1 Project Plan to Rehabilitation Service Connecting and Collaborating in the Continuity of Care in Rehabilitation Presented By: Arlene Whitehead, May 31, 2011
2 Rehabilitation Collaborative Overview OUTLINE WGH Rehab Planning Team Team Membership Rehab Facilities Rehab Foundation: Our Mission/Vision/Values Planning Update Patient Referral Processes Inpatient Rehabilitation Unit Intensive Rehabilitation Outpatient Program Outcomes
3 WGH Rehab Planning Team
4 WGH Rehabilitation Facilities
5 Inpatient Rehab Unit
6 Inpatient Rehab Therapy
7 Outpatient Therapy
8 Rehab Team Foundation MISSION VISION VALUES
9 Inpatient Integrated Rehabilitation Right person, right place, right time: Clear, defined referral/admission criteria, includes patient assessment Interprofessional Collaborative Processes: Integrated Assessment/Discharge Planning, Daily/Weekly Rounds, Patient/Family Meetings Patient-Focused Care: Individualized (SMART) Goal Setting and Treatment Plans, Clear Team Roles to ensure communication with patient/family, Rounds/Patient/Family Meetings
10 Inpatient Integrated Rehabilitation Best Practice: 2010 Stroke Best Practice Bone and Joint Health Network Benchmarking LOS & efficiency External Collaboration: To ensure the Rehab Programs reflect the County, London Rehab needs and that the processes are userfriendly. Collaboration will continue into the future.
11 WGH New Rehabilitation Programs Inpatient Rehab Planning Update: Medical Director of Rehabilitation Care Team: full scope rehab professionals Referral, Admission, D/C: Criteria, forms, processes, roles Patient/family Orientation Booklet Process Standards of Care: Discharge Planning: LOA, TLU, evaluation survey CIHI NRS: software selection, direct input, roles
12 WGH New Rehabilitation Programs Inpatient Rehab Planning In Development: Integrated Initial Assessment: includes goal setting Weekly Rounds: benchmarking, monitoring, documentation, roles, technology Equipment Purchasing Hire Director of Patient Care Patient/Family Meetings Rehab Planning Future Development: Inpatient Discharge Processes Outpatient Program Development: staffing & #s directs service, group therapy Recreational Therapy: equipment, programming with documentation, volunteers
13 Inpatient Rehabilitation Program Primary program streams offered at WGH are: Orthopaedic / MSK Stroke Other Neurological Conditions (Exceptions: ABI, Spinal Cord) Geriatric
14 Rehabilitation Referral Process REHABILITATION CANDIDATE? NO SUGGEST ALTERNATIVES YES REHABILITATION READY? NO CONTINUE TO MONITOR
15 Rehabilitation Candidate Includes: 18 years of age or over. Patients less than 18 years of age will be assessed for admission on an individual basis. The patient resides in Oxford County. Residents from other areas will be considered based on bed availability when an appropriate rehabilitation service is not available/accessible locally. There will be an expectation of repatriation once the inpatient rehabilitation process is completed. The patient has demonstrated improvement in function over time. There are clearly identified goals for rehabilitation that are specific, measurable, achievable, realistic and timely that require an inpatient rehabilitation stay and involvement of an interdisciplinary team to achieve.
16 Rehabilitation Candidate Includes: The patient s needs cannot be adequately met with outpatient or community-based services. The patient is able to minimally follow one-step commands. The patient/substitute decision maker has consented to the assessment/treatment in the rehabilitation program. The patient is willing and motivated to participate in the rehabilitation program. (Exception: patients with reduced motivation/initiation secondary to a diagnosis, i.e.: depression, stroke) The Rehabilitation Candidacy Tool is completed Stroke Part I and II All other referrals Part II only
17 Exclusion Criteria Patients that do not meet WGH eligibility requirements for rehab include: Patients requiring 5-point restraint or seclusion for aggressive behavior that can place other patients at risk Patients with significant assault behavior that could be harmful to self or others. Patients demonstrating active exit-seeking who require a locked area for their safety. Patients with severe cognitive impairment not amenable to treatment.
18 Rehabilitation Referral Process REHABILITATION CANDIDATE? NO SUGGEST ALTERNATIVES YES REHABILITATION READY? NO CONTINUE TO MONITOR
19 Rehab Readiness Includes: The patient is ready for rehabilitation if: The patient meets the criteria for rehabilitation candidacy. All medical investigations have been completed or a followup plan is in place at the time of referral and follow-up appointments made at the time of discharge. Patient has the tolerance to minimally sit for 1 hour, twice a day and tolerate 2 therapies per day. Discharge options following rehabilitation have been discussed. The patient is medically and surgically stable
20 Determining Medical Stability Guidelines for determining medical stability: The Most Responsible Physician (MRP) in acute care determines that the patient no longer requires acute care, i.e.: all acute medical issues have been resolved or reached a plateau. A clear diagnosis and co-morbidities have been established. Co-morbid medical conditions are managed/stable and would not preclude participation in a rehabilitation program, i.e.: dialysis or active cancer treatment resulting in excessive fatigue or frequent absences from the unit during rehab treatment sessions.
21 Determining Medical Stability continued: Guidelines for determining medical stability: Patient s vital signs are stable. No undetermined medical issues (i.e. excessive shortness of breath, congestive heart failure). Medication needs have been determined.
22 Rehabilitation Referral Process REHABILITATION READY? NO CONTINUE TO MONITOR YES INPATIENT STAY REQUIRED? NO REFER TO OUTPATIENT/COMMUNITY SERVICE YES
23 Inpatient Rehabilitation Criteria Inpatient admission is the most appropriate setting if: Patient needs 24 hour nursing care/assistance Patient cannot be safely managed at home Patient requires a frequent and intense interdisciplinary rehabilitation program Patient rehabilitation needs cannot be provided by an outpatient/community program Patient has a diagnosis of stroke. Patients with an early FIM < 80 and Motor FIM < 62
24 Rehabilitation Referral Process BED AVAILABLE? NO PUT ON WAITLIST AND MONITOR YES ADMIT
25 Discharge Criteria Patients are discharged when: The patient has completed the rehabilitation plan and/or has achieved most mutually agreed upon goals to allow safe community living. The patient has progressed such that community/outpatient resources can meet continuing needs. The patient has not demonstrated adequate improvement as determined by program standards, i.e., has reached a plateau. A suitable discharge destination has been identified. A competent patient or legal guardian wishes discharge regardless of the team s opinion.
26 Discharge Criteria Continued: Patients are discharged when: The patient is physically/emotionally unable to participate in the Rehabilitation Program. The patient is non-compliant with the mutually identified goals and/or policies of the program. The patient is non-compliant with the rules of the hospital, i.e. alcohol, drug abuse. The patient requires further investigation, surgery, and treatment, becomes medically unstable, or requires specialized services not available at Woodstock Hospital.
27 Intensive Rehab Outpatient Program Program Purpose: The Intensive Rehabilitation Outpatient Program provides interdisciplinary rehabilitation and healthcare services that promote independence and function. The program allows early discharge from acute and rehabilitation hospital beds for clients who are well enough to go home, have transportation, but would still benefit from further intensive rehabilitation. It also prevents hospitalization for those who require intensive rehabilitation but are still living at home and have transportation.
28 Intensive Rehab Outpatient Program Program Intensity: typically 2-3 days per week for 3 hours each day, length of program is based on each individual rehab plan which is developed in collaboration with the client during admission process Health Care Team: Physiatrist, Physiotherapist, Occupational Therapist, Therapeutic Recreation Specialist, RN, Speech Language Pathologist, Dietitian, PT/OT Assistant, Pharmacy consult.
29 Intensive Rehab Outpatient Program Most Common Reasons for referral/streams include: Neurological Geriatric Orthopaedic/MSK
30 Referral Process Intensive Rehab Outpatient All referrals require a physician signature. New Rehabilitation Referrals: Additional client information to further evaluate the potential client. An interdisciplinary assessment to determine rehabilitation candidacy and readiness. Referrals from Inpatient Rehabilitation Programs: Fast track WH Inpatient Rehabilitation Program and Parkwood referrals.
31 Rehabilitation Candidate Includes: The client is a rehabilitation candidate if: The client s needs can be met by outpatient rehabilitation services. The client has appropriate transportation to and from Woodstock Hospital.
32 Rehabilitation Candidate Includes: The client is ready for rehabilitation if: The client has sufficient tolerance for transportation plus participation in the Intensive Rehabilitation Outpatient Program, i.e.: travel time plus 3 hours therapy per day. Exceptions will be assessed on an individual basis.
33 Discharge Criteria The client has been educated regarding a continued home program and can achieve/maintain progress without further therapeutic input. If there is a duplication of service identified, and another provider is meeting the client s needs.
34 Expected Outcomes Clear admission and discharge criteria, assessment tools and protocols Strengthening the appropriate use of Rehab resources (reducing ALC days) Improved uptake and adherence to evidence-base best practices A clear and strong vision as well as conceptual framework for Rehab Continuous collaboration and learning
35 Thank You Contact Information: Arlene Whitehead Director, Ambulatory Rehabilitation