04 2000-2001 # OF INDIV. UNITS SERVED 201,488 1,528 4,766 4,111

2001-2002 # OF INDIV. UNITS SERVED 183,974 1,482 4,699 4,170

2002-2003 # OF INDIV. UNITS SERVED 167,670 1,393 4,671 4,042

2003-2004 # OF INDIV. UNITS SERVED 167,919 1,514 3,896 3,503

469

323

451

312

371

338

52,650 4,017 3,422

2,276 589 900

49,522 2,727 2,400

2,304 479 713

46,214 3,170 2,580

2,097 567 792

49,069 3,576 618

2,166 631 1,801

1,413 2,196 202

158 253 75

879 2,351 202

114 255 57

1,342 1,578 164

134 190 61

840 1,901 67

69 271 38

Source: Cochrane District CCAC and Ministry of Health and Long-Term Care

For units of service, homemaking declined by 16.8 percent over the four year period. The units of nursing services also declined during the same four years but by a smaller percentage (6.8 percent decline). Nursing units declined by 5.9 percent between 2000/01 and 2001/02 and 6.7 percent between 2001/02 and 2002/03. Nursing units increased by 6.2 percent from 2002/03 to 2003/04. As of May 31, 2004, the Cochrane District CCAC had no waiting list for nursing or homemaking services. Fewer people were served in 2003/04 as compared to 2000/01 for homemaking, case management, nursing, social work and dietetic service with only a slight decline of 14 individuals for homemaking during this period. The decline in utilization and the lack of a waiting list for services are in part explained by more stringent eligibility criteria for these services, resulting in fewer people being able to access these services. The CCAC increased the number of persons served during this same period for a number of therapy services including physiotherapy, occupational therapy (OT), and speech language pathology. Of note is the substantial decrease in the OT units of service provided relative to the number of persons served. In 1999/00, individuals served received on average 3.8 units (hours) of service but an individual receiving services in 2002/03 received on average 0.34 units (hours) of service. The decrease in units was due in part to a decrease in human resources.

3.2

Assessment of CCAC Home Care Clients

The following figure describes the Cochrane District CCAC caseload, for the previous year, for age and sex with a prevalence of clients in the age categories for 75 to 79 years, 80 to 84 years and 85 to 90 years. Female clients accounted for over 72 percent of the caseload.

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Figure 1:

Cochrane District CCAC Clients by Age and Sex, February 2003 to February 2004

140 120 100 80 CCAC Male CCAC Female

60 40 20 0

less 40

Source: Cochrane District CCAC

5059

6669

7579

8590

94+

Clients’ Age Group

The Cochrane CCAC provided data on service units as reported to the MOHLTC in 2002/03. Recent Key Stakeholder interviews for a different ACMS DHC planning project (i.e. Needs Assessment for Community Support Services) were also taken into consideration. Of the total 804 clients, 49.4 percent were living alone, 27 percent were living with a spouse only, and the remaining clients were living with others or in a group (non relative) setting. It is noted that those living alone are likely to be at greater risk of placement as their conditions deteriorate. The Cochrane CCAC provided information on disease diagnosis categories and these are described in the following table. Table 20:

Distribution of Clients by Disease Categories, Cochrane District CCAC, February 2003 to February 2004 DISEASE CATEGORIES

Heart/Circulation Musculo-Skeletal Other Diseases Senses Neurological Psychiatric Mood Infections Others (Not Captured by MDS)

# OF CLIENTS 590 494 453 218 142 79 43 24

PERCENTAGE OF TOTAL CASELOAD 73.4% 61.4% 56.3% 27.1% 17.7% 9.8% 5.3% 3%

Source: Cochrane District CCAC

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The Cochrane District CCAC provided information from the application of the Resident Assessment Instrument (RAI) tool to 804 CCAC clients served between February 2003 and February 2004. For most categories, information was currently not available to compare the Cochrane District with the ACMS, Northern Ontario or Ontario experience. The assessment determined the following: • • •

•

•

For cognitive performance (skills for daily decision-making, making self understood, and short term memory recall), close to 80 percent of clients scored either 0 or 1 out of a scale from 0 to 6, with the lower scores indicating a lesser degree of cognitive impairment. For a depression rating scale, 4.1 percent of CCAC clients scored in the range suggesting possible depression. For scores related to activities of daily living and self-reliance, 2.1 percent of clients had scored 4, 5, or 6 out of a scale of 0 to 6 with higher scales indicating a greater degree of dependence. Over 82 percent of clients had a score of 0 indicating the highest level of independence. Clients presented with a range of pain frequency and intensity. Four scores (0 to 3) were assigned to measure pain frequency and intensity at the time of assessment. The percentages of clients for each category (the higher scores indicating more pain) were 36.8 percent for category 0, 16.5 percent for category 1, 30.6 percent for category 2 and 16.0 percent for category 3. Cochrane District CCAC clients had lower scores for medical complexity and health instability with close to half scored at 0 and another 27 percent with a score of 1. Approximately 7 percent were in the top three scores (scale of 1 to 5) with these individuals having higher levels of medical complexity.

In comparison to the Ontario experience, the RAI-Home Care assessment tool generated information to describe triggers that alert the assessor to the client’s potential problems or needs (referred to as Client Assessment Protocols). For six of 30 Client Assessment Protocols, the Cochrane District CCAC clients had higher scores comparable to clients from 42 other CCACs in the province. These CAPS included: - Brittle support - Cardio Respiratory - Vision - Medication Management - Prevention/Health Measures - Reduction of Formal Services It is noted that medication management and prevention/health measures are concerns that could be addressed by allied health professionals in a community based environment (e.g., home care services, supportive housing).

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MAPLe scores (Method for Assigning Priority Levels) were also compared across 42 CCACs. The MAPLe Assessment System differentiates clients into 5 priority levels, based on their risk of adverse outcomes. Fewer Cochrane District CCAC clients (22 percent) were reported in the ‘high’ and ‘very high’ categories in comparison to the rest of the province that showed 34 percent in these same categories. Thirty-six percent of Cochrane CCAC clients were low priority clients having no major functional, cognitive, behavioural or environmental problems (26 percent for Ontario). Clients in this low category were considered self-reliant.

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4.0 COMMUNITY CARE ACCESS CENTRE – LONG-TERM CARE PLACEMENTS 4.1

Placement Coordination Statistics

Over the past five years, the Cochrane District CCAC reported relatively stable caseload numbers until 2003 when the caseload increased by 40.4 percent. Table 21 shows caseload comparisons for the three ACMS CCACs. Table 21:

Average Monthly Placement Caseloads, ACMS CCACs, 2000 to 2003 and January to April 2004

Algoma CCAC Percentage Increase/Decrease Cochrane District CCAC Percentage Increase/Decrease Manitoulin-Sudbury CCAC Percentage Increase/Decrease

366

2000

386

157

154

352

463

2001 +5.5% -1.9% +31.5%

403 168 475

2002 +4.4% +9.1% +2.6%

421 236 414

2003 +4.5% +40.4% -12.8%

2004 436 +3.6^ 271 +14.8% incomplete data

With the increasing caseload at the Cochrane CCAC, there has been a corresponding increase in the monthly waiting list for a long-term care bed. Table 22 shows the total average monthly waiting list for the past 4 and a half years has grown from an average of 91 persons in 2000 to 160 in 2003, with the current waiting list standing at 196 (April 2004). This represents a doubling in the average monthly waiting list for the noted period. Table 22:

Average Monthly Waiting List for Cochrane CCAC, 2000 to 2003 and January to April 2004 2000

Cochrane District CCAC Percentage Increase/Decrease

91

2001 104 +14.3%

2002 115

2003 160

+10.6%

2004 180

+39.1%

+12.5%

Placements/Admissions to Long-Stay21 Beds The number of long-stay placements coordinated by the ACMS CCACs, between 2000 and 2004, are shown in Table 23. It is noted that within any given year, there is considerable turnover in the resident population (column four of Table 23), necessitating the need for a waiting list to maintain occupancy in long-term care facilities. In the Cochrane District, the annual turnover of residents is considerably lower than the turnover in other ACMS districts. Given the lower Case Mix Index in Cochrane District facilities, and that residents are reported to be healthier, it is no surprise that the annual turnover rates are lower. The result is that Cochrane District facilities are less able to admit new residents as compared to other districts. 21

Most long-term care beds are identified for long-stay residents as opposed to short-stay beds; short-stay beds are for convalescence, respite, and short-term emergency placements.

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Table 23:

Admissions to ACMS LTC Facilities, 2000 to 2004

Year Ending

# OF LONG-STAY ADMISSIONS

TOTAL # OF LONGSTAY BEDS

PERCENTAGE TURNOVER

ALGOMA CCAC March 31, 2000 291 695 March 31, 2001 314 698 March 31, 2002 244 739 March 31, 2003 479 844 March 31, 2004 419 869 COCHRANE DISTRICT CCAC March 31, 2000 217 622 March 31, 2001 219 624 March 31, 2002 200 622 March 31, 2003 175 621 March 31, 2004 206 631 MANITOULIN-SUDBURY CCAC March 31, 2000 580 1,211 March 31, 2001 629 1,243 March 31, 2002 486 1,244 March 31, 2003 505 1,321 March 31, 2004 Year end data not yet available

41.9% 45.1% 33.0% 56.8% 48.2% 34.9% 35.1% 32.2% 28.2% 32.6% 47.9% 50.6% 39.0% 38.2%

Source: Placement data from CCACs in the ACMS Planning Area.

Table 24: Number of Persons Waiting for a LTC Bed and Present Location, ACMS Districts, February 2004

COMMUNITY

LTC FACILITY

CHRONIC CARE

ACUTE CARE

OTHER

OTHER PCS

TOTAL

WAIT TIMES PER CAPITA (75+)

Algoma

142

214*

8

17

0

10

391

50.6

Cochrane

90

37

2

44

2

8

183

44.1

ManitoulinSudbury

87

96

5

24

21

15

248

22.6

CCAC

* Includes 132 temporary beds scheduled to close with opening of new F. J. Davey Home.

The location of persons awaiting long-term placement is shown in Table 24. At the time that the information was summarized, consistent information for all three CCACs was only available for the month of February 2004. The Cochrane District CCAC provided wait list information for April 2004 that indicated that 196 individuals were waiting for a long-term care bed at the end of April. Of these individuals, 90 were residing in the community and 25 in either an acute or a chronic bed. Placement Coordination staff indicated some difficulties with comparing data sources; namely that hospital and Placement Coordination Statistics (PCS) may differ as applications to the CCAC for placement may be in process and individuals not officially waitlisted. Placement staff also indicated that crisis admissions were not reflected in the monthly PCS statistical reports. Review of the Increasing Pressures of an Aging Population on the Health Care System in the City of Timmins and the Cochrane District – June 2004

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Of those already accepted on the waiting list for April 2004 (applications processed), 126 individuals identified Timmins facilities as their first choice, with an additional 11 individuals who have commenced the process to be waitlisted. This translates into close to 70 percent of all current applications choosing placement within a Timmins facility. Golden Manor is the most requested facility in Timmins, with CCAC placement staff indicating that the average waiting time for admission has increased significantly in the past 4 months. Table 25 shows the wait time by gender. Table 25:

Average Wait Time for Placement within Golden Manor, Timmins, by Sex

PRIOR TO JANUARY 2004 Males – 3 to 6 months Females – 6 to 9 months

JANUARY 2004 TO CURRENT TIME Males – 9 months Females – 1 year plus

In comparison to other districts in the ACMS area, the Algoma District continues to report the longest waiting times, as shown in Table 26. However, the Cochrane District was a close second. The waiting times for Timmins facilities exceeds the district average waiting times. Table 26:

Waiting Times for ACMS Area Long-Term Care Facility/Placements, February 2004

CCAC AREA Algoma Cochrane Manitoulin-Sudbury

LONG-STAY ADMISSIONS – AVERAGE DAYS WAITED FOR ADMISSION TO A LTC BED Category 2 Category 3 188 16 127 41 6 17

PERSONS ON THE CURRENT WAITING LIST – AVERAGE DAYS WAITING FOR A LTC BED Category 2 Category 3 205 583 200 306 143 260

Source: CCAC Placement Coordination Services in the ACMS area, February 2004 Monthly Report Note: Refer to Appendix B for definitions of Category 1A, 1B, 2 and 3.

Basic versus Preferred Accommodation The Long-Term Care Facility Design Manual (May 1998) states: “The ratio of standard and preferred accommodation, as set out in the regulations governing all long-term care facilities, requires that 40 percent of the residents must be charged at the basic accommodation rate. This permits charging up to 60 percent of the residents at the preferred accommodation rate (this is the rate for semi-private and private rooms). This charging policy must be adhered to regardless of the design of the building. For example, a long-term care facility may have all one bed private rooms, but 40 percent of the residents must still be charged the basic accommodation rate.”

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Table 27:

Individuals Accepted and Waitlisted For Basic and Preferred Accommodation, ACMS Long-Term Care Facilities, February 2004 BASIC

ALGOMA LTC FACILITIES Females 243 Males 151 Total 394 COCHRANE LTC FACILITIES Females 120 Males 59 Total 179 MANITOULIN-SUDBURY LTC FACILITIES Females 129 Males 57 Total 186 TOTAL ACMS LTC FACILITIES Females 492 Males 267 Total 759

%

PREFERRED ACCOMMODATION

%

81.2%

48 43 91

18.8%

79.9%

29 16 45

20.1%

72.9%

37 32 69

27.1.0%

78.7%

114 91 205

21.3%%

Source: February 2004 Placement Coordination Statistics for Algoma CCAC, Cochrane District CCAC, and Manitoulin-Sudbury CCAC

In comparison to the provincial experience of only 63 percent of applicants requesting basic accommodation in March 2004, ACMS CCACs reported a greater percentage (78.7 percent for ACMS planning area in February 2004). The percentage of requests for basic accommodation in the Cochrane District was close to the ACMS picture, as shown in Table 27.

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5.0 LTC INSTITUTIONAL FACILITIES As compared to other LTC facilities in the province, Table 27 shows all Cochrane facilities reporting Levels of Care information falling below the provincial CMI average of 100. This indicates that Cochrane District LTC facility residents have lighter care needs when compared to the rest of the province. Table 28:

LTC Facilities in the Cochrane District, April 2004

FACILITY

COMMUNITY

APPROVED LONGSTAY BEDS

SHORT STAY BEDS 1

CMI % INCREASE/ DECREASE 2002 TO 2003

CMI22 (2003)

Foyer des Pionniers

Hearst

65

North Centennial Manor

Kapuskasing

70

Extendicare Kapuskasing

Kapuskasing

59

Smooth Rock Falls LTC

Smooth Rock Falls

20

Golden Manor

Timmins

173

3

95.02

-0.86%

Extendicare Timmins

Timmins

118

1

95.80

-0.67%

Villa Minto

Cochrane

33

97.69

+3.56%

Rosedale Centre

Matheson

20

South Centennial Manor

Iroquois Falls

68

Timmins & Dist. Hospital

Timmins

TOTAL Cochrane District

1

88.25

-1.25%

93.98

-3.19%

84.67

-2.78%

No data

No data 1

94.00

+2.13%

10 temporary 636

7

642 Beds

Sources: Cochrane District CCAC Placement Coordination Services, April 2004. 2003 Levels of Care Classification Results, Ontario Ministry of Health and Long-Term Care, January 2004.

5.1

Comparison to the Provincial LTC Bed Ratio

The Long-Term Care Redevelopment Project continues to monitor the development of new longterm care beds and the redevelopment of Level ‘D’ long-term care beds. In speaking with Ministry staff assigned to this project, a target of 100 LTC beds per 1,000 population over 75 years of age was used to determine the appropriate number of beds per district.

22

The Case Mix Index along with the Case Mix Measure are the results of classifying residents according to care levels. The provincial Case Mix Index stands at a constant 100. CMIs above 100 indicate higher levels of care needs than the provincial average.

Review of the Increasing Pressures of an Aging Population on the Health Care System in the City of Timmins and the Cochrane District – June 2004

27

In March 2004, the provincial average was reported to be 95.3 LTC beds per 1,000 population over 75 years of age. Providers in the Cochrane District operate 137.5 LTC beds per 1,000 population, which is the third highest ratio on average among 42 CCAC areas. When the provincial government announced the development of 20,000 new long-term care beds in the mid-1990’s, the Cochrane District was not identified for new beds. At the end of the redevelopment project in 2006, the Cochrane District ratio is expected to drop to 128.6 LTC beds per 1,000 population over 75 years (Table 29) and will rank fourth overall in the province for the greatest number of beds for this population. Benchmarks are based on a bed to population ratio and fail to account for a number of important factors such as a lack of community-based supports or alternate affordable housing options for the aging population.

Review of the Increasing Pressures of an Aging Population on the Health Care System in the City of Timmins and the Cochrane District – June 2004

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Table 29:

Long-Term Care Beds per 1,000 Population Over 75 Years of Age, COCHRANE DISTRICT Provincial Bed Ratio Target = 100 beds per 1,000 population over 75 years of age (LTC Redevelopment Project) Population 75 years plus (2001)

Area Hearst Kapuskasing Smooth Rock Falls Cochrane Iroquois Falls Matheson Timmins Unorganized North James Bay Coast

TOTAL

Males

Females

Total M/F

120 170 290 265 385 650 45 55 100 95 165 260 125 225 350 55 95 150 775 1,395 2,170 50 30 80 No complete data –not all communities participated in 2001 Census *

1,600

2,545

4,145

CURRENT LTC BEDS (APRIL 2004)

PROPOSED LTC BEDS FOLLOWING REDEV.

65 130 20 33 69 20 305 0 Planning is ongoing. *

642

CURRENT USING 2001 POP

65 136 20 33 69 20 295 0

224.1 201.5 200.0 126.9 197.0 133.3 140.6 0 0

637

154.8

BED RATIOS POST NEW & REDEV. 2006 BEDS 2001 POP 224.1 175.03 Projected district pop over 75 yrs = 4,955

Projected district pop over 75 yrs = 5,531

Assuming no additional LTC beds; not including 10 temporary beds at TDH for both 2006 and 2011. 128.6

115.2

Using 2006 population estimates

153.7

2011

Sources: April 2004 Placement Coordination Services Monthly Report (Cochrane District CCAC) 2001 Census Population Ministry of Finance Population Projections Notes: 10 LTC at Timmins District Hospital are temporary. *Planning continues for the development of long-term care beds for the James Bay Coast. Although not all data has been submitted for a needs assessment, a preliminary study has proposed 100 to 120 long-term care beds. Population figures are not available for the population over 75 years of age with a total overall population reported to be 9,183 in 1996. Considering the greater incidence of chronic disease and poorer health status, Aboriginal people residing along the James Bay Coast may require long-term care beds earlier than the rest of the ACMS and Ontario population. Therefore, comparisons with the provincial target of 100 beds per 1,000 population over 75 years of age may not be appropriate.23 While reliable population projections are not available at the sub-district level, estimates of the 2006 population for Kapuskasing and Hearst have been calculated assuming that the proportion of the district’s population residing in each area will remain similar for future years. The year 2006 was used for post redevelopment as both communities should have the renovated long-term care facilities complete by 2006.

23

Preliminary study entitled, An Estimate of the Number of Long-Term Care Beds Needed by the Communities of the Mushkegowuk Territory, was prepared for the Regional Long-Term Care Committee of the Mushkegowuk Territory by Clark MacFarlane, Community Solutions.

Review of the Increasing Pressures of an Aging Population on the Health Care System in the City of Timmins and the Cochrane District – June 2004

29

6.0 ALTERNATE HOUSING OPTIONS 6.1

Retirement Facilities

The District of Cochrane has a limited supply of private retirement facilities as shown in Table 30. Four are located in Timmins and one small facility is located outside of Kapuskasing in Moonbeam. Table 30: NAME OF FACILITY

Inventory of Retirement Homes in the Cochrane District, 2004

Georgian Residence

Timmins

TOTAL # OF BEDS 68

Rainbow Suites

Timmins

29

28

3.4%

Residence Lefebvre

Moonbeam

13

12

7.7%

St. Mary’s Manor

Timmins

73

58

21.5%

Spruce Hill Lodge

Timmins

51

49

4%

COMMUNITY

# OF BEDS OCCUPIED

VACANCY RATE

67

1.5 %

COMMENTS/COSTS Beds are $1,118/mo.24 for a single semi private room and $1,712/mo. for a single private room. All rooms are private, individual rooms with a rate of $1,500/mo. * a few existing residents are still paying $1,250/mo. because of previous agreements with the former facility owners. All beds are in single private rooms. Rates range from $870/mo. to $1,000/mo. for rooms with no private washrooms (price varies depending on size of room) up to $1,300/mo. for a room with a private washroom. Beds are $900/mo. for a single semi private room and $950/ mo. for a single private room. The facility also has 3 larger private rooms which can accommodate couples. These suites are priced at $1,650/mo. The facility has the potential for the development of 16 additional beds, should extensive renovations be undertaken. Beds are $1,100/mo. for a private room with two piece washroom. There are also 6 suites with a 4 piece bath available for $2,300/mo. ($2,700/mo. for a couple).

In September 2003, the Ramada Inn converted 9 hotel rooms into retirement living suites and opened them to the public. However, they were unable to attract a sufficient number of seniors to make the venture financially sustainable and the Ramada Inn ended this service in May 2004. The cost to live in private retirement facilities ranges from $870 per month (for a smaller private room with no private washroom) to $1,500 per month (for a semi-private room or a private room with a washroom) to $2,300 per month (for a private suite with a four-piece bath). There is some indication that affordability is a key barrier for the seniors’ population within the Cochrane 24

All rates include three meals per day plus snacks.

Review of the Increasing Pressures of an Aging Population on the Health Care System in the City of Timmins and the Cochrane District – June 2004

30

District. In 2001, Statistics Canada defined the low income cut off (LICO) for an urban area the size of the City of Timmins at $16,048 per annum. Data indicates that the median income of all seniors living within Timmins is at the LICO, with the median income for females in the City being 12 percent lower than the LICO.

6.2

Supportive Housing

Supportive housing complements the long-term care continuum by providing an option for seniors who find themselves needing increasing support but who are still too high functioning to warrant placement within a long-term care facility. A supportive housing program25 must provide homemaking/personal support /attendant services with the personal support/attendant component of the service available 24 hours a day. There are no supportive housing services for the frail elderly, persons with Acquired Brain Injury or persons with HIV/AIDS in Cochrane District. The only supportive housing facility is for adults with disabilities. This 15-unit housing complex located in Timmins is operated by Access Better Living. Demand for these units varies greatly, but as of May 2004, there were 14 people on the waitlist, many of which have neurological disorders. In January of 2004, the ACMS District Health Council began a review of supportive housing needs within the Cochrane District. The report is underway and will be completed in the fall of 2004. The report will provide an estimate of projected need based on comparative benchmarks. For seniors in Ontario, the age criterion is set at 60 years of age for supportive housing. At this time, the Ministry has not established benchmarks or targets for supportive housing programs with respect to the number of spaces or clients that will be needed as the population of seniors increases. Without established Ministry benchmarks it is difficult to quantify the level of supportive housing needs of Timmins or the district. Table 31 attempts to calculate the need using a range of benchmarks derived from the literature. Crude calculations suggest that a community the size of Timmins should have somewhere between 152 to 355 supportive housing spaces. The low end of the range refers to individuals whose needs would be considered high, and the high end of the range refers to individuals with low supportive needs.

25

Ministry of Health and Long-Term Care’s Planning, Funding & Accountability Policies and Procedures Manual for Long-Term Care Community Services.

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Table 31:

COMMUNITY

Summary of Benchmarks for 65+ for Cochrane District

POPULATION 2001 CENSUS

POPULATION 65+ YEARS OF AGE (2001 CENSUS)

43,686 5217 5690 9238 2912 1830

5065 855 720 1350 410 270

5825 936

Timmins Iroquois Falls Cochrane Kapuskasing Matheson Smooth Rock Falls Hearst Moosonee Cochrane Unorganized

6.3

PYRAMID MODEL Live Independently

High End

Low End

LTC Facility

85%

4305 727 612 1147 348 230

3% 152 26 22 41 12 8

7% 355 60 50 95 29 19

5% 253 43 36 68 21 14

650

553

20

46

755

642

23

53

BOLDY AND HEUMANN

BENCHMARK ESTABLISHED BY B.C. GOV’T

4.5%

4% 228 38 32 61 18 12

202 34 29 54 16 11

33

29

26

38

34

30

Social Housing for Seniors

All social housing units for seniors in the District of Cochrane is managed by the Cochrane District Social Services Administration Board (CDSSAB). As shown in Table 32, there are 1,131 social housing units in total for seniors aged 60 and over in the District of Cochrane, and 568 units in the City of Timmins. All seniors’ apartment buildings with 3 storeys or more, and some buildings with 2 storeys, have an elevator. Some units have also been modified to incorporate assistive devices (i.e. grab bars in bathrooms) but few are wheelchair accessible. The CDSSAB indicates there is a wait list for all seniors’ accommodations in the Cochrane District. There are 396 applicants on the district-wide waitlist and 270 on the City of Timmins wait list. Access is based on a first-come first-served basis or by date of application. The CDSSAB indicates that the average wait time is two years. Table 32:

Social Housing Unit for Seniors 60 Years +, 2004

COMMUNITY Cochrane

Fauquier

ADDRESS

NUMBER OF UNITS

UNIT SIZE

TYPE OF BUILDING

235-13th Avenue

15

1 BR

2 storey apt.

437-11th Avenue

31

1 BR

2 storey apt.

436- 11th Avenue

37

1 BR

2 storey apt.

RR#3 Genier

10

1 BR

1 storey apt.

383 -8th Street

13 1

1 BR 2 BR

1 storey apt.

1210 Doyon St

10 6

1 BR 2 BR

2 storey apt.

Review of the Increasing Pressures of an Aging Population on the Health Care System in the City of Timmins and the Cochrane District – June 2004

SPECIAL FEATURES

2 MU

32

COMMUNITY Hearst

Iroquois Falls

Kapuskasing

ADDRESS

NUMBER OF UNITS

UNIT SIZE

TYPE OF BUILDING

SPECIAL FEATURES

54-8th Street

24

1 BR

2 storey apt.

47-13th Street

24

1 BR

2 storey apt.

1 MU

1015 Edward (St. Paul) 471 de Troyes

24

1 BR

3 storey apt.

E & 1 MU

14

1 BR

2 storey apt.

156 Picadilly

25

1 BR

2 storey apt.

628 Majestic

10

1 BR

2 storey apt.

250 Cambridge

1 BR 2 BR 1 BR

2 storey apt.

E & 2 MU

55 Cedar Street

19 4 51

3 storey apt.

E

12 MacPherson

49

1 BR

6 storey apt.

E 3 MU 3 wheelchair MU

32 MacPherson

1 BR 2 BR 1 BR

2 storey apt.

E

Matheson

414-6th Ave

22 9 23

Mattice

160 Melrose

15

1 BR

2 storey apt.

Moonbeam

1 Pelletier Niska Rd.

1 BR 2 BR 1 BR

1 storey apt.

Moosonee

13 6 28

Ramore

375 McIntyre

15

1 BR

1 storey apt.

374 McIntyre

10

1 BR

1 storey apt.

Smooth Rock Falls

92 Ross Rd.

24

1 BR

2 storey apt.

Timmins

491 Melrose

42

1 BR

2 storey apt.

620 Park

12

1 BR

2 storey apt.

646 Bartleman

51

1 BR

2 storey apt.

58 Lakeview

60

1 BR

6 storey apt.

E

217 Pine

103

1 BR

7 storey apt.

E

615 College

51

1 BR

2 storey apt.

255 Lee

15

1 BR

1 storey apt.

33 Golden Ave.

61

1 BR

6 storey apt.

E

67 Mountjoy

61

1 BR

6 storey apt.

E

77 Mountjoy N

32

1 BR

3 storey apt.

E

Review of the Increasing Pressures of an Aging Population on the Health Care System in the City of Timmins and the Cochrane District – June 2004

1 MU

E

33

COMMUNITY

Val Gagne

Val Rita Total Number of Units

ADDRESS

NUMBER OF UNITS

UNIT SIZE

TYPE OF BUILDING

44 Borden Ave

50

1 BR

6 storey apt.

231 Huot St, South Porcupine Lessard St

30

1 BR

2 storey apt.

10

1 BR

2 storey apt.

59 Lessard

11

1 BR

2 storey apt.

24 Deschenaux Ave.

10

1 BR

1 storey apt.

1105 26

1 BR 2 BR

Source: CDSSAB

SPECIAL FEATURES E

Legend: Apt. – Apartment T.H. – Townhouse Semi-D – Semi-Detached House Single – House

M.U. – Modified Unit E. - Elevator BR - BR B – Bachelor

Review of the Increasing Pressures of an Aging Population on the Health Care System in the City of Timmins and the Cochrane District – June 2004

34

7.0 HOSPITAL UTILIZATION DATA The Timmins and District Hospital is a district referral centre for Rural and Northern Hospital Network 13. The Hospital has a total complement of 147 beds. Table 33 breaks down the classification: Table 33:

Timmins and District Hospital Bed Complement by Classification, 2004

BED CLASSIFICATION

# OF BEDS

Acute

92

Mental Health

20

Rehabilitation Chronic (Complex Continuing Care)

Total

35

147

Source: 2003/2004 Business Planning Brief (BPB)

7.1

Emergency Department Visits

Across Ontario, there were 430 visits per thousand population in 2002/03, as shown in Table 34. Overall, there is high use of hospital emergency departments by residents of the ACMS area. In 2002/03, residents visited hospital emergency departments at a rate of 789 per 1000 population or 83 percent higher than the provincial experience. The standardized rate for the Cochrane District was 1,146.6 or 166 percent higher than the provincial experience. Table 34:

Emergency Department Visits, Population Age-Standardized Rates, ACMS Districts and Ontario, 2002/03

JURISDICTION Algoma Distsrict Cochrane District Manitoulin District Sudbury District Greater Sudbury ACMS total Ontario

EMERG. LOWER UPPER DEPT. S-RATE CONFIDENCE CONFIDENCE VISITS PER 1000 E LEVEL E LEVEL 115,215 983.7 982.4 985.1 96,858 1,146.6 1,143.3 1,150.0 19,117 1,501.0 1,485.0 1,517.0 20,547 927.1 924.5 929.8 57,706 373.6 371.3 376.0 309,443 789.1 787.9 790.2 4,912,169 430.5 430.2 430.8

Visits to hospital emergency departments are assigned a main reason or diagnosis. The following analysis uses the assigned main reason/diagnosis based on the International Classification of Disease version 10 (ICD10) chapter headings. Table 35 shows the ten leading reasons for visits to hospital emergency departments across the ACMS area and the province. These accounted for 88 percent of all visits (ACMS hospitals and Ontario).

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35

Table 35:

Emergency Department Visits by Main Cause, ACMS Hospitals and Ontario, 2002/03

ACMS Main Reason for Visit

Visits Injury and poisoning 58,159 Factors influencing health status 47,293 Symptoms, signs not elsewhere classified 46,586 Respiratory system diseases 38,608 Muskuloskeletal diseases 21,896 Digestive system diseases 15,945 Skin and subcut diseases 12,262 Genitourinary system diseases 11,677 Ear and mastoid diseases 10,997 Circulatory system diseases 9,946 Top 10 totals

273,369

Ontario

Percent of Visits Visits 18.7% 1,259,010 15.2% 407,826 15.0% 865,769 12.4% 554,180 7.1% 284,714 5.1% 302,238 3.9% 170,148 3.8% 201,975 3.5% 158,280 3.2% 177,509 88.0% 4,381,649

Percent of Visits 25.29% 8.19% 17.39% 11.13% 5.72% 6.07% 3.42% 4.06% 3.18% 3.57%

Timmins Hospital Percent Visits of Visits 6,866 18.9% 4,162 11.5% 5,828 16.1% 4,563 12.6% 2,685 7.4% 2,236 6.2% 1,273 3.5% 1,382 3.8% 1,420 3.9% 1,217 3.4%

88.03% 31,632

87.2%

The leading ten reasons for visits to hospital emergency departments are consistent across ACMS hospitals and the province. There is also marked consistency in the proportion of visits by main cause with the exception of the two leading causes. Visits due to factors influencing health status in ACMS hospitals are the second leading cause of emergency department use. As Table 35 indicates factors influencing health status assume a much higher proportion of visits to emergency departments in ACMS hospitals as compared to the province. To understand the application of the above definition, the following are some of the specific ICD10 codes that appear as main reason for visits to a hospital emergency department for factors influencing health status: Attention to surgical dressings and sutures Issue of repeat prescription Follow-up examination after other treatment for other conditions Other specified orthopaedic follow-up care Table 36 documents the leading reasons for a visit to an ACMS hospital emergency department when the main cause was factors influencing health status. Recall that these “factors” accounted for 15 percent of all visits to ACMS hospital emergency departments or over 47,000 visits in 2002/03.

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36

Table 36:

Emergency Department Visits Due to “Factors Influencing Health Status”, ACMS Hospitals, 2002/03

ICD-10 Diagnosis "factors influencing health status" Attention to surgical dressings and sutures Follow-up examination (after other treatment, surgery, etc.) Issue of repeat prescription Other prophylactic chemotherapy Procedure not carried out (patient decision or other reason) Other specified medical care Other specified counselling Other specified orthopaedic follow-up care Total of leading diagnoses in ACMS hospitals

ACMS Hospitals Percent Visits of Total 8,367 18%

Timmins Hospital Percent Visits of Total 528 13%

8,654 6,772 2,394

18% 14% 5%

330 505 277

8% 12% 7%

2,222 1,815 1,623 1,577

5% 4% 3% 3%

1,364 7 10 94

33% 0.2% 0.2% 2%

33,424

71%

3115

75%

Examining Table 36 reveals that a very significant volume of visits to ACMS hospital emergency departments is for health issues that could be provided in alternative settings. Removal of surgical dressings/sutures, follow-up examinations and repeat prescriptions are all notable reasons for visits to ACMS hospital emergency departments. In the context of the health system in the ACMS area, these observations may be consistent with desired use and intent of emergency department services and/or the limited availability of alternatives for patients.

7.2

TDH Profile of Admissions and Length of Stay (LOS)

Timmins and District Hospital provided data on their senior population occupying acute and complex continuing care beds. The information provides insight for the last two 2 fiscal periods, 2002/03 and 2003/04. While two years does not provide sufficient data to determine a trend, it does provide insight into the years that resulted in the current crisis. The patient profile reveals the following: Admissions The senior population (65+) accounts for about 54-55 percent of all hospital admissions. Seniors over the age of 80 account for about 22 percent of all hospital admissions. Length of Stay (LOS) The average LOS of patients 80 years and over increased over the past two years by about 4.7 percent. Average LOS for a patient 65 years and over has increased from 8.98 days (in 2002/03) to 10.21 days (2003/04); total LOS has stayed constant but the number of patients 65 years and over has decreased by 12 percent. Review of the Increasing Pressures of an Aging Population on the Health Care System in the City of Timmins and the Cochrane District – June 2004

37

Emergency Room (ER) Overall, (all ages) ER visits increased 8 percent over the last two fiscal years. Seniors (65+) account for 14-15 percent of all ER visits. Seniors 65 years and over visits to the ER decreased by 3 percent since last fiscal year. Admissions from the LTC facilities26 in Timmins have decreased 28 percent (or 28 patients).

7.3

Hospital Resource Utilization (CCC Beds)

The Health Planning Branch of the MOHLTC has provided data on the average Resource Utilization Group (RUG III) Case Mix Index of all Network 13 hospitals for three fiscal periods, from 1999/00 to 2001/02. The data provides insight into each hospital’s overall relative resource intensity in comparison to Network 13 members and the provincial average. Each RUG-III group has a corresponding case mix index (CMI)27 weighting. The CMI for a group in the RUG-III classification system is the relative weight of resource use in that group compared to a base resource use level. RUG-III classifies patients into one of seven major categories, from the most to the least resource intensive. These categories are further divided into 44 groups. The top four groupings are appropriate for a complex continuing care unit. COMPLEX CONTINUING CARE

1. 2. 3. 4.

Special Rehabilitation Extensive Services Special Care Clinically Complex

LONG-TERM CARE

5. Impaired Cognition 6. Behaviour Problems 7. Reduced Physical Functions

Anson General Hospital, Kirkland and District Hospital, and Timmins and District Hospital stand out as having the highest resource intensity needs in the Network, higher than the provincial rate for most years (Table 37). In general however, the CMIs of most Network 13 hospitals are low, which indicates that the relative resource needs of clients occupying these beds are less than the provincial average. This data must however be considered within the context of alternate health care services available within a given community as the absence of more appropriate services may affect a resident’s decision to enter the hospital system for the provision of care. Conversely, the range of health care services within the community may influence a hospital’s ability to discharge back to the community to a more appropriate level of care.

26 27

Golden Manor and Extendicare. CMIs are the ‘weights’ used in RUG-III to reflect the relative resource intensity of different patient groups.

Review of the Increasing Pressures of an Aging Population on the Health Care System in the City of Timmins and the Cochrane District – June 2004

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Table 37:

Network 13 Hospitals Case Mix Index, 1999/00 to 2001/02

HOSPITAL FACILITY Anson General Hospital Bingham Memorial Hospital Chapleau Health Services Kirkland and District Hospital Lady Minto Hospital Notre Dame Hospital Sensenbrenner Hospital Smooth Rock Falls Hospital Timmins and District Hospital Provincial

CMI (1999/00)

A 1.0555 0.7468 0.8873 0.9032 0.9536 0.8582 0.8239 0.7500 1.1805 1.0266

B 1.0555 0.7468 0.8873 0.8906 0.9536 0.8569 0.8239 0.7500 1.1348 1.0194

CMI (2000/01)

A 1.0275 0.7061 0.9229 0.8891 0.8353 0.8733 0.8450 0.8476 1.2530 1.0427

B 1.0275 0.7061 0.9229 0.8891 0.8353 0.8733 0.8450 0.8476 1.2237 1.0406

CMI (2001/02) A B 1.1159 1.1159 0.8172 0.8172 0.9947 0.9947 1.1436 1.0426 0.8207 0.8207 0.8355 0.8334 0.9223 0.9223 0.6901 0.6901 1.2795 1.2395 1.0775 1.0757

Source: Ontario Ministry of Health and Long-Term Care: Provincial Health Planning Database, December 2003 Notes: Column A excludes cases with no assessments carried out within 13 days of admission. Column B includes cases with lowest CMI value assigned if no assessment has been done after 14 days of admission. It is also noted that staff education regarding the weighting of cases can in part be responsible for the changes in the CMIs over the three-year period.

The Timmins and District Hospital provided their facility RUG Report summary for a five-year period (1998/99 to 2002/03). The information in Figure 2 reveals that a large majority of all assessed clients are classified under the most resource intensive grouping: rehabilitation. The percentage of rehabilitation clients that are occupying a complex continuing care bed ranges from 53 percent in 1998, to 74 percent in 2002. It should be noted that all patients who are awaiting placement to an alternate setting, continue to receive therapy services on a daily basis which may “inflate” the rehab numbers. Figure 2:

Timmins and District Hospital RUGS Report, 2000 to 2003 (1st Quarter) Rehab

80 70

Extensive Services

60 50

Special Care

40 30

Clinically Complex

20 10 0

Cognitively Impaired

2000

2001

2002

Q1 2003

Behavioral

Source: Timmins and District Hospital Facility RUG Report

Review of the Increasing Pressures of an Aging Population on the Health Care System in the City of Timmins and the Cochrane District – June 2004

39

Table 38 depicts average length of stay for complex continuing care (CCC) for each Network 13 hospital over a three-year period. The analysis is based on discharged patients in a given fiscal year and those who accumulate a full year of residence for the fiscal year of analysis. The Timmins and District Hospital and the Sensenbrenner Hospital have the lowest average length of stay of the nine Network 13 hospitals. It is noted that the range of long-term care services available at the community level influences a hospital’s average length of stay. Table 38:

Network 13 Average Length of Stay for Complex Continuing Care, 1999/00 to 2001/02

HOSPITAL Anson General Hospital Bingham Memorial Hospital Chapleau Health Services Kirkland and District Hospital Lady Minto Hospital Notre Dame Hospital Sensenbrenner Hospital Smooth Rock Falls Hospital Timmins and District Hospital

AVERAGE LENGTH OF STAY 1999/2000 2000/2001 2001/2002 241.82 225.15 197.57 129.69 161.00 111.30 366 365.00 195.29 132.25 201.60 155.94 147.25 135.92 70.50 153.73 251.61 153.18 92.91 94.92 74.17 272.00 273.25 365.00 49.78 42.85 49.33

Source: Ontario Ministry of Health and Long-Term Care: Provincial Health Planning Database, December 2003

7.4

Admission Patterns to Complex Continuing Care (CCC) Beds

The Ministry provided data on where clients were located prior to being admitted to a CCC bed (Table 39). The majority of clients are transferred from a hospital’s acute care unit to the CCC unit. A few Network 13 hospitals report an increase in clients coming from a home care setting. A number of facilities note an increase in the number of client cases that were ‘not-transferred’, which means that they were carried over from a previous fiscal year. Table 39:

Client Location prior to Admission to CCC Beds, 1999/00 to 2001/02

HOSPITAL Lady Minto Hospital

Notre Dame Hospital

28

DISCHARGE TO: Acute Treatment Home Care Program Nursing Home Private Home Acute Treatment Home Care Program Home for the Aged Chronic Care Treatment Private Home OP of same28

1999/00 (%) 92 8

2000/01 (%) 92

2001/02 (%) 33 50

8 98

96

2

4

17 62 3 6 3 21 6

Outpatient facility of same institution.

Review of the Increasing Pressures of an Aging Population on the Health Care System in the City of Timmins and the Cochrane District – June 2004

40

HOSPITAL Sensenbrenner Hospital

Anson General Hospital

Bingham Memorial Hospital

Timmins & District Hospital

Smooth Rock Falls Hospital Kirkland and District Hospital

Chapleau Health Services

DISCHARGE TO: Acute Treatment General Rehab. Hospital Home Care Program Private Home Acute Treatment Chronic Care Treatment General Rehab. Hospital Mental Health Program Nursing Home Acute Treatment Home Care Program Private Home Nursing Home Acute Treatment Chronic Care Treatment General Rehab. Hospital OP of Same Home Care Program Home for the Aged Nursing Home Private Home Mental Health Program Unclassified Acute Treatment Acute Treatment Home Care Program Home for the Aged Nursing Home Private Home Acute Treatment Nursing Home Private Home

1999/00 (%) 85 2 4 9 82 12 6

85 8 8 96