Rehabilitation is a Journey. Report prepared by the Central East LHIN Rehabilitation Task Group

Transcription

1 Rehabilitation is a Journey Report prepared by the Central East LHIN Rehabilitation Task Group

2 Table of Contents Letter from the Chairs 4 Acknowledgements 5 Executive Summary 6 Background 14 Central East Local Health Integration Network (CE LHIN) 4 Integrated Health Service Plan (IHSP) 4 Moving People Through the System: Significance of Rehabilitation 5 Rehabilitation Task Group Project Charter Summary (see Appendix II) 8 Purpose 8 Benefits 19 Goals 19 Project Methodology/Information Gathering Process 9 A. Group Meetings and Deliberations 9 B. Sub Groups 20 C. Guiding Document and Literature Review 20 D. Common Language Definitions 20 E. Survey of Rehabilitation Services 21 F. Communications/Discussion 21 G. Models of Care for Elective Joint Replacement and Fractured Hip 22 H. Clinical Services Plan Linkages 24 Summary of Findings Guiding Documents and Literature Review: Key Themes and Focus Areas for Consideration 24 Rehabilitation Organization and Delivery 24 Rehabilitation Overview 25 Utilization of Rehabilitation Beds in Ontario 25 Rehab Profile/Considerations for CE LHIN 25 Rehabilitation Utilization 25 Rehabilitation Service Providers 26 Rehabilitation Service Settings 26 Rehabilitation Population/Diagnoses 27 Alternative Level of Care (ALC) Summary 34 CE LHIN Initiatives 35 Rehabilitation is a Journey

3 2. Rehabilitation Common Language Definitions Document CE LHIN Rehabilitation Survey 38 Purpose 38 Methods 38 Limitations 38 Results 39 A. Quantitative Data 39 i) Service Environment 39 Table 1: Rehabilitation Service Settings 39 Table 2: Services Provider by Setting 40 Table 3: Therapies or Specialized Programs by Service Setting 41 ii) Client Population 42 Table 4: Primary and Secondary Types of Rehabilitation Program by Service Setting 42 B. Qualitative Data 43 iii) Referral/Application Processes 43 iv) Assessment of Services Communication Plan/Linkages Models of Care: Status of Implementation 46 Discussion/Analysis Guiding Document and Literature Review: Common Language Definitions Document: Population Groups, Service Settings Inventory Gap Analysis 49 i) Service Environment 49 ii) Client Population 50 iv) Assessment of Services Models of Care for Primary Hip and Knee Replacement and Fractured Hip 59 Strategies/Recommendations 61 Summary 77 Next Steps 78 Endnotes 82 References 86 Appendix I CE LHIN Integrated Health Service Plan 87 Rehabilitation is a Journey 2

4 Appendix II CE LHIN Rehabilitation Task Group Terms of Reference and Project Charter 89 Appendix III Task Group Meetings 101 Appendix IV Rehabilitation Guiding Document 103 Appendix V Draft Principles of Rehabilitation Services 118 Appendix VI Rehabilitation Common Language 119 Appendix VII Inventory of Rehabilitation Services in CE LHIN Survey Tool 125 Appendix VIII Inpatient Rehabilitation Model of Care Research Project 131 Appendix IX Models of Care (Elective and Fractured Hip) Symposium 133 Appendix X Status Update Models of Care (Elective and Fractured Hip) 135 Appendix XI CE LHIN Rehabilitation Task Group Symposium Evaluation 141 A. Evaluation Tool 41 B. Symposium Evaluation Responses 42 Appendix XII Current and Future State Population and Services Clinical Services Plan 144 A. Rehabilitation Separations by Site and RC Group 44 B. Rehabilitation Total Days by Site and RC Group 45 Appendix XIII Survey Results 146 Rehabilitation is a Journey 3

5 Letter from the Chairs We would like to take this opportunity to thank the many members of the Rehabilitation Task Group, who participated in the Rehabilitation Priority Project for the CE LHIN. This group of dedicated professionals offered their time, passion and insights into this project while continuing with their individual jobs and numerous other commitments. It was a pleasure working with such a hard working and knowledgeable group! Rehabilitation has been identified as a key enabler, to assist in moving people through the system, to improving the outcomes of care for many people suffering illnesses, injury and major life changes. Rehabilitation plays a critical role in sustaining health and preventing illness and injury for our communities. Rehabilitation crosses many sectors in our health care system and is a critical component of any service delivery system. The scope and extent of rehabilitation is evidenced by the various health professionals and service settings that our members represent. We would also like to sincerely thank those service providers who took the time to participate in our inventory of services across the CE LHIN. They played a critical role for our group to assist in identifying the key focus areas, through the gaps and opportunities analysis, to continue to plan for a more integrated and comprehensive rehabilitation system within the CE LHIN. The plan for continued engagement of this group is reflected in the recommendations as a means to continue to move forward with an agenda to improve access and service delivery for rehabilitation! A special thank you to the members of the Greater Toronto Area (GTA) Rehabilitation Network, whose continued work and dedication to improving rehabilitation services, in the GTA and beyond, helped to inform some of the directions for this project. Thank you to the CE LHIN staff, Project Coordinator and Project Consultant who were critical to assisting us in the completion of our mandate. We have moved a step closer to achieving a vision of improving the health status of our communities and defining the critical role that Rehabilitation plays in this journey! Sincerely, Heather S. Reid Chair Shelley A. Santerre Co-chair Rehabilitation is a Journey 4

6 Acknowledgements A great deal of work, collaboration and time from many are culminated in this report. We would like to acknowledge and thank all those individuals who contributed to this project as well as the organizations that supported their time and participation to make this document possible. Thank you. The Rehabilitation Task Group Members Heather Reid, Chair Director, Complex Care Rehabilitation and Patient Flow Rouge Valley Health System Margaret Aerola Bendale Acres Home for the Aged City of Toronto Homes Janet Burn Program Director Complex Care, Long Term Care, Palliative Care, Rehabilitation and Pharmacy Northumberland Hills Hospital Laszlo Cifra Regional Manager Program Director, Aging at Home CE CCAC Dr. Janice Lessard Geriatric Medical Services Inc. Seamless Care for Seniors Network Member Judy Moir Assistant Executive Director, ABI Network Project Coordinator, GTA Rehab Network Barbara Rimmer Physiotherapist Arthritis Society Paul Sawyer Clinical Leader Cardiovascular Prevention & Rehab Program Lakeridge Health Corporation Shelley Santerre, Co-chair Clinical Leader, Health Disciplines Post Acute Specialty Services Lakeridge Health Corporation Catherine Berges Manager, Professional Services Peterborough Regional Health Centre Barbara Cawley Vice President, Rehabilitation Services COTA Health Jodi Dunn Program Director, Continuing Care Program and Rehabilitation Therapies Ross Memorial Hospital Dr. Brian McCormack Whitby Mental Health Centre Seamless Care for Seniors Network Member Diane King Clinical Instructor Trent University Jane Rosenberg Administrator/Director of Care Extendicare - Haliburton Cassie Turnbull Speech-Language Pathologist York-Durham Aphasia Center (YDAC) The Rehabilitation Task Group would like to extend an additional thank you to: Kate Reed Susan Plewes Senior Integration Consultant, CE LHIN LHIN Project Manager Amanda Tassie Interim Project Coordinator Anita Saltmarche Consultant Scott Ovenden M.H.Sc. Student, University of Toronto Rehabilitation is a Journey 5

7 Executive Summary Rehabilitation is a goal-oriented process that enables individuals with impairment, activity limitations and participation restrictions identify and reach their optimal physical, mental and/or social functional level through client-focused partnership with family, providers and the community. Rehabilitation focuses on abilities and aims to facilitate independence and social integration. It involves many different health care professionals including (but not limited to) occupational therapists, physiotherapists, recreational therapists, social workers, speech language pathologists, physicians (for example physiatrists, neurologists, orthopaedic specialists, cardiologists, respirologists). Rehabilitation crosses many sectors of the health system and is offered in many diverse settings. Due to the broad scope of rehabilitation and the extensive size of the Central East Local Health Integrated Network (CE LHIN), it becomes apparent that services need to be integrated and coordinated with many other groups and sectors. The challenges of providing services within this diverse LHIN are significant. The CE LHIN is the sixth-largest Local Health Integration Network (LHIN) in land area in Ontario and includes Durham Region, the City of Kawartha Lakes, the County of Haliburton, Northumberland County, Peterborough County and the eastern portion of the City of Toronto (formerly called Scarborough). The CE LHIN is a mix of urban and rural, from densely populated urban cities, suburban towns, rural farm communities, cottage country villages to remote settlements. The younger urban population has on average higher income and more availability to health services versus the older, more diverse rural population in the north with low service availability. The rehabilitation needs across the CE LHIN are numerous. The demand for rehabilitation services will increase significantly. Factors that will drive this demand include: aging population, overall population growth, increasing chronicity and complexity of conditions, increasing public expectation, advances in health care, expanding scope of rehabilitation practice, availability of resources, both funding and health human resources and an emphasis on health promotion and disease prevention. Based upon all of these factors and as the baby boomer generation ages, it is reasonable to assume that the need for rehabilitation services will continue to grow. Therefore, rehabilitation will become even more critical in restoring, preventing and/or maintaining health of the Central East population, and contribute to the sustainability of the system. The provision of rehabilitation services continues to be cost effective for the health system overall. In order to realize the health priorities outlined in the Integrated Health Service Plan (IHSP) for the CE LHIN, enablers or common ways to achieve these goals were identified. One of these enablers for Moving People through the System is access to rehabilitation providers and services at the right time and in the right place. The CE LHIN Rehabilitation Task Group was struck in the summer of 2007 given the mandate to improve access to appropriate, timely and quality rehabilitation services through enhanced partnerships and collaborations. A literature review of the seminal provincial and local reports related to rehabilitation in general and for diagnosis specific conditions was completed. Through this literature review, and utilizing the results of a gap analysis completed following a survey, a draft set of principles was developed. It is the hope that these will be used in further discussions and planning groups within the CE LHIN. In addition, a common, standardized set of definitions for rehabilitation populations and service settings has been Rehabilitation is a Journey 6

8 developed. A Rehabilitation Inventory Survey of the publicly funded rehabilitation services collected quantitative and qualitative data from stakeholders from across care settings including the completion of a strengths, weaknesses, opportunities and threats (SWOT) analysis. Through the review and assimilation of all of this information, 37 corresponding recommendations were created. These were organized into the components of the decision making framework developed by the CE LHIN, in order to facilitate further discussion and review of the merits of the strategies and recommendations. It is understood that several of the recommendations are at a higher, more strategic level and many are more detailed. As rehabilitation is one of the enablers for the system, the recommendations are not purely reflective of rehabilitation alone and do reflect the need for further assessment and exploration with many of the other LHIN Committees and Networks including Seamless Care for Seniors, the ER/ALC wait list initiatives, the Clinical Services Plan, Aging at Home Strategy, and Mental Health and Addictions, to name a few. A need for coordinated planning with these groups will be essential to address the landscape of rehabilitation services across the LHIN. It is the intent of the task group that a priority setting process be part of the next steps, in planning the overall strategy for a systems approach to rehabilitation within the CE LHIN. The strategies and recommendations are outlined below in the categories of the decision making framework: Alignment and Accountability 1. All hospitals implementing Total Joint Models of Care will have access to appropriate resources: CCAC in pre-admission clinics PT/OT in pre-op clinics CCAC PT pre-op home visit 2. Utilize the information, lessons learned and successes from the hospitals that have implemented the models of care for elective joint replacement patients and patients who have sustained a fractured hip to inform the next steps of the Clinical Services Plan review for musculoskeletal services: Outline the key components of rehab service required that has led to the success Ensure participation of rehab professionals on the Advisory Groups for CSP planning 3. Ensure that the ongoing planning of the CSP implementation for Cardiac Rehabilitation Services addresses the key concepts outlined in this report: Outlines the draft principles, utilizes the common language terminology for cardiac rehabilitation Accessibility 4. Ensure continued access to publically funded inpatients and outpatient rehabilitation services across the CE LHIN: Working in alignment with the GTA Rehab Network, conduct a more detailed review of ambulatory services available within the CE LHIN Outline the role that these services play in enhancing flow across the system, enhancing access and care delivery and meeting wait list targets, e.g., primary joint replacement Rehabilitation is a Journey 7

9 5. Access to 7-day week therapy services in hospitals: Ensure access to physical therapy 7 days per week including sick time and vacation coverage Further assess the ability of providers to offer rehabilitation assistant service and occupational therapy on weekends 6. Develop strategies to increase awareness of existing rehabilitation services across the CE LHIN: Investigate the feasibility of developing an on-line Rehab Finder, similar to the GTA Rehab Network, as a web-based resource Develop forums or opportunities for rehabilitation service providers to meet and share experiences about the services and programs provided 7. Access to 7-day week admissions to inpatient rehabilitation: Assess resource requirements for each inpatient program, to enable these admissions. Recommend re-allocation as required or potential new resources 8. Review in more detail, the provision of, and access to, Acquired Brain Injury (ABI) services in CE LHIN: Complete a more detailed gap analysis for the ABI population Identify services that may be required to fill the gaps that currently exist in CE LHIN and that the mechanisms of funding are appropriate to the models of care Develop a comprehensive ABI strategy, similar to those that have been developed for other populations 9. Re-assess the transportation needs of clients for rehabilitation services with an emphasis on the rural and northern regions of the CE LHIN: Link to the Transportation Strategy to identify next steps where it will impact access to rehabilitation services 10. Need to review the convalescent care programs with respect to rehabilitation services offered and presence of different professionals: Meet with leaders to assess exclusion criteria, service components as they relate to rehabilitation 11. Formally review the extent of comprehensive geriatric assessment services available in hospitals (e.g., GEM nurses, geriatric consultation teams, numbers of rehabilitation professionals): Review the extent of physical, occupational and recreational therapy services Assess the infrastructures that exist for GEM nursing, geriatric consultation and treatment teams as a baseline 12. Assess the current status of Occupational Therapy, Physical Therapy, Speech and Language Pathology, Rehabilitation Assistants, and Therapeutic Recreation in acute care: With identified gaps as outlined in the survey, recommend review of these professionals in acute care to enhance functional outcomes, safe discharge planning and care for the elderly Rehabilitation is a Journey 8

10 Effectiveness 13. Utilize continued data and information to inform planning, review of services, e.g., customized data reports from CIHI on the NRS data: Develop new reports to share information specifically across the CE LHIN in collaboration with CIHI Utilize common data reports from HiNext Treat product to assist in developing common reports for the hospitals in the CE LHIN with inpatient rehab beds 14. Link with the Seamless Care for Seniors Network to establish the infrastructure and requirements for a Senior Friendly Hospital as it relates to the rehabilitation supports required: Assess key core components of rehabilitation professionals required in various service areas Assess the opportunity for joint submissions to the LHIN to address the gaps 15. Development of a shared program rehabilitation/activation framework which may reduce the functional and cognitive decline of hospitalized elderly patients: Review the results from the pilot project at Ross Memorial Assess next steps to spread across the other facilities Identify a project lead/champion to assist in the coordination and implementation of the program Ensure linkages with specialized geriatric services and the Regional Geriatric Program (RGP) 16. Review the collection and dissemination of CCAC data elements to support more system alignment and understanding among all groups: Assess measurements, both process and outcome measures 17. Review the status of professional practice leadership models for rehabilitation professionals across the LHIN: Complete inventory of the practice leadership models for physical therapy, occupational therapy, speech and language pathology, and social work in all hospitals within the LHIN Explore the leadership and support models in non-hospital based areas Identify the gaps and complete action plans to address these Safety 18. Utilize the Guiding Document/literature review in this report as a basis for providers to use as a reference in assessing services, analyzing alignment of programs with documented best practices: Contact key stakeholders, managers to review, assist in identifying next steps 19. Investigate electronic resource (library system) so all practitioners have access to latest research and can review recommendations from the experts: Linkage with the e-health committee to review feasibility 20. Explore the next steps required to create communities of practice within the CE LHIN, building upon the format and structures identified at the University of Toronto: Identify a key lead/champion to identify the key components, structure required, next steps Rehabilitation is a Journey 9

11 Person-Centered 21. Ensure participation of consumers/patients on task groups, planning committees for rehabilitation service: Communication to chairs of new committees/ongoing committees and task groups that will address rehabilitation issues, to consider consumer representation wherever possible 22. Enhance the work in community agencies (e.g., Arthritis Society) to ensure the ongoing availability of rehabilitation professionals and services: Plan focus groups with various community agencies to explore the issues identified in the survey Focus on Population Health 23. Falls Prevention: explore and link with Public Health and other groups that have established programs to review the spread and applicability across the LHIN especially as it relates to rehabilitation professional health human resources: Linkage with GEM initiative, Public Health 24. Osteoporosis: linkage with Osteoporosis strategy to assess alignment and current status of implementation across the LHIN: Open discussions with community health providers, e.g., Osteoporosis Canada, The Arthritis Society, Family Health Teams for further review and dialogue 25. Chronic Disease Management: review projects and continue to link for the implementation of initiatives that involve rehabilitation professionals: Meet with members of this group to assess opportunities for collaboration in upcoming initiatives Further assess the needs for amputee rehabilitation in particular, in Peterborough region 26. Cardio-vascular and stroke care: key linkage with Cardiac and Vascular planning groups, stroke groups and the chronic disease management group: Review current projects and define role for rehabilitation services Assess opportunities for centres of excellence in stroke rehabilitation both at the local, district and regional levels Equitable 27. Utilize the Accreditation standards in Rehabilitation for the hospitals to review consistency in the application of clear admission, discharge criteria, exclusion criteria and follow up services: Creation of a road map concept with articulated action plans and accountabilities at the LHIN level, to support hospitals in their achievement of the standards 28. Implementation of the GTA Rehabilitation Network s definitions: Continue linkage and review with the GTA Rehab Network to ensure work of CE LHIN is in alignment and consistent with common definitions Integrated 29. Explore the feasibility of forming a CE LHIN Rehab Network or planning group: Review the structures across the other LHINs Review of the draft vision and principles to develop common and consistent approach to planning Rehabilitation is a Journey 0

12 30. Provider-Academic Institutions: establish network for meetings with key academic institutions within the LHIN: Initiate meetings, discussions on programming for rehabilitation professionals, support staff, use of student placements 31. Private-Public clinic linkage: Explore opportunities for sharing, working in synergy, e.g., bone and joint plans of care 32. Advance initiatives that encourage coordination and partnership to address the barriers to access and integration identified in survey, in particular, with Community Care Organizations Consider holding focus groups with a few organizations to explore opportunities 33. Investigate the enhancement of or implementation of Inter-Professional Collaborative Practice Models within and between various rehabilitation settings in the LHIN Inventory the models currently existing. Assess next steps for review and dissemination across the LHIN Appropriately Resourced 34. Explore innovative ways to enhance recruitment, retention and identify novel care delivery systems to best meet client needs in light of the human resource shortage: Explore placements for BScN students to increase the awareness of opportunities in rehabilitation nursing 35. Investigate the status and capacity of Community Health Centres/Family Health Teams in the provision of rehabilitation components: Identify specific gaps and make recommendations to enhancing service provision, e.g., lack of rehabilitation professionals in Family Health Team in Haliburton 36. Investigate the role of supportive professionals (rehabilitation assistant, communicative disorders assistant, therapeutic recreational assistant, activationist) in the delivery of new models of care and in current practice: Linkage with various groups of rehabilitation professionals to more fully investigate this direction Link with the academic institutions to assess student placement options in various rehabilitation settings both within hospitals and in the community 37. Focus on the review of specialized human resources in the provision of rehab services, e.g., rehabilitation nursing, advanced practice physiotherapists, physiatry: Investigate the role of advanced practice physiotherapists in the ER for the management of strains, sprains etc. and in orthopaedic assessment centres Review current complement of physiatry in CE LHIN and make recommendations for further review and recruitment In addition to the strategies and specific recommendations noted above, the work of the rehabilitation task group identified the following key focus areas to support the goal of enhancing service integration. Rehabilitation is a Journey

13 To enhance service integration by: Promoting consistency in service definitions Sharing knowledge Improving coordination and streamlining of processes Building on current expertise Improving system capacity Creating a common level of understanding about rehabilitation services across the LHIN Responding to the needs of patients in a timely fashion Assisting in improving overall patient flow The work of the rehabilitation task group and the completion of key components of the charter, have moved us closer to realizing the above benefits. The following outlines additional next steps and priorities for action to enhance the achievement of service integration at a strategic level: Consistency of Definitions Utilize the Common Language Document for rehabilitation in the continued work of the various task groups and networks, to ensure consistency for planning purposes and standardization Ensure the integration of this language within the work and implementation of the Clinical Services Plan Support rehabilitation providers across the LHIN as they continue to plan for integration of services and ensure that the service settings and population groups reviewed are consistent with this common language Sharing of Knowledge The Guiding Document review in this report may be used as a basis for providers to use as a reference in assessing services, analyzing alignment of programs with documented best practices The success of the symposium on models of care for the primary joint replacement and fractured hip populations is evidence of the ability within the LHIN to share knowledge and support each other with the implementation of new initiatives Improving Coordination and Streamlining of Processes Results from the survey analysis on the gaps, solutions tried and partnerships, will enable various providers to review opportunities for future work, future development of programming The areas of focus identified in the results around threats and challenges, need to be reviewed and make a determination where more detailed assessment of resources is required. Many respondents indicated the desire to continue to meet and be able to provide feedback and input into improving the coordination of services across the LHIN Building on Current Expertise Continue to support and work with the Research Scientist and Northumberland Hills Hospital (NHH) and Peterborough Regional Health Centre (PRHC) in the implementation of the model of care for fractured hip patients with cognitive impairments Utilize the guiding document to build, change or revise service delivery based on the best practices work outlined here, e.g., Stroke Strategy, Osteoporosis, Specialized Geriatrics Rehabilitation is a Journey 2

14 Improve System Capacity There will be a need to link to the Seamless Care for Seniors project charter, the Chronic Disease Management group, the Wait times strategy, and the ALC/ER strategies to outline how rehabilitation services will improve system capacity especially in the area of providing patients with services in the right place and the right time, avoiding the designation of ALC and avoiding placements into Long Term Care Homes (LTCHs) prematurely The need to review the access to acquired brain injury services within the CE LHIN will need focused attention Common Level of Understanding About Rehab Services Utilize the results of the survey analysis to focus more in-depth review in areas that were identified as gaps in service Ensure the uptake of the use of the Common Language document for planning purposes Respond to Needs of Patients in a Timely Manner Explore the model of rapid assessment and treatment for populations other than fractured hip, e.g., stroke patients Review access issues identified in the survey with a lack of resources, e.g., rural areas Review and assess the types and numbers of rehabilitation service providers available in the LHIN Ensure the continued access to outpatient rehabilitation services by identifying the areas of decreased service and outlining focus areas that will align with the Clinical Services Plan, the Seamless Care for Seniors initiatives, the ALC/ER strategy, Wait List Strategy for musculoskeletal patients, and the Stroke Strategy, to name a few To Assist in Improving Patient Flow Ensure ongoing linkage to the ALC Implementation Committee to review areas where rehabilitation providers and services will support improved care and potential avoidance of ALC Focus rehabilitation services for the geriatric population in all areas of the continuum, e.g., emergency, acute care, post acute care, CCAC, long term care homes (e.g., convalescent care programs) and the community Participate and expand the programs and models of care to support wait time strategies, e.g., elective joint replacement, fractured hip The Rehabilitation Task Group acknowledges that the next steps and the achievement of many of the strategies and recommendations outlined in the report, will require an ongoing commitment to work in partnership with many of the other LHIN Networks, Committees, Collaboratives and Task Groups. Rehabilitation as an enabler for the system, must be a critical component of new initiatives focused on improving the health of the communities served in the LHIN. Rehabilitation is a Journey 3

15 Background Central East Local Health Integration Network (CE LHIN) The Central East LHIN is the sixth-largest Local Health Integration Network (LHIN) in land area in Ontario (16,673 km2), includes Durham Region, the City of Kawartha Lakes, the County of Haliburton, Northumberland County, Peterborough County and the eastern portion of the City of Toronto. This area stretches from Victoria Park to Algonquin Park accounting for 11.7% of the provincial population or approximately 1.4 million residents. It is one of the fastest growing geographic regions in Ontario. According to 2006 Census estimates, the population has grown by five percent and 13.0% is age 65 years and over. This represents a slightly greater proportion of seniors living in the CE LHIN compared to with other LHIN s in the provincial average. 1 The CE LHIN is a mix of urban and rural, from densely populated urban cities, suburban towns, rural farm communities, cottage country villages to remote settlements. The geographical distribution related to the age distribution for the population of the CE LHIN presents a distinct pattern of a younger population with high service availability in the southeast and an older population in the northeast with low service availability. 2 The neighbourhoods have a rich diversity of communities, ethnicity, language and socio-demographic characteristics. 3 CE LHIN data and further details can be reviewed directly on Integrated Health Service Plan (IHSP) The Central East LHIN is one of 14 LHIN s established by the Government of Ontario in The LHIN is a community-based organization who s mandated is to plan, co-ordinate, integrate and fund health care services at the local level. Organizations and services include hospitals, long-term care facilities, community care access centres, community support services, community mental health and addictions services and community health centres. The mandated goal of the CE LHIN is to plan for the most appropriate and cost effective delivery of health services, including a vast and varied group of organizations that had historically functioned independently prior to the inception of the LHINs. To undertake this enormous task the CE LHIN developed an Integrated Health Service Plan (IHSP) to guide the process of meeting the unique needs of its population. Through the process of community engagement and information assessment and integration, the following four health care priorities, or the initial focuses for system changes were identified: 1. Mental health and addiction services 2. Seamless care for seniors 3. Chronic disease prevention and management 4. Wait time and critical care In order to realize these health priorities of the CE LHIN, common ways to achieve these goals were identified. One of these enablers is Moving People through the System (see Appendix I). As part of this component, the Rehabilitation Priority Project was identified and the Rehabilitation Task Group was formed. One essential method of accomplishing this movement for people is access to rehabilitation providers and services at the right time and in the right place. Rehabilitation is a Journey 4

16 Moving People Through the System: Significance of Rehabilitation Access to therapeutic services/rehabilitation professionals across the continuum of care from a presence in the emergency room, into acute care, post acute care, long term care and the community are essential to enhancing the care of the patients and in achieving the desired outcomes to support the improved health of the individual. In fact, the Greater Toronto Area (GTA) Rehabilitation Network has as its vision of rehabilitation in the GTA: Rehabilitation is an integral and essential component of the continuum of health care, reinforcing positive health behaviours, rebuilding lives and re-integrating individuals in the community. (GTA Rehabilitation Network Annual Report, 2007/08). It is important to understand the broad scope that rehabilitation encompasses and the extent to which it crosses over and intersects with many sectors and in many health care settings. Rehabilitation services are a core element of Ontario s health system. The provision of these services is fundamental across the continuum from prevention and well-being at one end, to specialized acute care following illness, diseases and injury at the other. However, as demand for publicly-funded health services tends to always surpass supply, there remain ongoing challenges in providing a fully integrated system that includes comprehensive rehabilitation services. Landry et al. (2006) 4 Due to this broad scope of settings requiring access to rehabilitation services, there is also a need for more comprehensive rehabilitation services in order to meet the demands for the aging population, the increasing chronicity of conditions and the overall focus on health, prevention and well being of the communities. To address this broad scope, it will be imperative to address the key performance dimensions of accessible, equitable, integrated and appropriately resourced as it pertains to rehabilitation services. This rehabilitation enabler is critical to meet the vision for the health care system that helps people stay healthy, delivers good care to them when they get sick and will be there for their children and grandchildren (Integrated Health Service Plan, 2006). In highlighting the importance of the continuum of rehabilitation services, key focus areas require attention and review to further assess the role of rehabilitation in the area, the accessibility and equity of resources across the LHIN, the assessment of whether they are appropriately resourced and to review the opportunities for integration and coordination: A. Emergency room: a review of the various rehabilitation professionals situated within the emergency rooms is required in order to support various new initiatives within the LHIN (ALC reviews, Specialized Geriatric Services) and to enhance the full interdisciplinary teams that may improve the flow through of patients and the avoidance of admissions to the hospital. It is becoming increasingly important to expand the team of professionals that assess the geriatric population in emergency and to support the work of the Geriatric Emergency Management Nurses. Feedback received from this group has indicated the desire to have consistency in social work, physical therapy and occupational therapy resources available. More work will be required to assess further. Preliminary reviews of Rehabilitation is a Journey 5

17 care provision in emergency rooms has outlined the need for teams often described as Coordinated Care Teams (CCT s) with varying professionals noted ranging from social work, physical therapy, occupational therapy, registered nurses, specialized Geriatric Emergency Management Nurses, dieticians etc. 5, 6 B. Acute care: various disciplines of rehabilitation professionals provide service within acute care to support a full multidisciplinary model of care focused on the provision of acute care and to support functional enhancement, the prevention of decline and de-conditioning and preparation of timely safe discharges. Many of these professionals include physical therapy, occupational therapy, speech and language pathology, recreational therapy, and physical and occupational therapy assistants, to name a few. In fact, a new initiative in the LHIN focuses on the need for an activation project to support one of the recommendations in the ALC Task group report. C. Post acute care (inpatient rehabilitation and complex continuing care services): it is well understood how access to these services support the system by providing services focused on increasing the function of patients in preparation for discharge and re-integration into the community, avoiding admission to long term care prematurely and in achieving an overall enhancement of the quality of life of patients following a serious injury, post surgery, or other exacerbation of a medical condition. The recent implementation of the Fractured Hip Rapid Assessment and Treatment (FHRAT) Programs are evidence that access to rehabilitation services, despite the level of cognitive function, improves patients ability to return home, increases their level of functional independence and may avoid long term care placement. More research is required to more fully assess some preliminary findings of these programs. D. Outpatient rehabilitation programs: a variety of ambulatory programs support many of the specialized populations requiring rehabilitation services. They also support several of the LHIN initiatives focused on improving wait times and improving access to service for our communities. Access to outpatient services for musculoskeletal care for patients following elective hip and knee surgery (knee surgery in particular) is critical to the flow through of patients and to achieving successful outcomes post surgery. Access to continued service for stroke patients improves patients outcomes, enhances the flow of patients from inpatient rehabilitation programs, to assist in the continued availability to support flow through the hospital and to reduce ALC days. In addition, there are few stroke patients that have the ability to pay for private services on an outpatient basis. Many of the services that can be provided on an ambulatory basis support the increasing number of chronic conditions seen in our health system and enhance and support the chronic care strategy. E. Long Term Care Homes: it is well understood that rehabilitation services and the need for activation, ambulation and appropriate seating assessment, to name a few, enhance the quality of life for the residents of long term care. Improved function and the ability to provide maintenance for the residents assists in the avoidance of re-admission to emergency rooms and hospitals. The success of the New Convalescent Care Programs has demonstrated that not only can these homes offer new services to enhance functioning; this program improves the flow through from acute care services. Many of the potential services that could be offered in long term care are not available due to a lack of resources. Occupational therapy is an example of a service often not available in these homes, and yet, is so important to improving the resident s quality of life with proper assessment of their activities of daily living, their ability to incorporate leisure activities into their daily life and to ensure proper seating for Rehabilitation is a Journey 6

18 the avoidance of positioning issues, decline in postural control etc. The access to Speech and Language Pathology would enhance many of the resident s assessment of swallowing and eating difficulties, ensuring the avoidance of progression of issues requiring transfer to a hospital. F. CCAC: the importance of home support services to our aging population and the many other populations is clear. The CCAC services and their providers ensure timely care for patients in many of the streams including patients post elective hip and knee surgery, palliative care patients, stroke patients, patients with chronic conditions and other patients that are unable to get to outpatient services. The CCAC staff are crucial members of the hospital team working within the emergency departments and all other areas to assist in identifying patients that can return home with the support of service providers such as nursing, physical therapy, speech and language pathology, occupational therapy, personal support workers and others. G. Community care providers: many of these groups are essential for the patients to be re-integrated and maintained in the community setting. Extending the chain of health care for wellness and prevention initiatives would require a comprehensive and well resourced network of community care providers. Partnering with other groups and providers will support the overall outcomes of care for the patients and residents and support independent functioning outside of the walls of institutions. A recent research project in Toronto demonstrated this concept. The Toronto Balance of Care Research Pilot Project estimated that roughly 50% of Toronto individuals waiting to be relocated to a LTCH could be maintained in the community if integrated care options such as supportive housing, clusters of care were available. H. Home at Last (HAL) Program: this recent initiative demonstrates the partnership to support patients returning home from the hospital in a timely manner that still require some additional support to return home and to avoid early re-admission. The demand for rehabilitation services will increase significantly. It is estimated that Canada will see a population increase of 14% between 2001 and This estimate does not reflect the changing proportions. The fastest growing strata of the population are those aged 65 years and over, and they are predicted to account for 20% of the population in 2021 and 25% by As indicated in a report by Landry et al, 2006, eight factors are driving demand including: 1. Aging population 2. Increasing chronicity and complexity of conditions 3. Overall population growth 4. Increasing public expectation 5. Advances in health care 6. Expanding scope of rehabilitation practice 7. Availability of resources, both funding and resources 8. Emphasis on health promotion and disease prevention The aging population is very committed to maintaining its independence. The baby boomers are now entering their fifties and sixties and will ultimately place increased demands on the health care system. The fastest growing segment of the population is 65 years of age and over which will account for an estimated 20% of the population in 2021 and increase to 25% in (Landry, et al., Final Report, 2006). This is particularly important for the CE LHIN with its slightly higher proportion of seniors than in other Rehabilitation is a Journey 7

19 LHINs. 7 As one grows older, rehabilitation services become more necessary to maintain independence and function, especially in light of increased prevalence of arthritis, osteoporosis, stroke and hip or knee replacements. Rehabilitation services also focus on maintaining wellness and reducing risk of injuries. Based upon the average life expectancies, it is reasonable to assume that the need for rehabilitation services will continue to grow for the next years. Therefore, rehabilitation may not only become more critical in restoring and or maintaining the health of the Central East population, but it may contribute to the sustainability of the system overall. Rehabilitation services are also critical resources within the system, to enable the timely flow of patients into and out of acute care services, thus improving the overall patient flow while improving the health outcomes for patients. Access to these resources allows patients the opportunity to receive the appropriate care they need, once they no longer require acute hospital services. This results in an overall reduction in Alternative Level of Care (ALC) days and assists in one of the system goals to improve the flow through the emergency rooms. Community rehabilitation services are provided by outpatient clinics, through the Community Care Access Centres (CCAC) in the CE LHIN and through other community providers such as The Arthritis Society and COTA Health. There is no accurate inventory of both publicly and privately funded services across Ontario or coordination of these community rehabilitation services. 8 The geographic distribution of services are predominantly located in the more populated and younger population based southeastern region, compared with the lower service availability in the rural often more remote northeastern region of the CE LHIN. There are limited options to access publicly funded community physiotherapy or occupational therapy services, especially for the many residents with lower average household incomes. Additionally, clients have difficulty moving across boundaries to access closer services in either South East or North Simcoe-Muskoka LHIN s. Although there is an increasing demand for rehabilitation services in Ontario, this does not mean that there is, or will be, sufficient financial and human resources to meet these same demands. Rehabilitation services are funded through a mix of public and private sources, and delivered through a blend of private for-profit and not-for-profit providers. As a result, access to rehabilitation is often based on availability of funding in a particular setting rather than demand. Further research is needed in order to fully understand how a public/private mix of funding and delivery will meet increasing demand for rehabilitation in Ontario. Moreover, further research is required to understand the degree to which the presence of unmet demand for rehabilitation has short and long term implications at the client and health system levels. Rehabilitation Task Group Project Charter Summary (see Appendix II) Purpose To improve access to appropriate, timely and quality rehabilitation services through enhanced partnerships and collaborations. This will lead to a common philosophy of care that is patient, family and caregiver-centered, based on a common set of definitions. Rehabilitation is a Journey 8

20 Benefits To enhance service integration by: Promoting consistency in service definitions Sharing knowledge Improving coordination and streamlining of processes Building on current expertise Improving system capacity Creating a common level of understanding about rehabilitation services across the LHIN Responding to needs of patients in a timely fashion Assisting in improving overall patient flow Goals 1. Create a summary guiding document that outlines a shared philosophy and principles of rehabilitation care delivery. Review and consolidate current strategy documents and literature on rehabilitation best practices. Utilize this document and integrate with the information from the knowledge experts surveyed across the LHIN to prepare an analysis for use at the LHIN to assist in guiding and informing further planning on service delivery. Draft shared principles of care delivery based on the literature and survey findings will be developed to stimulate further discussion and feedback with the goal of achieving more consistency and standardization across the CE LHIN related to access and delivery of rehabilitation services. 2. Create a common, shared understanding of the rehabilitation population definitions and service settings. 3. Complete a gap analysis of publically funded rehabilitation services available in the CE LHIN to inform the recommendations and next steps for rehabilitation within the CE LHIN. 4. Develop a communications/action plan to ensure linkages with other key CE LHIN Networks and working groups for ongoing dialogue and sharing of information. 5. Improve the quality of care processes related to the models of care for elective joint replacement surgery and hip fractures and to increase the uptake of these models of care across the hospitals within the CE LHIN. Project Methodology/Information Gathering Process A. Group Meetings and Deliberations In June 2007 the Rehabilitation Task Group was struck and held their first meeting at the CE LHIN Planning Symposium to develop a better understanding of how rehabilitation can enhance the Movement of People through the System. It should be noted that the mandate of this Task Group did not include the paediatric population, however, it is recommended to address this group in future projects and review. Rehabilitation is a Journey 9

21 The Rehabilitation Task Group membership included representatives from multi-disciplinary health care providers and management from the hospital, community and long term care (LTC) sectors. Membership selection ranged from appointees to interested volunteers. Bringing all of these members together also allowed an opportunity to improve communications amongst the CE LHIN rehabilitation stakeholders. In the end, from June 2007 to March 2009, the Rehabilitation Task Group held over 20 meetings throughout the CE LHIN region, with a plan for further engagement and collaboration (see Appendix III). Site tours of the facilities/services were offered and conducted upon request. CE LHIN Office Ajax CE CCAC Whitby Office Haliburton Highlands Health Services Minden Site Lakeridge Health Bowmanville and Oshawa Sites Northumberland Hills Hospital Peterborough Regional Health Centre Ross Memorial Hospital Rouge Valley Health System Ajax and Centenary Sites B. Sub Groups To accomplish the first three goals of the charter the Task group divided into three sub groups. Each sub group set out a meeting schedule and met regularly to achieve the key tasks identified within each goal. The sub groups reported back to the Rehabilitation Task Group at every meeting. C. Guiding Document and Literature Review A review of relevant provincial, regional and local rehabilitation initiatives was completed to set the context for identifying particular trends, issues and areas of focus requiring further review and analysis of the rehabilitation landscape in the CE LHIN. The Guiding Document working group reviewed over twenty-five reports highlighting relevant content and outlining the key learnings to assist in the development of the principles and recommendations for the next steps of implementation (see Appendix IV). It is intended to assist with directing and shaping rehabilitation service delivery in the CE LHIN. A draft of principles of rehabilitation care delivery (see Appendix V) was developed to be utilized for further discussion and feedback as noted in the recommendations/next steps. The task group members, who themselves had knowledge expertise in their particular areas of specialty and sector, also recommended and forwarded key relevant documents to be reviewed and incorporated into the discussion and analysis of rehabilitation services in the final report. D. Common Language Definitions The development of definitions for rehabilitation and the population groups served as the first step towards providing continuity and standardization of terminology. The definitions working group was able to utilize previous work on population definitions from the Greater Toronto Area (GTA) Rehabilitation Network as well as other sources, to inform their work. The intent was to use work that Rehabilitation is a Journey 20