Island Health’s Care Delivery Model Redesign (CDMR)

Overview

Island Health (formerly VIHA) is reconfiguring nursing care teams in medical and surgical units at select hospitals as a part of a new Patient Care Model called Care Delivery Model Redesign (CDMR). The reconfiguration is a part of a nation-wide trend to change how care is provided to patients in hospitals. In essence, CDMR would implement a team-based nursing approach between Registered Nurses (RNs), Licensed Practical Nurses (LPNs) and Health Care Aids (HCAs), with HCAs playing a significantly larger role in patient care delivery.

According to Island Health, the new model will address strains on the system while increasing the individual care time a patient receives. However, critics argue that the new model is overly focused on cutting costs and will put patients at risk. In essence, they argue that nurses will be stretched too thin to provide adequate care to patients, making one nurse responsible for up to 10 to 12 patients, and that Health Care Aids do not have the necessary training to safely take on this larger role.

Andrew Weaver, MLA for Oak Bay-Gordon Head and Deputy Leader of the BC Green Party, is calling on Island Health to delay further implementation of CDMR until comprehensive, independent and publically-available evaluations can be completed. If critics are right, the cost of going forward with CDMR will be borne by patients who may well receive inadequate and potentially harmful care in island hospitals.

Background

Health Authorities across the province are faced with the challenge of continuing to provide quality service in the context of limited budgets, staffing challenges and changing demographics, principally defined by an aging population. This context has led Island Health to explore new ways of meeting patients’ care needs. One approach has been CDMR.

According to Island Health, over the past several years researchers have been collecting data on typical patient care needs so as to better calibrate their care teams to those needs. There are 3 main types of health care professionals that make up an affected care team:

1. Registered Nurse (RN)—A licensed and regulated nurse requiring an undergraduate degree and representing the highest level of training of the three types of professionals.
2. Licensed Practical Nurse (LPN)—A licensed and regulated nurse that works under an RN and requires a two-year certificate of training.
3. Health Care Aid (HCA)—An unlicensed and unregulated care provider that supports an RN or LPN to provide basic care to patients. HCA’s generally complete a four-to-five month training course, but there are no regulated standards for HCA training programs or HCAs in general.

The conclusion from Island Health’s research is that HCAs could play a larger role in providing basic care (e.g. bed baths, patient mobility). The result is CDMR—an approach that would see HCA’s take on this larger role and effectively reduce the number of RNs and LPNs on medical and surgical units. However, HCAs are not a regulated profession meaning there is no quality control or scope of practice governing their training or role in the health care system.

Island Health introduced CDMR at Cowichan Hospital and Saanich Peninsula Hospital roughly two years ago. CDMR was then introduced at Nanaimo Regional Hospital in September 2013, with additional plans to implement it at Victoria General Hospital and Royal Jubilee Hospital in January or February 2014.

Differing Perspectives

Both Island Health and the British Columbia Nurses Union have been vocal about CDMR, offering differing perspectives.

Island Health: According to Island Health CDMR is a ‘data-driven’ model that will allow care teams to better meet patient needs, provide more staff hours per patient and address, in part, staffing issues such as overtime. Island Health asserts that HCAs are sufficiently trained to offer support services, such as bed baths and mobility support, as a part of a broader care team. Island Health also states that they have been conducting on-going studies of CDMR to evaluate the care model.

Link to Island Health’s publications on CDMR: http://www.viha.ca/about_viha/news/new-patient-care-model.htm

BCNU: The BC Nurses Union has been highly critical of CDMR citing research that suggests such care models would have negative impacts on patient care outcomes and arguing that the data on which CDMR is based has not been released for public scrutiny to know if CDMR would be any different. The BCNU is in favour of team-based care models, but argues that the teams need to have the right make-up of skills and CDMR as proposed does not offer this. They suggest that CDMR would stretch nurses too thin, making them responsible for more patients than they can safely care for and offering too large a role to unregulated and inadequately-trained HCAs. They suggest that patients may receive inadequate and potentially harmful care as one RN may be required to care for up to 10 or 12 patients.  As such, they have expressed concerns that it would be difficult for them to provide the standard of care required by the College of Registered Nurses of British Columbia, the College of Licensed Practical Nurses of British Columbia and the College of Registered Psychiatric Nurses of British Columbia.

Link to BCNU’s statements on CDMR: https://www.bcnu.org/Search.aspx?search=cdmr

Academic Research: There is no publicly available research specifically on CDMR itself, as CDMR is a tailor-made model for Vancouver Island. However there is significant academic research looking at “nurse staffing” levels and what happens when you decrease the number of highly trained RNs and increase the number of comparatively less-trained LPNs or HCAs. The research generally suggests that this change is associated with a significant drop in the quality of care a patient receives. There is enough of this research out there to raise serious questions about the risks associated with CDMR.

Two Canadian researchers who have published in this area are: Dr. Linda O’Brien-Pallas and Dr. Linda McGillis Hall

Questions

It is difficult at this stage to definitively assess whether CDMR is a good model or not. Island Health claims to have data that suggests it is. However, their evaluations are not publicly available and run contrary to existing academic research. Nurses are highly opposed, arguing they will not be able to provide sufficient quality care under CDMR since they will be responsible for more patients than they can manage. What is clear is that if critics are right, CDMR may have a significant impact on the quality of care patients receive in BC hospitals and lead to a rise in potentially harmful care situations. This context begs three key questions.

1. If there is research showing the success of CDMR, then when will Island Health make it available?
2. CDMR has been implemented at Cowichan and Saanich Peninsula Hospitals for two years. Has Island Health evaluated CDMR in these settings and if so, when will the evaluations be made publicly available?
3. If Island Health has not yet completed comprehensive evaluations showing that CDMR is a successful model, then why are they rolling it out in more and more hospitals amidst strong opposition that raises serious questions about its validity as a care model?

Andrew Weaver on CDMR

In light of the potentially serious risks associated with CDMR, Andrew Weaver is calling on Island Health to:

1. Delay further roll-out of CDMR, including all plans at Victoria General and Royal Jubilee Hospitals, until comprehensive, independent and publically-available evaluations of CDMR can be completed.
2. Further involve relevant stakeholders, including representatives of BC’s Registered Nurses and Licensed Practical Nurses, in the evaluation of current CDMR pilots as well as in the development of future plans involving the realignment of care teams.