Waterloo Wellington CCAC Community Stroke Program

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1 Waterloo Wellington CCAC Community Stroke Program Stroke Collaborative 2014 October 27, 2014 Maria Fage, OT Reg. (Ont.) Manager, Client Services

2 Map of Waterloo Wellington LHIN 2

3 Background Integration of Stroke Services Across the Continuum (April 1, 2014) Waterloo Wellington Stroke Steering Committee LHIN Integration Order (August, 2013) Hospital reorganization Reports Improving Access to Quality Stroke Care in Waterloo-Wellington (2011); Transitioning to a System of Rehabilitative Care in Waterloo-Wellington (2012) Stroke Implementation Task Force CCAC to deliver bestpractice stroke care Access Outcomes System efficiencies 3

4 Waterloo Wellington Stroke Steering Committee & Implementation Task Force 4

5 CCAC Community Stroke Program is One Component of the Waterloo Wellington Integrated Stroke Care System 5

6 Program Components & Timelines Phase 2: April 1, 2014 Discharge Link Meeting (Rehabilitation & Acute Sites) Consolidated Service Provider Stroke Team Use of Rehabilitation Assistants 24 hour on-call access Transition to Next Phase of Rehabilitation Evaluation Phase 3: Fall 2015 Incorporate Nursing & PSW into Stroke Team Phase 1: November 2013 Designated Stroke Care Coordinators: Hospital & Community First home visit by therapist within 48 hours of hospital discharge Link to Primary Care Clinical Rehab Pathway as per best practice guidelines; including rehab assistants Phase 2 Phase 1 Phase 3 6

7 Consolidated Service Provider - Community Stroke Team Care Coordinators Dedicated Additional training and knowledge of stroke system and resources Stroke Care Coordinator OT (Lead Therapist) SW Stroke Team Dedicated Education and skill requirements: Neuro/stroke rehabilitation PT Rehab Assistants Knowledge of stroke best practices SCA TM SLP RD Best practice assessment tools 7

8 WWCCAC Stroke Pathway Pre-Discharge Weeks 1-2 Weeks 3-4 Weeks 5-8 Weeks 9-12 Discharge Planning Discharge Link Meeting Assessment & Goal Setting Care Coordinator Assessment Case Conference Treatment Treatment CSS linkages Transition & Discharge Case Conference Care Coordinator Reassessment CSS linages Based on the clinical stroke pathway developed by NSM CCAC and adopted by the OACCAC. Based on Canadian Stroke Best Practice Guidelines, and validated by the OSN. Defines expected outcomes and interventions of the Care Coordinator and Therapists; OT typically the lead therapist and attends Discharge Link. Available visits to provide an intensity of therapy (OT, PT, SLP, SW, Nut, Rehab Assistants) that is in keeping with best practice (45 min-3hour visits; 3-5x/week) Patient s progress determines how he/she move through the pathway. Patient transitioned to the next phase of rehabilitation upon completion of the pathway. 8

9 Waterloo-Wellington Banding Model: - Used to Guide Patient Flow & Eligibility Band 1 Assessment and Triage; TIA Band 2 Short Stay Rehab High Intensity and Short Duration Band 3 Moderate Intensity/Duration Outpatient or Community Program CCAC Stroke Program Band 4 Low Intensity/Long Duration Band 5 Severe Strokes Palliative Little or No Improvement Eligibility for WW CCAC Stroke Program: Band 2, 3, or 4 Need for multi-disciplinary stroke rehabilitation Willing to participate Rehabilitation needs are best met in the home Patient lives greater than 30 minutes from an outpatient program 9

10 Number of Patients Acute & Rehab vs CCAC Stroke Volumes Average: Total Acute+Rehab WWCCAC Average: April May June July August Month 10

11 Number of Stroke Pathways Started & Completed 1 Apr - 17 Aug Total # of Pathways Pathway Completed: goal met Client Still Active on Pathway 11

12 120% Therapy Utilization as a Percentage of Patient Pathways 1 Apr - 17 Aug % 100% 86% 80% 60% 59% 44% 40% 20% 16% 0% Visit OT Visit PT Visit SW Visit SLP Visit RD 12

13 Time per Visit by Therapy Discipline 1 Apr - 17 Aug Visit OT Visit PT Visit SW Visit SLP Visit RD Average time per visit (mins) Min. time per visit (mins) Max time per visit (mins)

14 Magnitude of Functional Change: - RAI-HC - Barthel Index - RNLI Patient & Caregiver perspective on impact of program: - Patient Experience Survey Program Evaluation System Impact: - Hospital readmission rates - In-patient rehabilitation length of stay 14

15 Brant Haldimand Norfolk Community Stroke Rehabilitation Pilot Model Metrics Update September 2014 Lori Schiappa Manager, Client Services

16

17 Partners 17

18 Development of HNHB- CSR Brant Haldimand Norfolk Pilot Model Integration of the Community Stroke Rehab Model into the care path of the Integrated Stroke Unit (ISU) Identification of patient s rehabilitation needs in the hospital stay, within hours Strong link with District and/or Regional Stroke Centre s ISU 18

19 Development of HNHB- CSR Brant Haldimand Norfolk Pilot Model Strong link with primary care physician Post discharge interdisciplinary meetings monthly Transferability of model (is the model able to be spread across the HNHB based on the pilot results) Standardized reporting requirements

20 Development of HNHB- CSR Brant Haldimand Norfolk Pilot Model Consistency of Service Provider Stroke Team (80% of care is to be provided by a consistent OT/PT/SLP in the community) Stroke Team Members Expertise (e.g. FIM, MoCA (OT), Neuro Motor Rehab, Supportive conversation for Adults with Aphasia) Dedicated Care Coordination 20

21 Development of HNHB- CSR Brant Haldimand Norfolk Pilot Model Time to first visit within 72 hours following hospital discharge for provider and the Care Coordinator Care pathway into streams (mild, moderate, severe) based on best practice standards: 2-3 outpatient or community based allied health professional visits/week (per required discipline) for 8-12 weeks and incorporates milestones and opportunities for reassessment

22 Eligibility Persons post stroke will be triaged into two CSR program Outpatient clinic based therapy Outreach home based therapy (CCAC) Eligibility for in home therapy will be based on the following criteria: Live beyond a 30 minute drive of a specialized clinic based OP stroke rehab program (BCHS) Do not have the tolerance to travel 30 minutes to an OP program and participate in therapy 22

23 Care Coordination - Value for the Patient Dedicated Community Care Coordination Assessment in patients home within 72 hours of CCAC admission Additional training for Care Coordinator (Hemispheres training, Aphasia) Standardized assessment tool (interrai-ca, RAI-HC) Link patients to community programs (Health Care Connect to find a physician) Referral to other agencies (Adult Day Program, supportive groups in community, other rehab in the community) Connection with service providers (post discharge meeting monthly, updates) Care Coordinator housed in office to address urgent patient calls Assistance with transitioning to alternate levels of care (RHs, LTCHs) Coordinates post discharge stroke team meetings monthly 23

24 Community Stroke Rehabilitation Pilot Model Metric Results from December 2013-June 2014 (Data Source: HNHB CCAC CHRIS) 24

25 Community Stroke Rehabilitation Pilot Model Stream & Services # Patients Visits Avg. Visits per Person PT Visits Mild Moderate Severe OT Visits Mild Moderate Severe SLP Visits Mild Moderate Severe Average visits per person were highest in the Severe stream for PT and OT. Average visits per person for SLP were higher in the Mild stream and highest in the Moderate stream 25

26 Community Stroke Rehabilitation Pilot Model Services # Patients # Patients Received PT Services 10 Total PT Visits 129 Average PT Visits per Person # Patients Received OT Services 11 Total OT Visits 151 Average OT Visits per Person The number of visits and average visits per person were highest for SLP, followed by OT and lastly PT # Patients Received SLP Services 9 Total SLP Visits 160 Average SLP Visits per Person

27 Community Stroke Rehabilitation Pilot Model Goal Met 80% Consistency in Service Delivery Patient Discharged to a Community Program Stream # Patients Yes No Yes No Yes No Mild Moderate Severe Total 11 72% (8 out of 11) patients met their program goals; 3 patients went to hospital 10 out of 11 of patients had 80% consistency in service delivery All patients were discharged to a community program

28 Community Stroke Rehabilitation Pilot Model DRS (Depression Rating Scale) # At Admission # At 3 Months DRS DRS DRS From admission to 3 months DRS Score remained the same for 6 patients; improved for 4 patients; worsened for 1 patient DRS DRS

29 Community Stroke Rehabilitation Pilot Model RNLI (Reintegration to Normal Living Index) Score # Patients Avg. RNL1 Initial # Patients Avg. RNL1 Discharge Mild Moderate Severe Used to evaluate degree to which a patient is able to return to normal life. Higher scores represent better perceived integration (up to a max of 100) Scores From Initial to Discharge Mild Increased by 24% Moderate Increased by 31% Severe Increased by 31% 29

30 Community Stroke Rehabilitation Pilot Model FIM (Functional Independence measure) Scores Number of Patients Avg. FIM at Admit Number of Patients Avg. FIM at Discharge Mild Moderate Severe Measures level of disability and indicates how much assistance is required to carry out activities of daily living. Higher scores represent increased independence (up to a max of 126) Scores From Admit to Discharge Mild - Increased by 9% Moderate Increased by 30% Severe Increased by 19% 30

31 Community Stroke Rehabilitation Pilot Model All 11 of the patients received a Inter-RAI CA on admission, a RAI-HC within 72 hours and at 3 months, from a CCAC Care Coordinator 100% of patients had a RAI-HC completed at admission and at 3 months 31

32 Background Community Stroke Rehabilitation Pilot Model Patients were called at the 3 month mark to determine their level of satisfaction with how the team has been supporting them post hospitalization. 6 of the 12 patients (March- June) agreed to provide feedback. (Non- participants included, language barrier, unavailable, did not want to participate) Patients or Caregivers were approached (4 caregivers, 2 patients) Preliminary Results Overall, how satisfied were you with the help you or your loved one received from the team? 100% of respondents indicated they were Satisfied or Very Satisfied. The team members and I decided together what would help me. 33% strongly agreed they felt included in deciding together what would help them 50% neither agreed or disagreed: Comments: The plan was outlined for us. 17% strongly disagreed Comments: The amount of service in the beginning was overwhelming My therapy program was explained to me in a way that I could understand. 83% either strongly agreed or agreed 17% strongly disagreed The team helped me adjust to my life after stroke. 83% either strongly agreed or agreed 17% disagreed Comment I am not sure we will ever adjust Would you recommend this team to another family member of friend needing this type or assistance? 83% Yes 17% Maybe

33 Community Stroke Rehabilitation Pilot Model Survey Comment We were not expecting all of the care that we received from the CCAC. Myself and my sister are very busy and appreciative of all the support for my mom

34 Community Stroke Rehabilitation Pilot Model In summary, this CSR model provides seamless transition through a standardized care path that details the patient s journey from ER to community. The model facilitates collaboration between Hospital and community supporting patients to work on their Rehab goals in a home setting. Thank you! 34

35 David Ure, OT Reg. (Ont.), CPA, CMA

36 Development of the model In response to the request for proposal issued by the Ministry of Health and Long-Term Care in September 2001, the Southwestern Ontario Region submitted a pilot project titled: A Regional Stroke Rehabilitation System: From Vision to Reality

37 Development of the model This Outreach Service was effective in meeting the needs of service providers in the region and the clients/families they serve. This is demonstrated by the demand for the service, high levels of satisfaction by the requesters and the improvement in knowledge self-rating by the participants. Pilot report submitted to the MOH December 2004 Permanent funding received for 2009 launch

38 Development of the model Designed to offer rehabilitation in the community for stroke survivors with on-going rehabilitation needs Mandate 1. Provide rehabilitation in the most appropriate setting (home and community) 2. Offer secondary prevention, system navigation and community re-integration 3. Provide caregiver support

39 Key elements of the model - Stakeholders

40 Key elements of the model Access Grey Bruce Huron Perth Thames Valley Southwest Local Health Integration Network

41 Key elements of the model Multidisciplinary Teams Nurse Physiotherapist Occupational Therapist Speech Language Pathologist Social Worker Therapeutic Recreation Specialist Rehabilitation Therapist

42 Key elements of the model Specialized team Treatment setting home & community Service delivered to remote communities Transition from long term care to community living Community reintegration/linking with community services 6 month follow-ups after discharge

43 Development and implementation Key Success Factors: Ease of referral Comprehensive data base Outcome measures on intake, discharge and 6 month follow-up (FIM, PHQ2/9, Bakas, RNLI) Self-Management focus Communication: Weekly Rounds, cell phones, Wi-Fi

44 Number of Clients Referred Development and implementation Annual Referral Volume Year

45 Metrics Referrals per month: 50 Days referral to first contact: 1-20 Days contact to first visit: 2-15 Days Average length of service: 53 Days Max Ave. Length of service: 84* Average visits per client: 41 Average intake FIM : 100 Minimum intake FIM : 26

46 Evaluation and Outcomes System Impact Parkwood Hospital - Inpatient Rehabilitation Program Year of implementation: 32% decrease in alternate level of care days 18% decrease in average length of stay 44.9% decrease in days waiting for admission to inpatient rehabilitation

47 Evaluation and Outcomes Evaluating the Effectiveness of Southwestern Ontario s Community Stroke Rehabilitation Teams Gains on the FIM and the physical, communication and social participation domains of Stroke Impact Scale Fewer signs of anxiety and depression Required less caregiver assistance Caregivers (informal, unpaid) experienced improvements in well-being over the course of the program Patient and caregiver gains were maintained at 6 month follow-up Allen et al. Evaluating the effectiveness of Southwestern Ontario s Community Stroke Rehabilitation teams. Stroke 2013; 44:e213 and Canadian Journal of Neurological Sciences (in press)

48 Evaluation and Outcomes Projecting the Impact of Southwestern Ontario s Community Stroke Rehabilitation Teams: An Economic Analysis Based on the analysis, it is suggested that the community stroke rehabilitation team model is a cost-effective way to provide community rehabilitation services. Allen et al. Assessing the impact of Southwestern Ontario s Community Stroke Rehabilitation Teams: An economic analysis. World Congress of Neuro-Rehabilitation, Istanbul Turkey, April 2014.

49 Evaluation and Outcomes A Comparison of Rural versus Urban Stroke Survivors Treated with a Homebased, Specialized Stroke Rehabilitation Program When provided with access to a home-based, specialized stroke rehabilitation program, rural dwelling stroke survivors make and maintain functional gains comparable to their urban-living counterparts. Allen et al. A comparison of rural versus urban stroke survivors treated with a home-based specialized stroke rehabilitation program. Stroke 2013; 44:e192.

50 Community Stroke Rehabilitation Alliance An alliance of community-based stroke rehabilitation programs: Support and learn from each other (various stages of development) Compare and contrast existing models Distribution list for questions/contacts Forum for addressing issues

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