Fall 2013 A progress report on improving rehabilitative care in Waterloo Wellington The Waterloo Wellington Rehabilitative Care Council Improving rehabilitative care in Waterloo Wellington, fall 2013, page 1
Since 2011, health service providers in Waterloo Wellington have worked together to improve rehabilitative care for area patients. Care providers work hard on behalf of patients. However, the rehabilitative care system has not met patients needs across the continuum of care. The Waterloo Wellington Local Health Integration Network (WWLHIN), in partnership with health service providers, undertook a review of regional rehabilitation services. The review in 2011 identified opportunities to streamline the rehabilitation system to increase access to care and provide better outcomes for patients. As you can see in the table on page three, the rehabilitation services review found that rehabilitative care best practices were not fully in place across the local health integration network. Hospitals and the Waterloo Wellington Community Care Access Centre have since worked closely together to plan and put in place best practices. Improvements are now beginning to appear in the four condition-specific streams of care within the rehabilitative care system. In this report, we will describe changes we have made in the following rehabilitative care streams: Stroke and neurology; Musculo-skeletal; Frail elderly and medically complex; and Cardiopulmonary. Regional partners in better rehabilitative care Improving rehabilitative care in Waterloo Wellington, fall 2013, page 2
The case for change: status of select rehabilitative care best practices in Waterloo Wellington (as of the 2011 review) Stream of care Best practice Implementation in WWLHIN? 7 day a week rehabilitation Variable Fractured hip Referral to rehab on post-op day #3 if not progressing Transfer to rehab on post-op day #5 if required t Measured Total joint arthroplasty 7 day a week rehabilitation in acute Variable Orthopedic Quality Scorecard - 90% (+/- 10%) discharge rate to home from acute care hospitals. Yes ALPHA FIM completed on day #3 Onset to rehab - Day 5 (Ischemic Strokes) or Day 7 (Hemorrhagic) Stroke 7 day a week admission process to rehabilitation 45 per cent of patients admitted to inpatient rehabilitation with severe strokes (RPG= 1100 or 1110) 7 day a week rehabilitation Elder care Comprehensive Geriatric Assessment (CGA) is required for frail elderly patients with rehabilitation needs Geriatric rehabilitation should be managed by a physician and interdisciplinary team trained in care of the elderly Frail elderly rehabilitation candidates with mild to moderate dementia should not be excluded from rehabilitation A common rehabilitation/activation framework is required to reduce the functional and cognitive decline of hospitalized elderly patients Improving rehabilitative care in Waterloo Wellington, fall 2013, page 3
Stroke and neurology By April 2014, health service providers will move forward with an integration that will develop an integrated stroke program. This will include the implementation of stroke best practices. The new program will support the delivery of best practice care, better coordination between health service providers and better support for patients through their stroke care and return to the community. Why are we making changes? About 870 patients a year in Waterloo Wellington experience a stroke. In community consultations, patients frequently spoke about feeling a lack of support when their hospital stay concludes and they return to the community. In the past, care providers have also talked about barriers that prevent patients from receiving the best care. Care practices have been inconsistent and outcomes have been below provincial benchmarks. How have we done to date? Waterloo Wellington hospitals and the Community Care Access Centre have come together to make major changes to improve care for patients. Some successes to date include: Establishing an integrated clinical program for all stroke services in Waterloo Wellington. This ensures all stroke patients have timely access to best practice stroke care regardless of where they live or receive their stroke care; New monitoring and quality improvement steps are in place to ensure changes are leading to better outcomes for patients; Establishing streamlined referrals for stroke patients to inpatient rehabilitative care for faster access to recovery services and reduced paperwork for providers; and Improved access to community stroke services (outpatient rehabilitative care, aphasia services, stroke recovery support groups and community support services) upon discharge from hospital. The Care Dove website (www.caredove.com) and Easy Coordinated Access referral process are under development to ensure stroke patients are linked with appropriate community-based programs to continue their recovery. We have seen the following improvements: Stroke-related mortality rates have improved and are now better than the provincial average; The proportion of severe stroke patients moving to rehabilitation has improved from 27.4 per cent in 2010/2011 to 36.8 per cent in 2011/2012; and Acute stroke alternate level of care hospital days have declined from 36.9 per cent in 2010/2011 to 31.8 per cent in 2011/2012. Improving rehabilitative care in Waterloo Wellington, fall 2013, page 4
Patients who require inpatient rehabilitative care services will receive specialized stroke rehabilitation at Cambridge Memorial Hospital, Grand River Hospital s Freeport Site and St. Joseph s Health Centre Guelph. These sites are launching stroke rehabilitation best practices to help improve recovery for stroke patients. What are our next steps? In August 2013, the Waterloo Wellington Local Health Integration Network approved an integration of stroke services throughout Waterloo Wellington. Next steps for the integrated stroke program include the following: The expansion of emergency stroke services to include Guelph General Hospital (GGH) as a telestroke supported site. This will give more patients timely access to the clotbusting drug tpa. Proposed changes would see ambulances bringing Waterloo Region patients to Grand River Hospital (GRH) in Kitchener and rth Wellington patients to GGH. Time is brain is vital in stroke care, and faster access to clot-busting drugs will result in improved patient outcomes; These changes will take place by April 2014. How will we measure results? The stroke system will pay close attention to the following key areas to determine the effectiveness of improvements and to match changes happening across Ontario: Ensuring all stroke patients are served in specialized acute stroke units. Patients have better outcomes when they receive care in specialized stroke hospitals; and Ensuring access to dedicated stroke rehabilitation for all patients. This is to ensure the best outcomes and function after a stroke. All stroke patients will receive care in specialized acute stroke units at Grand River Hospital in Kitchener and Guelph General Hospital. Right now, the only dedicated stroke unit is at GRH, with other area hospitals offering stroke care (but not within dedicated units); and Improving rehabilitative care in Waterloo Wellington, fall 2013, page 5
Streams of care: musculoskeletal, frail elderly/medically complex and cardiopulmonary The Waterloo Wellington Rehabilitative Care Council has overseen changes throughout the regional rehabilitative care system since June 2012. It also supports stream steering committees in developing and implementing rehabilitative best practice care pathways. The musculo-skeletal stream is implementing system-wide improvements. These are based on best practices for patients undergoing total hip arthroplasty and total knee arthroplasty and those receiving care for a fractured hip. The frail elderly/medically complex stream is developing a framework to support access to comprehensive geriatric assessment with a rehabilitative focus and a care pathway for amputation. The cardiopulmonary stream has developed and is implementing best practice, rehabilitative care pathways to support patients with congestive heart failure and chronic obstructive pulmonary disease. How have we done to date? Several new cross-continuum rehabilitative care pathways based on the best evidence are now available for care providers across Waterloo Wellington. These are now available on line at www.regionalhealthprogramsww.com, which is the regional health programs website shared by health providers across Waterloo Wellington. What are our next steps? Each of the stream steering committees will develop standardized regional patient education material packages. These will ensure patients receive the same information and resources wherever they receive care within the system. Health service providers across Waterloo Wellington will now begin implementing evidencebased care pathways within their organizations. The target completion date is June 2014. Why are we making changes? These changes will help ensure a single standard of care is available to every resident in Waterloo Wellington regardless of where they live. Working together to put in place standard care pathways will also support the local implementation of several provincial quality-based procedures (QBPs). This will help position Waterloo Wellington health service providers to best handle provincial funding changes, standardize care and improve outcomes for patients. Improving rehabilitative care in Waterloo Wellington, fall 2013, page 6
The Waterloo Wellington Rehabilitative Care Council is also supporting the development of a regional falls prevention strategy for health providers across Waterloo Wellington. Planning will be complete in 2013. The strategy will come into effect through 2014. Each of the stream steering committees will develop a monitoring and evaluation process as well as sustainability structures to support the changes across the system. Finally, the committees will also develop solutions to system-level gaps and barriers related to their respective rehabilitative patient population. Here are some specific changes to come within each stream of care: Musculo-skeletal The committee will consider opportunities to standardize pre and post-operative rehabilitative care for total joint arthroplasty clients and support timely access to inpatient rehabilitation for patients with fractured hips. Frail elderly/medically complex This committee has decided to focus on developing a care pathway that will ensure that patients receive a comprehensive geriatric assessment. The results of this assessment will help address the symptoms of frailty among elderly and medically complex populations. An additional care pathway will be introduced in October for patients who have undergone an amputation. Cardio-pulmonary Two care pathways have already been introduced for chronic obstructive pulmonary disease (CODP) and congestive heart failure (CHF). All health service providers in Waterloo Wellington are working on implementing the respective best practices for these strategies at their own sites. How will we measure improvements and outcomes in the streams of care? The Waterloo Wellington Rehabilitative Care Council is overseeing the development of a regional rehabilitation scorecard. The council will monitor progress over time. The scorecard will include certain key indicators related to the system s performance in providing better care, better health, better value and better outcomes. It will also use the information from the scorecard to drive further improvements in the system. Our current status is available on page eight. Improving rehabilitative care in Waterloo Wellington, fall 2013, page 7
Our progress: improvement throughout the rehabilitative care system in Waterloo Wellington Stream of care Fractured hip Total joint arthroplasty Best Practice 7 day a week rehabilitation Referral to rehab on post-op day #3 if not progressing Transfer to rehab on post-op day #5 if required 7 day a week rehabilitation in acute Orthopedic Quality Scorecard - 90% (+/- 10%) discharge rate to home from acute care hospitals. Status in WWLHIN The Waterloo Wellington Rehabilitative Care Council is monitoring: Processes to support achievement of these targets, which are embedded in the MSK care paths; and Expected outcomes. Stroke Elder care ALPHA FIM completed on day #3 Onset to rehab - Day 5 (Ischemic Strokes) or Day 7 (Hemorrhagic) 7 day a week admission process to rehabilitation 45 per cent of patients admitted to inpatient rehabilitation with severe strokes (RPG= 1100 or 1110) 7 day a week rehabilitation Comprehensive Geriatric Assessment (CGA) is required for frail elderly patients with rehabilitation needs Geriatric rehabilitation should be managed by a physician and interdisciplinary team trained in care of the elderly Frail elderly rehabilitation candidates with mild to moderate dementia should not be excluded from rehabilitation A common rehabilitation/activation framework is required to reduce the functional and cognitive decline of hospitalized elderly patients The integration of stroke services and development of a regional stroke program across Waterloo Wellington (Apr 14) will allow access to these best practices to be standardized across the system. The rehabilitative care council will monitor the associated patient outcomes. The rehabilitative care council has made recommendations regarding the development of a regional inpatient specialized geriatric rehabilitation program. This has happened from local planning and in alignment with provincial directions related to Assess and Restore. Approval and implementation of these recommendations will support the delivery of these best practices. Also, the frail elderly and medically complex stream steering committee is developing a care map, in alignment with the provincial Assess and Restore Framework. Improving rehabilitative care in Waterloo Wellington, fall 2013, page 8
Other changes to come Using technology to improve access The rehabilitative council has endorsed a request for information for a web-based tool to enhance the flow of patients to inpatient rehabilitative care beds. There are benefits and efficiencies by using an electronic bed board. This kind of tool would reduce the number of phone calls and faxes in the current process. The bed board would also support the stroke navigator and Waterloo Wellington Community Care Access Centre in their roles to find the most appropriate bed for a patient as fast as possible so they can begin rehabilitation and recovery. Stakeholders have been consulted to identify key features that would be critical to such a tool. collaboration, referral and admission processes now provide more streamlined access to rehabilitative care beds in alignment with the new rehabilitative care system in Waterloo Wellington (around the four streams of care). Next steps include the consideration of an electronic solution to support and enable the re-designed processes to replace the current paper and fax method of sending information from acute to rehabilitation and complex continuing care facilities. Additional information and contacts For more information, please contact Melissa Kwiatkowski (Melissa.Kwiatkowski@sjhcg.ca) or Emmi Perkins (emmi.perkins@sjhcg.ca). Physical medicine recruitment The physician recruitment working group has actively been working to bring together physical medicine specialists throughout Waterloo Wellington to recruit additional candidates to support physical medicine needs throughout the area. Additional physiatrists will be crucial to supporting excellence in rehabilitative care throughout Waterloo Wellington. Please visit our website to learn more about and access tools to support rehabilitative care: www.regionalhealthprogramsww.com. Care Dove is a tool to improve access to community-based rehabilitative care services and programs. It will help patients with functional goals to be matched with community programs. Visit www.caredove.com/wwrehab for more information. CCAC s expanded role The Waterloo Wellington Community Care Access Centre has fully implemented its expanded role effective May 2013. It now manages eligibility and bed level matching referrals to rehabilitative care (complex continuing care and inpatient rehabilitation beds). Through stakeholder consultation and Improving rehabilitative care in Waterloo Wellington, fall 2013, page 9