WWLHIN Rehabilitation Services Review. Transitioning to a System of Rehabilitative Care in Waterloo-Wellington

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1 WWLHIN Rehabilitation Services Review Transitioning to a System of Rehabilitative Care in Waterloo-Wellington Final Report of the Rehabilitation Review Committee to the WWLHIN May 2012

2 Table of Contents 1. Executive Summary 2. Introduction 3. Background 4. Methodology 5. Guiding Principles 6. Key Findings from the Current State Analysis 7. Key Issues for WWLHIN 8. The Future State of Rehabilitative Care in WWLHIN 9. Recommendations A. System Governance B. System Design C. Rehabilitative Care System Coordinator D. Navigation of the Rehabilitative Care System E. Stroke F. Data Collection, Use and Availability G. Transitioning from Acute to In-patient Rehabilitative Care H. Implementation of Rehabilitative Care Best Practices I. Enhancement of In-patient Rehabilitative Care J. Enhancement of Out-patient Rehabilitative Care K. Enhancement of CCAC Rehabilitative Care L. Other Recommendations 10. Key Priorities and Next Steps 11. References Appendix A - Summary of Recommendations in the Context of Three Key Issues [2]

3 Transitioning to a System of Rehabilitative Care in Waterloo Wellington Local Health Integration Network (WWLHIN) providing them - (http://www.who.int/topics/rehabilitation/en/). 1. Executive Summary Background This Rehabilitation Services Review was conducted across Waterloo Wellington Local Health Integration Network, from August 2011 to May 2012, to identify key areas for improvement and in response to a number of local and provincial initiatives. First, a provincial has been working to provide direction for ways in which Ontario might -think the delivery of rehabilitation Care Expert Panel, 2011). Next, the identification of rehabilitation-specific best practices, the release of other best-practice literature and standards of care, provincial directions, and several local service review processes have all identified opportunities to improve the way that rehabilitation is delivered, measured and funded. Purpose The purpose of Phase I of the review was to: Complete an analysis of the current model of delivery of LHIN-funded rehabilitation services, programs and resources in Waterloo Wellington. Develop a re-designed rehabilitation service delivery model incorporating stakeholder feedback and best practices to enhance patient access to and flow through the system, improve patient satisfaction and outcomes, and improve system integration. Develop recommendations to support implementation of the re-designed model of rehabilitative care. Note: Implementation of approved recommendations was intended to be completed in Phase II of the project. Process and Key Findings The Rehabilitation Review Committee was co-chaired by Dr. Ashok Sharma, Joint Chief Services [3]

4 Review Committee, supported by a Project Coordinator (Emmi Perkins), provided guidance to the review process including the completion of a current state analysis (including a literature review, community and stakeholder engagement, quantitative data collection and expert advisor review and feedback), information analysis, and the development of recommendations for system improvement. Based on the findings of the current state analysis, three key issues were identified: i) Best practices and standards are not fully implemented in the WWLHIN ii) A fundamental lack of trust was identified as a barrier to flow, access, and achievement of desired patient outcomes across the continuum of care. Care providers described a lack of trust in the ability of the current services to meet the needs of patients. A clear lack of integration and data transparency between service settings and providers is eroding provider and patient confidence in the ability of the rehabilitation services in WWLHIN to meet the needs of patients and the local health care system. iii) Movement of patients across the continuum of care (i.e. from acute to in-patient, inpatient to out-patient, out-patient to CCAC, CCAC to community services) is hindered by a lack of integration of services between settings/providers. Information from the current state analysis was used by the Committee to develop a redesigned system of care and recommendations to support the re-designed model. This model and recommendations were compiled in a draft report that was submitted to the WWLHIN in December Once approved, the draft report was released for stakeholder feedback. All feedback received was reviewed by the Committee and considered in the development of this final report. The final report was submitted to the WWLHIN in May The Future State Stakeholders have very clearly identified that the future state of rehabilitation in - it is a philosophy of car Thus, the future state model and supporting recommendations have services across the continuum of care that act collaboratively to maintain or restore a -based interventions nt tolerance level and -social needs. [4]

5 The delivery of high quality rehabilitative care in a rapidly changing health care system requires formal and coordinated leadership that supports improvements to the patient experience of care, advances the integration of services to improve the health of populations and maximizes the value and efficiency of the care provided within the system. As such, governance of the future system will be prov Care will be organized around condition- be sup develop, implement and oversee the on-going monitoring and evaluation of evidence-based clinical care pathways e. from acute to the community). The system will be supported by standardized assessment and communication tools across the continuum of care, specialized case management for highneeds patients, a standardized medical coverage model, centralized intake for in-patient services and improved integration with community services and primary care. High quality care is more cost effective care (Baker, 2012). It is expected that system efficiencies will mobilize resources that can then be re-invested in the system to further support service delivery. Accountabilities and funding models will support the re-investment to standardized, evidence based care delivery. Recommendations and Summary The recommendations contained in this report will require a significant shift in philosophy and culture. The Committee is confident, however, that these recommendations terloo-wellington and will enable the system to deliver evidence-based best practices and standards of care, restore integrated transitions. The Committee recognizes that this transition will take time to operationalize and that significant change management strategies will be required to support the system through the transition process. The Committee recognizes that course corrections may be required as enabling initiatives unfold. [5]

6 2. Introduction individuals and populations increase the likelihood of desired outcomes and are consistent Historically, general rehabilitation programs in WWLHIN have endeavoured to provide high quality rehabilitation services that are responsive to best practices and trends given the resources allocated to such care. The delivery of high quality rehabilitative care in a rapidly changing health care system requires formal and coordinated leadership that supports improvements to the patient experience of care, advances the integration of services to improve the health of populations and maximizes the value and efficiency of the care provided within the system. High quality rehabilitative care also ensures that the needs of all of its users are met even its most complex and high needs patients. Almost 80% of Ontarians over the age of 45 have a chronic condition and about 70% of those suffer from two or more chronic conditions (Government of Ontario, 2011). In 2010, approximately 96% of patients who attended in-patient rehabilitation in WWLHIN were over the age of 45 years. It follows then that chronic disease prevention and management (CDPM), and its relevant principles of care, should be incorporated into the design of a system of rehabilitative care where the aim is to assist individuals with disabilities (and often chronic disease) to reach and maintain their optimal functional levels. These principles include: Strong leadership Aligned resources and incentives Commitment to quality improvement Accountability for outcomes Innovation Client Follow-up Engaged clients included in decision making Enhanced health promotion and prevention Clients as empowered selfmanagers Out-reach and population needs-based care Organized selfmanagement support and services Provider education Access to specialist expertise Collaboration between community & health care organizations Standardized, evidence-based clinical guidelines embedded in daily practice Interdisciplinary teams with defined roles & responsibilities supported by clinical care management tools [6] Care planning, care paths and care management Measurement, evaluation, routine reporting and feedback

7 The re-designed described in this report incorporates the principles of CDPM and ensures the standardized delivery of evidence-based rehabilitative care best practices across the continuum of care. The Committee is confident that the re-designed system will provide more accessible and integrated rehabilitative care to all users of the system and will result in improved patient satisfaction and outcomes. Stakeholders have very clearly identified that the future state of rehabilitation in WWLHIN - Committee) to describe its vision for a system that provides integrated services across the a set of standardized interventions that adapt in order to provide functional activation up to a and psycho- has been adopted to describe the reach and maintain their optimal physical, sensory, intellectual, psychological and social ndations contained in this report have been WWLHIN. It is expected that system efficiencies will be realized through process re-design and improved quality of care which can then be re-invested in the system to further support service delivery. The patient perspective, experience, and outcomes have been the top priority of the work was to develop a system that is comprehensive enough to meets the needs of all patients, while being focused and adaptable enough to provide best-practice care that meets the often fluctuating needs of each individual patient. Stakeholders have identified the challenges that they face trying to make patients fit into the confines of the current system. Patients in the redesigned system will have their individual needs met with the most appropriate intensity of functional activation, in the most appropriate setting, at the ideal time. The following story describes the experience of a patient, Mr. R, with the current rehabilitation services (as told by his wife). -designed ehabilitative System of Care will be described at the end of this report. After suffering a mild stroke, tests revealed the presence of a blood clot in right arm. The clot was removed but Mr. R suffered a massive stroke post-operatively leaving him with left hemiplegia and aphasia. He required a feeding tube. The acute care centre applied to a specialized stroke rehabilitation program in Hamilton but Mr. R was not accepted. Mr. R [7]

8 was transferred to a general in-patient rehabilitation program in WWLHIN approximately 6 weeks after his stroke. Mr. R spent 40 days in in-patient rehab. Mrs. R understood that the 40 days was her husband had reached his goals. At the time of discharge, Mr. R required the assistance of a mechanical lift to transfer with nursing but was able to transfer with the help of two therapists during his therapy sessions. Mr. R was repatriated to his home hospital where he was designated ALC to LTC. Mr. R underwent a swallowing assessment and was allowed a pureed diet. The feeding tube was subsequently removed. Mr. R receives therapy 3- are very limited so Mrs. R has hired a private SLP. The private SLP has been coming for 4 weeks and Mrs. R Mrs. R is also seeking a private Physiotherapist. Mr. R continues to require the of one person from the bed to the wheelchair/commode, I could take him home. I need to get a Physiotherapist in to give my husband a chance to come home rather than going to a nursing Mr. and Mrs. R live in a bungalow with 2 steps to get in. Mrs. R had a lift installed after Mr. R suffered his stroke. Mr. R uses the mobility van to get home for 3-4 hours once per Mrs. R prepares pureed meals for him at home! 3. Background As part of the provincial strategy to enhance quality of care and reduce alternate level of care (ALC) days in hospitals, a provincial ehabilitation and Complex Continuing Care (CCC) Expert Panel was formed. The purpose of the provincial panel was to fundamentally re-think the delivery of rehabilitation and complex continuing care across the continuum (Rehabilitation and Complex Continuing Care Expert Panel, 2011). The release of the plex Continuing Care Expert Panel Phase 1 in June 2011 identified several key areas in which the rehabilitation process could contribute to and expertise of Rehabilitation and Comp (Rehabilitation and Complex Continuing Care Expert Panel, 2011). The Expert Panel Phase II report is expected in 2012 and is anticipated to include information regarding common definitions and data use and availability. Additionally, the identification of rehabilitation-specific best practices (i.e. for [8]

9 patents with a total joint arthroplasty, a fractured hip, a stroke and the frail/elderly), the release of other best-practice literature and standards of care (Caring for Our Aging Population and Addressing ALC, Dr. David Walker (2011), Developing an Integrated System of Care for Frail Seniors in Waterloo Wellington, Dr. George Heckman (2011), provincial directions (e.g. Community Care Access Centre (CCAC) Expanded Role/Centralized Intake, Resource Matching and Referral, Senior Friendly Hospital initiatives) and several local service review processes (i.e. Improving Access to Quality Stroke Care in Waterloo Wellington (2011), Waterloo Wellington Integrated Acquired Brain Injury Service System Overview (2011), Waterloo Wellington Local Health Integration Network Rural Health Care Review ( 2010), have identified opportunities to improve the way that rehabilitation is delivered, measured and funded. As a result, this Rehabilitation Services Review was conducted across Waterloo Wellington Local Health Integration Network to identify key areas for improvement. The purpose of this phase (Phase I) of the review was to: Complete an analysis of the current model of delivery of LHIN-funded rehabilitation services, programs and resources in Waterloo Wellington. Develop a re-designed rehabilitation service delivery model incorporating stakeholder feedback and best practices to enhance patient access to and flow through the system, improve patient satisfaction and outcomes, and improve system integration. Develop recommendations to support implementation of the re-designed model of rehabilitative care. Note: Implementation of approved recommendations was intended to be completed in Phase II of the project. 4. Methodology (Please refer to the supporting Technical Report (Section A) for the full Project Charter.) A Project Coordinator (Emmi Perkins) was hired in August 2011 to facilitate the review process. The Rehabilitation Review Committee was co-chaired by Dr. Ashok Sharma, Joint Chief of Staff for Hospital and Terrie Dean, Senior Director Clinical Services, (Guelph). The Rehabilitation Services Review Committee provided guidance to the review process including the collection of information, information analysis, and the development of recommendations for system improvement. The current state analysis was completed including: [9]

10 i) Literature Review - A review of current best practice and rehabilitation-related literature was completed. Refer to the Technical Report (Section B) for details regarding the references included in the literature review process. ii) iii) iv) Community/Stakeholder Engagement A robust stakeholder engagement process was completed to collect information i) during the current state analysis phase and ii) related to the DRAFT report that was released in February Feedback collected was used by the Committee to inform the development of the final report. Refer to Section C of the supporting Technical Report for a summary of the stakeholder engagement activities. Quantitative Data Collection Quantitative data was collected from the Ministry of Health and Long Term Care and from relevant internal and external WWLHIN organizations. Expert Advisor Review and Feedback Prior to being submitted to the LHIN, the report was reviewed by Dr. Mark Bayley, Medical Director of Toronto Rehab's Neuro Rehabilitation Program, Charissa Levy, ED GTA Rehab/ABI Networks and Dr. George Heckman, WWLHIN Geriatric Lead, Medical Director for Grand River Hospital - Freeport Site. Information from the current state analysis was then used by the Committee to develop a re-designed system of care and recommendations to support he re-designed model. This model and recommendations were compiled in a draft report that was submitted to the WWLHIN in December Once approved, the draft report was released for stakeholder feedback. All feedback received was reviewed by the Committee and considered in the development of this final report. The final report was submitted to the WWLHIN in May Guiding Principles The Committee engaged in a process to identify the guiding principles upon which to base the development of a re-designed ystem of Rehabilitative Care in WWLHIN. This process involved the review of a number of articles related to integrated health care delivery, as our own project charter, the visions of other provincial rehabilitation organizations and the terms of reference of the WWLHIN Rehab Managers Network. (See the Technical Report (Section D) for a list of references included in this process.) These resources were summarized, themed and then compared to the guiding principles of the provincial Rehabilitation and Complex Continuing Care Expert Panel: [10]

11 Equitable access for all patients as close to home as practical regardless of where their surgery or acute care may have taken place. Equitable access to appropriately resourced care regardless of ability to pay Rehabilitation services will be provided within a regional context, with linkages between hospitals and community services supported by system-wide navigation Rehabilitation services must be supported by recognized IT tools and databases Clinical best practices, metrics and standards will be based on the best available scientific evidence and updated as necessary by content Expert Panels (e.g. Orthopedic, Ontario Stroke Network). Given the high degree of alignment between the principles that the Committee identified in the literature, those identified through stakeholder engagement, and the P a system of rehabilitative care in WWLHIN. Additionally, the Committee added the principle of - 6. Key Findings from the Current State Analysis - This section highlights key findings of the current state analysis and is organized in the following categories: Strengths of the Current System, Data Availability, Rehabilitation Services Inventory, Provider and Service Gaps, Costs to the System and Root Causes, Identified Best Practices, and Additional Themes and Feedback. Strengths of the Current System According to the Ontario Ministry of Health and Long-Term Care, between and , WWLHIN had the shortest mean (16.3) and median (9) length of stay (LOS) in the province. (The provincial mean was 23.4 and median was 15). The LOS efficiency in WWLHIN during this time was in line with the provincial average (1.0). The mean (0.86) and median (0.62) cost weights in WWLHIN were below the provincial numbers (1.03 and 0.63) (Ontario Ministry of Health and Long Term Care, 2010). ommon referral form. While stakeholders identified issues related to its content, the presence of a LHIN-wide common form suggests a high level of collaboration between provider organizations. Other jurisdictions struggle to develop such system-wide tools. While no common, standard measure of patient satisfaction exists across the WWLHIN rehabilitation system, patients identified high levels of satisfaction with many of the [11]

12 - patients with total joint arthroplasties described positive outcomes from the pre-operative home visit to the coordination of equipment and services post-operatively. All patient groups described very positive experiences with therapy staff who were described as th a positive attitude who On a scale of 1 to 10, how would you rate your experience with the rehabilitation system, with 1 being the worst experience and 10 being the best experience? patients that were interviewed for this process provided an average score of 6.78/10. Patient comments collected during the interviews for this review include: A most satisfactory experience. Every effort was made to accommodate my needs. Absolutely impressed. Me compassion I received. The whole process has gone extremely well. I was out chopping wood 7 weeks post-surgery with no pain for the first time Data Availability Consistent with the findings of the Expert Panel, data from within the current rehabilitation services is limited and difficult to access. There are multiple tools and databases used to collect data in each different care setting. Because these tools are not ient flow and outcomes is difficult. Mandated/standardized data collection is limited largely to the in-patient setting with other settings having either no standardized data collection (outpatient services) or underutilized systems (i.e. InterRAI for CCC and Home Care). Where possible, the Committee sought data from individual reliability of the data is compromised by variations in data collection and reporting. It is with these quantitative data limitations that the WWLHIN Rehab Review was completed and shall be reported. Rehabilitation Services Inventory (Technical Report Section E (I. VII.) An identified deliverable of this review was the completion of a current state inventory. The inventory contains information about the current resources (physical and human) within the current WWLHIN rehabilitation system. In 2010 there beds per 100,000 in WWLHIN, which is below the provincial average of 14 (Section F, I.). rehabilitation programs in WWLHIN. In , 960 patients were discharged from in-patient rehabilitation in WWLHIN (Section F, II.) accounting for [12]

13 22,142 inpatient rehab patient days (Section F, III.). This data does not capture the patients that received rehabilitative care in Functional Enhancement Units (FEU) (i.e. slow stream rehabilitation) which are within Complex Continuing Care (CCC) programs as data in this program is captured in the MDS database and does not enable separation of patients who received rehabilitative care from those who received care at a CCC level. (Note: Complex Continuing Care is a specialized program of care providing programs for medically complex patients whose condition requires a hospital stay, regular onsite physician care and assessment and active care management by specialized staff, (OHA, 2006)). The inventory also details out-patient programs by organization. The Waterloo-Wellington Community Care Access Centre data outlines the number of clients served and total visits provided in Information by diagnosis is not available from out-patient or CCAC service providers. The analysis revealed some variations between WWLHIN settings with respect to ALC days from acute to in-patient rehab and CCC (Section F, IV.), occupancy rates in in-patient rehab (Section E, II.), active in-patient length of stay (Section E, II), and rates of decline and pending (Section E, II.). Provider and Service Gaps Stakeholders identified two care provider-specific service gaps in WWLHIN. First, stakeholders emphasized challenges encountered when trying to access Physical Medicine and Rehabilitation Specialist (Physiatry) resources for patients in the current rehabilitation system in WWLHIN. According to the Ontario Active Physician Registry, in 2010 there were 0.54 Physical Medicine and Rehabilitation Specialists per 100,000 in WWLHIN which is below the provincial average of 1.23 per 100,000 (Section F, V.). Currently, there are no Physiatry resources available to patients in in-patient rehabilitative care settings in WWLHIN. The second service provider gap that was emphatically identified by stakeholders was Speech-Language Pathology. Data from the College of Audiologists and Speech-Language Pathologists of Ontario (CASLPO) identified WWLHIN as having 16.4 SLPs per 100,000 whereas the provincial average is (Range = ) (CASLPO, 2011)(Section F, VI.). and Root Causes In its current state, WWLHIN rehabilitation services are costly to the health care system in terms of ALC days. accounted for 20.3 percent of the total ALC days in WWLHIN second to LTC (37.4%) (Section F, VIII). In Ontario, in December 2010, waiting for an in-patient rehabilitation bed accounted for 13% of acute care ALC days (OHA, 2010) placing WWLHIN ahead of the [13]

14 provincial average. From April 2010 to March 2011, there were 6,844 acute to rehabilitation ALC patient days in WWLHIN (Section F, IX). This is the equivalent of acute beds that te the root causes of these delays. erformance is embedded into the design of the system (IHI, 2011) and designed to get the results that it is required. The current state analysis revealed three potential system design issues that are contributing to the results of the current system i) the application/referral process, ii) discharge planning practices in in-patient rehabilitation and iii) down services. i) The current application/referral processes is a barrier to timely access to rehabilitative care: There are variable referral patterns within WWLHIN - while some organizations refer system-wide, others refer selectively to the closest in-patient rehabilitation facility. Section F, VII shows that in , in-patient rehabilitation facilities largely served residents of their own communities. While this is ideal f it does not necessarily ensure maximal utilization of in-patient rehabilitation resources (as high demand in one community/acute care centre may not be matched to potentially available resources in another community/in-patient rehabilitation centre) admission criteria and application processes with fewer levels of service Patients frequently questioned the multiple assessments they experienced during their journey through the rehabilitation system The application for in-patient rehab is not initiated until the patient is ALC, despite in most cases, there being advanced knowledge of in-patient rehabilitation being the likely discharge destination from acute. The application may take hours or days to be completed (depending on the day of the week as applications are not consistently completed on weekends) Once completed, the application takes a variable course before it is reviewed by a variable number of people (Note: Variability is dependant upon practices at the receiving organization) The course of an application is also affected by the day of the week as referrals are not reviewed on weekends at some organizations [14]

15 Patient information is shared selectively between some organizations that have electronic compatibilities. Given that all of this is occurring while the patient is ALC, the current acute to in-patient application/referral process is invariably costing the system ALC days while the patient is not receiving the care that has been identified as being required (i.e. in-patient rehabilitative care). ii) There are opportunities to enhance discharge planning practices in in-patient rehabilitation. of WWLHIN rehabilitation services was completed for 5 days in October 2011 through data collected and reported by rehabilitation managers (Technical Report, Section G) f current in-patient rehabilitation services revealed that on average, there were 15.8 patients in in-patient rehabilitation who were designated to other levels of care (on average, 12 were ALC to LTC and the rest were ALC to home/retirement home with or without CCAC). During this same period, there were on average 23 patients waiting in acute care beds for an in-patient rehabilitative care bed. These beds that are occupied by ALC patients in in-patient rehabilitation could be re-invested back into the system and would minimize the delays encountered by patients who were accepted but waiting for an in-patient rehabilitative care bed. (i.e. ALC to in-patient rehabilitation ). iii) identified as a barrier to timely flow through the current system. Care providers suggest that due to limited resources in out-patient, home-care and community resources (and limited knowledge of the resources that are available), igher resource intensity rehabilitative care settings (i.e. acute and in-patient) as a means of ensuring that patients receive the care that they require. Identified Best Practices the best practices for stroke, hip fracture and hip and knee replacement as provincial Additionally, Drs. Walker and Heckman both identify rehabilitative best practices in their recommendations. It is imperative that the future state of rehabilitative care in WWLHIN supports the full implementation, measurement and reporting of these best practices. Table 1 describes each of these best practices and comments on the current performance in WWLHIN. [15]

16 Table 1 Best Practices in Rehabilitative Care (See Technical Notes, Section F XII, XIII, XIV) BEST PRACTICE CURRENT PERFORMANCE in WWLHIN 7 day-a-week rehabilitation for patients with fractured hips, total joint arthroplasty and stroke in both acute and in-patient rehabilitative care settings. 1 Referral to in-patient rehabilitation on post-op day #3 for patients with fractured hips and total joint arthroplasty who are not progressing as per established best practice care pathways. 1 If rehabilitative care is required, transfer to in-patient rehabilitation on-post-op day #5 for patients with a fractured hip 2, on day #5 from onset for patients with an ischemic stroke and on day #7 for patients with a haemorrhagic stroke. 1 Maintenance of a 90% (+/- 10%) discharge rate to home from acute care hospitals for patients with a total joint arthroplasty 3 Completion of Alpha FIM on day #3 following admission for a stroke. 1 7-day-a-week admission process and rehabilitative care for stroke patients. 1 Severe strokes (Alpha FIM <40) require access to restorative care with process to ensure regular re-assessment for in- Performance is variable across the LHIN. There is currently no standardized measure in WWLHIN of this best practice recommendation. Performance is variable across the LHIN. There is currently no standardized measure in WWLHIN of this best practice recommendation. In 2010, the average acute LOS for patients with a fractured hip in WWLHIN was 8 days. There is currently no standardized measure in WWLHIN of this best practice recommendation for stroke patients. In the first quarter of fiscal year WWLHIN rate was >90%. There is currently no standardized measure in WWLHIN of this best practice recommendation for stroke patients. There is currently no standardized measure in WWLHIN of this best practice recommendation for stroke patients. Note: While there is best practice evidence to support this practice for stroke patients, the Committee identifies this as a critical feature of a re-designed system for all patients to enhance patient outcomes and timely access to rehabilitative care. There is currently no standardized measure in WWLHIN of this best practice recommendation for stroke patients. [16]

17 patient rehab. 1 Establish the infrastructure and Hos inpatient rehabilitation supports required. 4 Development of a common rehabilitation/activation framework which may reduce the functional and cognitive decline of hospitalized elderly patients. 4 Comprehensive Geriatric Assessment (CGA) is required for frail older persons with rehabilitation needs. 5 Geriatric rehabilitation should be managed by a physician and interdisciplinary team trained in care of the elderly. 5 Frail older rehabilitation candidates with mild to moderate dementia should be eligible for rehabilitation. 5 Performance is variable across the LHIN. There is currently no standardized measure in WWLHIN of this best practice recommendation. Performance is variable across the LHIN. Hospital Elder Life Program (HELP) is currently being implemented in WWLHIN. Performance is variable across the LHIN. There is currently no standardized measure in WWLHIN of this best practice recommendation. Performance is variable across the LHIN. There is currently no standardized measure in WWLHIN of this best practice recommendation. Cognitive impairments were cited by stakeholders as a barrier to accessing rehabilitation in WWLHIN. 1 Endorsed by Rehabilitation and Complex Continuing Care Expert Panel 2 Endorsed by Provincial Hip Fracture Model of Care, Bone and Joint Health Network/Orthopedic Expert Panel 3 Endorsed by Orthopaedic Quality Scorecard, Cancer Care Ontario 4 Endorsed by Caring for Our Aging Population and Addressing Alternate Level of Care (Dr. D. Walker) 5 Endorsed by Developing an Integrated System of Care for Frail Seniors in Waterloo-Wellington (Dr. G. Heckman) Additional Themes and Feedback Additionally, the following themes emerged from both the literature and from stakeholder feedback with respect to opportunities for improvement: Enhancement of rehabilitation services offered and presence of different professionals within complex continuing care, convalescent care and rehabilitation sectors, including creation of opportunities for Assess and Restore program that provides a period of assessment and restoration/rehabilitation in a postacute environment el of [17]

18 functioning and thereby allowing a more appropriate determi and discharge disposition than can be made from acute (Walker, D. 2011)) Develop strategies to increase awareness of existing rehabilitation services and programs (especially community programs) across the LHIN Enhancement of out-patient rehabilitation services and resources to improve access to publically funded rehabilitation services. The literature specifically mentions enhanced services to accommodate more people with mild strokes and TJA freeing up inpatient capacity for patients with severe strokes and fractured hips Improve the accessibility of rehabilitative care in rural and northern regions. Consider transportation, outreach programs and telemedicine/ tele-home care as opportunities to increase access Develop mec (community-based interdisciplinary care and support). While this is specifically recommended for mild-moderate stroke and hip and knee replacements in the literature, stakeholders identified that increased interaction with community-based services would facilitate patient flow through the system Provide assistance to patients and caregivers in accessing and navigating the system. Include formal processes to link patients with available community resources. Patients described feeling like they still had functional gains to be made and/or identified that they they struggled to access community programs and services Ensure patients/families have knowledge of and access to existing transportation services. 7. Key Issues for WWLHIN Based on the key findings of the current state analysis, the Committee has identified three key issues that are core to the development of a future ystem of Rehabilitative Care in WWLHIN. i) Best Practices and Standards of Care Evidence-based best practices and standards of care are not fully implemented in the WWLHIN. A standardized approach to the implementation and on-going evaluation of these practices is required to support quality care. [18]

19 ii) Trust A fundamental lack of trust was identified as a barrier to flow, access, and achievement of desired patient outcomes across the continuum of care. Care providers described a lack of trust in the ability of the current services to meet the needs of patients. A clear lack of integration and data transparency between service settings and providers is eroding provider and patient confidence in the ability of the rehabilitation services in WWLHIN to be responsive to the needs of patients and the local health care system. The future state system MUST be one in which partnerships between organizations are fostered and data transparency supports system monitoring and improvement. iii) Integrated Transitions Movement of patients across the continuum of care (i.e. from acute to in-patient, in-patient to out-patient, out-patient to CCAC, CCAC to community services) is hindered by a lack of integration of services between settings. Poorly executed transitions can result in complications and adverse events, duplication of services, discharge delays, increased lengths of stay, avoidable readmissions, frustration for families and care givers, and dissatisfaction with overall services (Ross, D.M., 2008). Management of care using standardized tools to support communication and information sharing and accountability across settings is required to support seamless transitions. These three key issues underlie the issues within the current WWLHIN rehabilitation services and as such have been addressed in the development of the recommendations for a re-designed rehabilitative care system in WWLHIN. 8. The Future State of Rehabilitative Care in WWLHIN According to Batalden and Mohr (1997), a system that maximizes value/minimizes waste is one that is composed of functionally related groups of interacting, interrelated, or interdependent elements that form a complex whole with a common aim. In designing the consistent with the terminology being endorsed by the Rehabilitation and CCC Expert Panel and to describe a system that is patient centered and includes the entire continuum of the health care system. The "continuum of rehabilitative care" describes the patient journey from acute to inpatient to CCAC/home care to out-patient to the community, including primary care and community services, recognizing that the continuum is not necessarily linear and has multiple access points. Care will be will not be dependent upon the will it be limited by the type of provider who is providing the care. For example, in in-patient rehabilitation, rather than having multiple levels of programs into which patients must are, those in-patient beds will [19]

20 be consolidated into a single system. Patients will move into the in-patient rehabilitative care setting and be provided with an assessment to determine the intensity of activation that is appropriate for their current tolerance. The intensity and delivery of rehabilitative care will be adapted (increased or decreased) bas while minimizing unnecessary patient movement within the system. Stakeholders clearly identified the need for an oversight or governing body in order for a true systems approach to be realized. As such, governance of the future system will be provided by a Rehabilitative Care Council that will act in an advisory capacity to oversee and coordinate the activities within the Care will be organized around condition- develop, implement and oversee the on-going monitoring and evaluation of evidence-based clinical care pathways within their respective stream and acute to the community). The system will be supported by standardized assessment and communication tools and practices across the continuum of care, specialized case management for high needs patients, centralized intake for in-patient services, and improved integration with community services an primary care. Opportunities for efficiencies (i.e. transitioning patients to the lowest resource intensity setting required to meet their needs, provision of care by alternative providers, estimated lengths of stay, innovative models of service delivery) will be embedded into clinical care pathways where appropriate. Stakeholders have clearly identified the need for standardized medical coverage of inpatient settings in the future state to accommodate more complex patients with higher improved and standardized access to specialized medical services (e.g. Physiatry, Neurology) is required. support physician recruitment and retention efforts. The timing of two enabling initiatives of the electronic centralized intake process is unknown. WWCCACs Expanded Role initiative is working to define and develop processes to act as the single point of access for CCC and rehabilitation beds. Resource Matching and Referral (RM&R), an electronic centralized referral management system, is an enabler for the CCAC expanded role and will support a more coordinated and efficient application and intake process. Enabled by these initiatives, the Committee envisions a future centralized intake process for in-patient rehabilitative care that includes the following: i. interdisciplinary clinical decision making that critically evaluates and identifies the most appropriate and efficient rehabilitative care service delivery setting [20]

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