A STAR is born. Collaborative Strategy that works!

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1 A STAR is born Collaborative Strategy that works!

2 Objective Demonstrate the importance of developing and nurturing partnerships in achieving quality outcomes, providing the right care at the right place at the right time

3 St. John s s Rehab The only hospital in Ontario solely dedicated to specialized rehabilitation Serve patients from throughout GTA and the province 160 beds in north Toronto (Central LHIN) Founded in 1937 by the Sisterhood of St. John the Divine 2,400+ inpatients per year (Average length of stay from 1 week to 3 months) More than 40,000 outpatient visits per year

4 Our programs We provide specialized rehab care for adults recovering from: amputations burn injuries (unique in Ontario) cancer (unique in Ontario) cardiovascular surgery organ transplants (unique in Canada) orthopaedic conditions strokes and neurological conditions traumatic injuries complex medical conditions/procedures (STAR program)

5 Referrals by Hospital (April February 2010) 40% 35% 30% 25% 20% 15% NYGH Sunnybrook UHN St. Mike's Southlake Markham Stouffville 10% 5% 0% Apr-09 May-09 Jun-09 Jul-09 Aug-09 Sep-09 Oct-09 Nov-09 Dec-09 Jan-10 Feb-10

6 North York General 400 bed acute care facility 194 bed long term care facility 12 hour urgent care centre Serves 450,000 residents in North / Central Toronto 3,100 Staff/ 900 Physicians

7 Rationale of partnerships Collaborate and focus on the strengths of the respective organizations to improve efficiencies and enhance patient outcomes

8 Partnerships 1. Reduced Wait Time for Inpatient Rehab Pilot Project To improve the continuum of care for patients requiring rehab To maximize appropriate and timely admissions to SJRH

9 Partnerships Referrals / Patient Flow Coordinator Collaborates with teams at SJRH and NYGH to assess and identify patients early in the acute phase of their hospitalization who may candidates for rehabilitation Liaises with teams at SJRH and NYGH to facilitate efficient and timely patient admissions to rehabilitation.

10 Partnerships Referrals / Patient Flow Coordinator Provides operational support in the coordination of referrals from NYGH to SJRH Provides operational support with a focus on implementing new processes, improving on existing ones and enhancing communication

11 Partnerships 2. SJRH / NYGH Integration Initiative Transfer of rehab program from NYGH to SJRH First major integration initiative of the Central LHIN

12 Benefits: Partnerships More focused rehab care for patients at SJRH Additional resources at SJRH for clinical enhancements Frees up resources at NYGH for acute care Focuses on Alternative Level of Care Issues

13 STAR Program Development of Short Term Active Reconditioning (STAR) Program The need for a reconditioning program was identified through communications with and referrals from NYGH and other hospitals Involvement of NYGH representatives in identifying admission criteria for program

14 STAR Program Admission Criteria: Medically stable Demonstrates motivation to engage in active rehab and has measurable, attainable rehab goals Safe and appropriate post rehab discharge destination plan should be identified Can tolerate at least 30 minutes of continuous daily therapy 1 2 times a day Able to sit unsupported for minutes Able to transfer (assist x 1 is accepted) Has behavioural and cognitive abilities that will support participation in active rehab Demonstrates potential to perform ADL activities Special needs are considered on a case-by-case basis

15 Key Components Focus on: pull strategy the needs of the patients the strengths and expertise of each partner win-win partnership communication & relationship building

16 Pull Strategy Focus on using a pull system rather than the traditional push system Push - patient is ready for discharge from acute care and will be sent to rehab Pull patient is a good candidate to benefit from rehab and will be sent to rehab after discharge from acute care

17 Patient Needs Focus on the patient s need for the right care at the right time at the right place Smooth transition across the continuum No unnecessary waiting Discharge from acute care to rehab as soon as ready

18 Strengths & Expertise Focus on the strengths and expertise of each organization NYGH acute care SJRH rehabilitation care Patients can receive the most appropriate care by the most appropriate provider

19 Win-Win Partnership Focus on creating a partnership where all parties involved can benefit: Patients right care at the right time at the right place NYGH freed up resources to better meet needs of ALC patients SJRH more efficient use of available capacity

20 Communication & Relationship Building Focus on clear / open communication and enhancing working relationship between partners Information sessions Planning / Implementation sessions Feedback sessions Have point person who can help solve issues identified

21 CLHIN Priorities The initiatives are aligned with the Central LHIN priorities under IHSP : Access Coordination Quality Efficiency

22 CLHIN Priorities Access: Improve access to specialized rehab services for patients, enabling them to get the most appropriate care in the right place at the right time Improve access to acute care services for patients by increasing bed capacity for ALC patients at NYGH Improve access to emergency services by decreasing the number of ALC patients in acute care beds

23 CLHIN Priorities Coordination: Improve the continuum of care for medical patients at NYGH that require rehabilitation services Improve the referral process between SJRH and NYGH through the use of the Referrals / Patient Flow Coordinator that can identify and assess patients early in their stay at NYGH who may be candidates for services at SJRH

24 CLHIN Priorities Quality: Increase quality of care for rehab patients receiving care at a specialized rehabilitation hospital Increase quality of care for ALC patients being consolidated on a single unit with specialized care by the right providers

25 CLHIN Priorities Efficiency: Improve patient flow by using a specialized ALC unit to transfer patients out of the medical inpatient units Improve cost per patient day for rehab patients, by transferring them more quickly to a specialized rehab hospital

26 Outcome Indicators Performance Measurement: Application rejection rate NYGH Other Hospitals 11.80% 27.40%

27 Outcome Indicators Performance Measurement: Time from application from NYGH to time of admission to SJRH NYGH Other Hospitals 2.3 days 3.3 days

28 Other Indicators For monitoring purposes, the following indicators are monitored to make sure there are no un-intended outcomes: Average Length of Stay Function Score Change Discharge Destination Patient Satisfaction

29 Challenges Communication Clarifying Expectations Balancing existing patient population and new needs identified

30 Key Messages Identify opportunities for win-win partnerships Communication is key Role of liaison is integral for success of partnership Need clear metrics and targets to evaluate initiatives Clear plan and strategy to manage change

31 Questions

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