THE REHAB PAG SUMMARY TEMPLATES AND MODEL

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1 THE REHAB PAG SUMMARY TEMPLATES AND MODEL July 6, 2009 Lynn Corbey Bettyann DeRonde Dr. David Harvey Jennifer Kodis Kathryn Leatherland Dr Rick McMillan Chuck McRae Wendy Robb Jane Rufrano Kanwal Shankardass Donna Thomson, Dominic Ventresca. Muriel Westmoreland, Ed Ziesmann Community Rehab Norfolk General Hospital Hamilton Health Sciences Hamilton Health Sciences HNHB CCAC Hotel Dieu Shaver Hamilton Health Sciences Niagara Health System Hotel Dieu Shaver Physician Hamilton Health Sciences Niagara Region McMaster Joseph Brant Memorial 1

2 TEMPLATE ONE: STRENGTHS AND CHALLENGES PAG: REHAB Strengths The multi/trans disciplinary approach Reasonable availability of professionals BUT pockets of the region where this is NOT SO! Availability of specialized rehab Pockets of excellence throughout the region Research and education utilizing evidenced based approach Strong training programs Focus on education and life skills training Falls Clinics work History of programs such as the concurrent disorder model FACILITAOR: SUSAN GOODMAN Challenges Transitions are a major challenge This is in our control but we need a clear mandate Haldimand Norfolk very limited access to rehab services There are geographic barriers to access Inequitable distribution of resources throughout the LHIN Need to rationalize through the region Need common definitions CCC CCC are a catchall CCCs step up to the plate but this leads to compromises in trying to be all things to all people CCC not consistent throughout the region How do we optimize the use of CCC beds throughout the region A lack of knowledge as to what CCC can and cannot do 7 day rehab lack of evidence that 7 day rehab is essential. It is important to maximize what happens during the days we do have with patients Falls clinics work but many have been closed because of lack of resources Challenging Populations Failed surgeries/medicals are referred to rehab with nowhere else to go There is a whole group of sub acute patients that may require rehab 2

3 PAG: REHAB FACILITAOR: SUSAN GOODMAN Strengths Challenges There is group of patients who could utilize rehab services but require medical monitoring De conditioned patients Need better linkages to long term care system Community and Outpatient Services Lack of outpatient rehabilitation services Inequitable availability of out patient services St Peters the only place left for out patient rehab therapy Outpatient services play an important role in preventing or identifying potential crashes Resources for community lacking As /if we reallocate resources to the community we need accountability. Resources are reallocated but the services are not sustained Private Rehab services are not part of the discussions and they have an important role to play Third party billing 3

4 TEMPLATE TWO: FACTORS MOST LIKELY TO INCREASE OR DECREASE THE FUTURE DEMAND FOR HEALTH CARE: PAG REHAB Factors influencing demand 2013 Demographics Aging population with complex morbidities (this group has difficulty travelling for care because of aging caregiver ) Younger people living longer developmentally challenged aging earlier Obesity population Economic Socio economic factors also influence the need for rehab Current economic crisis will drive the cost of community rehab The need for inpatient rehab is growing but community rehab is growing exponentially Changes in the rest of the system impact rehab Acute care General success of acute care creating a larger Rehab population Chronic Disease Management As we do better in this area the need for rehab grows Cancer care Enhanced focus in cancer rehab expanding Aging at Home strategy Needs to be sustained Beyond 2113 Human resources Environmental issues Technology Vascular and immune system related decease may decrease. SUSAN GOODMAN Impact HIGH HIGH HIGH HIGH HIGH HIGH HIGH 4

5 TEMPLATE THREE: THE REHAB SERVICE DELIVERY MODEL The Scope and Focus: The rehab model focuses across the client s continuum of care to maintain and enhance function physical, cognitive and behavioural through an inter professional team that includes the patient and caregivers and promotes independence (to the extent possible), stresses teaching and doing, and supports quality of life. It is goal orientated and looks back, as well as forward, to understand the cause of the functional problem and prevent it from happening again (or in the first place). The Principles: The model is based on the following principles: 1. Equitable Access availability of the right care when you need it 2. Access to rehabilitation through multiple points including self referral when appropriate 3. Patient and family centered care maximizing function, independence and quality of life throughout all ages and stages of life 4. Best and/or leading practices evidence based 5. Comprehensive care as close to home as possible 6. Shared accountability for the outcomes patients and families, providers, and the LHIN 7. Resources used efficiently 8. Collaboration between all members of the health team across all sectors maximizing opportunities for partnerships across communities and the continuum of care 9. Safe patient transitions and systems integration throughout the continuum of care 10. Common indicators, standards and language 11. Address the social determinates of health 5

6 THE REHAB MODEL THE REHAB CONTINUUM Patient/client Requirements and Focus Highly Specialized Rehabilitation Focus: LHIN wide (may be more than one site) Population Requirements and Prevalence Low prevalence High level of resources The patient is in need of an interdisciplinary rehab program. The patient has experienced a loss of abilities following neurological, orthopaedic or other conditions that resulted in a decreased level of functioning. Programs are specialized to treat one diagnostic/rehab population group. HOSPITAL IN PATIENT REHAB Mode of Delivery Examples Prevalence and Population Requirements Highly specialized rehab beds Spinal cord ABI Burns Amputees OUTPATIENT REHAB / COMMUNITY/ IN HOME /IN LTC Low prevalence A complex density of services required Client is in need of an interdisciplinary rehabilitation program. Programs are specialized to provide rehabilitation to specific rehab populations or reduce the impact of a particular disability or to assess/treat clients from a variety of diagnostic population groups. Involves interdisciplinary team including a physician. Mode of Delivery Highly specialized outpatient services Day Hospital In home services CCAC Specialized longterm care homes (in the future) Tele health Examples Spinal cord ABI Burns Amputees ALS, MS, Transplant General Rehab High Tolerance/Short Durations Focus: District Hamilton Niagara Brant Burlington Haldimand Norfolk High or Low prevalence High or low level of resources. The patient is in need of an interdisciplinary rehabilitation program. The patient has experienced a loss of abilities following neurological, orthopedic or other conditions that resulted in a decreased level of functioning. Rehab providers may treat one or a variety of diagnostic/rehab population groups depending on location of service. Patient requires an intensive interdisciplinary rehab program. General Rehab beds and acute beds Full spectrum of rehab diagnosis May be organized in general rehab units or patient/disease clusters or care bands Neurological, Stroke, MS, Hip fractures, TJR transplant, Cardiac, COPD High or low prevalence Client is in need of an outpatient rehabilitation service in a single specialty area/profession. Services may include assessment only or assessment and treatment. Clients are residing in the community with a specific rehabilitation need which may be an impairment, performance, activity or participation issue that requires assessment and/or treatment by a health professional General outpatient/ Community rehab Clinics In home services CCAC contracts Mobile units Stroke Ortho Sports injury Neurological Stroke, MS Ortho Hip fractures, TJR Arthritis Sports injury Cardiac, COPD 6

7 THE REHAB MODEL THE REHAB HOSPITAL IN PATIENT REHAB OUTPATIENT REHAB / COMMUNITY/ IN HOME /IN LTC CONTINUUM Patient/client Population Requirements and Mode of Delivery Examples Prevalence and Population Mode of Delivery Examples Requirements and Focus Prevalence Requirements Low tolerance long duration Focus: District and community High or low prevalence The patient is in need of an interdisciplinary rehabilitation program over an extended period of time. The patient has experienced a loss of abilities following neurological, orthopedic or other conditions that resulted in a decreased level of functioning. The patient may also have multiple chronic/complex conditions but is expected to benefit from low intensity, long duration rehabilitation. LTLD is targeted to geriatric and/or complex neurological/medical/surgical patients with multiple comorbidities who require a slower paced rehab program for a longer duration to maximize rehab potential. Complex Continuing Care Slow stream rehab Hips Stroke Complex wounds Severely deconditioned Multiple chronic/ complex conditions Same as above CCAC Outpatient Clinics Day Programmes Could be cared for in a LTCH or an alternate group supportive living environment Debility Chronic conditions Oncology Less intense community rehab Focus: District and community High prevalence Groups that focus on enhancing an individual s ability to cope with a particular disability or impairment. Groups may include short term transitional groups or longer term ongoing groups. Groups are led by professional rehab providers. Community care programs Clinics CCAC Community Chronic diseases Deconditioned people living in the community in their own home or LTC Falls prevention 7

8 THE REHAB MODEL THE REHAB HOSPITAL IN PATIENT REHAB OUTPATIENT REHAB / COMMUNITY/ IN HOME /IN LTC CONTINUUM Patient/client Population Requirements and Mode of Delivery Examples Prevalence and Population Mode of Delivery Examples Requirements and Focus Prevalence Requirements Organizations i.e. arthritis, Parkinson s, COPD/Lung Association, MS society Day Hospital Adult day program Family Health Teams Chronic Disease Management Programs Falls prevention Programs YM/YW Fitness Programs Please Note: All definitions as presented in this table are the definitions developed by the Hamilton Niagara Haldimand Brant LHIN Regional Rehabilitation Network Other Considerations Certain complex client populations such as renal clients on dialysis, oncology clients receiving treatment therapies (radiation and infusion, COPD clients on ventilators and neurological clients (Spinal Cord, ALS, MS and ABI) could be cared for with specialized care and support in residential settings. These could be in special LTC Homes or residential care facilities or in patient s own home More exhaustive discussions are required about the CCC model More discussions need to take place to ensure smooth transitions from paediatric rehab to adult services More discussions need to take place to ensure smooth transitions with mental health services 8

9 As many more medically complex patients are needing community rehab, higher levels of medical support are required in the home, in LTC and in CCC. Collaborative Partnerships and technology are key to making this model work Improved access to rehab services by removing barriers such as funding physicians Will be supported by a. Transportation Allowance b. LHIN wide access to CCC beds c. LHIN wide access to community based services System wide a. Common definitions b. Common pathways and assessment tools c. Protocols/pathways for transitions into and out of rehab Further discussions /planning for sub acute populations requiring rehab 9

10 10

11 REHABILITATION SERVICES Person in the Centre Across the Continuum of Care Primary Care Prevention Complex Continuing Care Less Intense Community Rehab General Rehab Highly Specialized Rehab Care Acute Care 11

12 TEMPLATE FOUR: ASSESS AND DESCRIBE THE MODEL USING LHIN HNHB CRITERIA PAG Name Rehab and CCC Domain Criteria Assessment Description Strategic Fit Alignment with LHIN priorities Yes. A continuum of rehabilitation services supports the aim of enabling individuals to age at home for health improvement Population Health System Values Alignment with trends in health care needs and system transformation Health status (clinical outcomes & QOL) Prevalence Health promotion & disease prevention Client focus This model is based on using all resources efficiently and building the capacity of the community to serve people with general and complex rehab needs The model supports the growing population living with chronic illness/ multiple co morbidities who require rehabilitation. as well as both a younger and older population who are living longer and aging with disabilities. Yes. This model builds in system wide monitoring and accountability to outcomes and the determinants of health Yes Yes. The model recognizes that health promotion & disease prevention requires a continuum of services including Hospital services in partnership with community based programs. It plays an important role in maintaining wellness, preventing acute care admissions, supporting timely discharge from acute care, and reintegrating individuals back into the community Yes Partnerships Community Engagement Innovation Equity The model will be implemented through strengthening and developing partnerships Community education and engagement will be key activities in implementing the model Yes. This model is based on community innovations Yes. A key principle in this model System Performance Efficiency (operational) Access Quality Sustainability Yes. This module is based on prevalence and intensity of services required Yes. Access will improve as long as the enablers are in place Yes Build on system wide best practices With support for the transition and to build capacity the model will be sustainable Integration This is conceptually an integrated model. The implementation will be based on all partners working together. 12

13 TEMPLATE FIVE: PRE REQUISITES, ENABLES AND CHALLENGES Category Pre requisites Enablers Challenges Policy/legislation Resources (e.g., human, fiscal, capital, etc.) Bring different policy perspectives to the table so that fee schedule can match the model Health Human Resources to support the model Enhanced resources to support the model Facilitate funding mechanisms More flexibility with funding Funding follows patient Enhanced medical resources Resources for prevention Education of the community An infusion of resources to support the transition and implementation of the model Technology to support rehab such as environmental controls, emergency aids, call systems to support people in their homes Community readiness An inventory of resources Partnerships Community education and key stakeholder engagement Remuneration at all levels such as physician billing Private vs Public Payers Provincially funded programs not considered with local programs Delisting of services Polices in other ministries such as ODSP, auto insurance Health Human Resources scarcity Capital challenges Realignment of resources Limited accessibility and affordable housing options Limited access to the required type and intensity of in home resources Limited number of LTC beds at basic rate Best use of available technology Services Transportation inter municipal Specialized LTC /community residential Eligibility transportation, travel allowance programs Diagnosis Creation of centres of excellence Mental health co morbidity Full access to LHIN wide services throughout the LHIN Treatment for 17/18 year olds Enhanced role of community support services Mobile clinics Partnerships/linkages Primary care Shared care model Public vs private sectors 13

14 Category Pre requisites Enablers Challenges Hospitals Community Coordinated approach with CCC One system with common definitions, pathways and protocols, Most responsible physician model Common plan of care. Each patient should have a personal health plan that promotes health, Common assessment tools and intake process Advocate Common and/ or simplified access Ongoing planning and implementation Further model development with CCC Expanded rehab network joint planning LHIN System Report Card Common indicators, standards and language and LHIN benchmarks and annual report on how the system is doing Summary Key Requirements to Move the Model Forward 1. Shared accountability and shared outcomes: Clearly defined roles and responsibilities must be linked to accountability agreements for both hospital and community services. In addition, the system needs to develop shared patient/client outcomes, common plans of care as well as repatriation agreements among all partners. 2. Transportation: In order for the model to work, patients must be able to get to services and/ or services must be able to get to patients. This includes inter municipality services and a transportation allowance. In addition, as appropriate, services and programs should be brought to the patients/clients. 3. Education: This includes education for patients/clients and their care givers, stakeholders and all community partners 4. Remuneration Policy: it is necessary to put in place the appropriate recuperation policies to support his model. 14

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