Senior Director, and Chief Nursing Executive Policy General Rehabilitation Page 1 of 7 The Waterloo Wellington Local Health Integration Network (LHIN) recommends access to general rehabilitation beds in planning of care with individuals who would benefit from an interim step in their transition home following an episode of care in an acute care Hospital. The focus of this transition is an effort to reduce the risk of a hospital readmission. LHIN-Wide Approach The General Rehabilitation Program is a partnership between the Waterloo Wellington CCAC, acute care sites and general rehabilitation sites. It is a LHIN-wide program comprised of general rehabilitation beds located at: Grand River Hospital, Freeport Health Centre (GRH FHC) St. Joseph s Health Centre (SJHC) Cambridge Memorial Hospital (CMH). Based on a LHIN-wide prioritization framework, individuals may be suited to a setting within the Waterloo Wellington LHIN. However, a location outside their home community may need to be selected according to the first available bed policy. As a result, a general rehabilitation setting available location may be any 1 of the 3 locations above. When multiple vacancy locations are available simultaneously, the geographic location (close proximity of the Patient/caregiver home) will be considered by the WWCCAC during the selection process. Any requests for exception will be considered with the General Rehabilitation program Manager. This LHIN-wide approach relates to all general rehabilitation settings. Role of CCAC Program Description The CCAC works with individuals in determining eligibility, site matching, coordination and access to the general rehabilitation program beds. This includes communicating program criteria, managing wait lists and managing program admissions in light of the LHIN-wide approach to care transitions. The purpose of the General Rehabilitation Program is to provides intensive, goaloriented rehabilitation for individuals living with stable medical conditions and require a level of nursing or medical care intervention not available in the home or community setting (refer to General Rehabilitation Program Description WW556 and Waterloo Wellington Rehabilitation/Transitional Program Framework WW555). Out-of-regional referral sources may complete an application. Program length of stay is determined by specific rehabilitation goals with a target ranging between 7-40 days in order that improved strength, endurance and/or function and safe transitions to the community can be achieved. The specific therapy service model includes: Occupational therapy (OT) and physiotherapy (PT) is 60 minutes per day (5-7 times per week) with a therapist and/or therapy assistant. Care plans are individualized and adjusted according to an individual s stamina and level of tolerance. Role of Discharge Planner An individual completing the application is responsible to complete the general rehabilitation application in its entirety. This individual may be a WWCCAC Care Coordinator (CC) or another health care professional who is working with the person (applicant) during the discharge planning process at the acute care hospital.
Senior Director, and Chief Nursing Executive Eligibility Criteria Page 2 of 7 The General Rehabilitation Program eligibility criteria, includes an individual that : is at least 16 years of age; that needs therapy intervention level that cannot be provided at the community resources level (community services, outpatient therapy, CCAC services and private pay services); or is currently working with the WWCCAC and service needs are more than what the community-based service programming; has stable medical health status (i.e., all acute issues are resolved or have reached a plateau) or progressing toward health stability with the interventions associated with a clinical care path; agrees to participate in the program and is committed, willing, and motivated to participate; and understands the regional program guidelines and has completed a Letter of Understanding WW553D; and will benefit from the program as evidenced by the assessor s clinical experience best practice and literature; demonstrates a potential for achieving the identified functional goals, has the ability to participate in the learning process and integrate new learning and skills into their daily life; has functional and/or clinical goals established that are specific, measurable, attainable, realistic and timely (SMART); and demonstrates potential to tolerate being up and out of bed for at least 2-3 hours per day; the individual has demonstrated a potential to endure greater than 1 hour of therapy per day for up to 7 days per week; demonstrates cognitive ability to participate in setting goals and assimilating the new learning into his/her activities of daily living e.g., where a patient scores 15/30 or less on a MOCA or a delayed recall of less than 2/5, he/she may not be able to achieve carryover of new skills; is has the expressed commitment of returning to the community, with family and community support services as needed; has verbalized with the assessor a realistic and viable discharge plan; has pre-determined special equipment needs if applicable; the ability to actively participate in the program on a daily basis and the treatment of other co-morbid illnesses/conditions will not interfere e.g., ongoing chemotherapy, radiation therapy, dialysis that requires frequent trips offsite and may impact activity tolerance; has a follow-up plan in place (where possible) at the time of referral and follow-up appointments are scheduled at the time of discharge from acute care. Refer also to Services in WW General Rehabilitation Care Units WW554C.
Senior Director, and Chief Nursing Executive Exclusion Criteria Page 3 of 7 The General Rehabilitation Program is not appropriate for patients who: exhibit violent behaviours with tendencies to harm self, others or property; have unresolved delirium; have acute psychiatric issues limiting their ability to participate in the program; have exit-seeking behaviours; are assessed as palliative with a prognosis of less than 3 months need humidified O2. Program Admission No HCN CHRIS On-Hold Change in Status Patient Discharge Flowcharts Admission to the General Rehabilitation Program is based upon, but not limited to: the patient s wait list date; or the care path ready date for patients who are on a stroke care path; and the patient s fit with an available bed considering the site s ability to meet the individual patient needs e.g., infection control, gender. If the individual does not have a valid health card number (HCN), the referral source is responsible for ensuring that there is an alternate plan in place regarding coverage e.g., private insurance. The CHRIS on-hold period does not apply to patients who are admitted to the General Rehabilitation Program. The acute care hospital site or referral source is responsible for completing and faxing a Change in Status Form WW551B if the patient: becomes medically unstable and needs to be placed on-hold becomes medically stable and needs to be placed off-hold requires a different program e.g., medically complex has been discharged. The Intake CC, Placement Coordinator and Hospital CC share responsibility for discharging CHRIS referrals based on the status of the individual s patient s application. Refer to Expanded Role - General Rehabilitation, Program Transfer - Idle Bed, Program Transfer - Wait List. Hospital Application Process General Rehabilitation Intake Team Assistant (TA) Monitor electronic folder for inbound application packages. Open application package (refer to Complex Continuing Care and Rehabilitation Inpatient Admission Referral WW550). Search CHRIS for active or non-active CCAC record. Add/update CHRIS Patient record including: health profile tab (diagnoses) details/demographics Patient information, addresses, phone, date of birth health card number (HCN) contacts (personal, medical) referral type (rehabilitation) method of consent (written) intake screen:
Senior Director, and Chief Nursing Executive Intake Team Assistant (TA) Page 4 of 7 Referral Date to CCAC (i.e., date fax received) Referral Contact Name, Referral Phone Number Referral Fax Number (i.e., enter under Presenting Problem field) Intake Team (E_CCC_Rehab) and Intake CC (if known) Assessing Team (E_CCC_Rehab) and Assessing CC (if known) referral coding tab (i.e., Rehab_IP_General - Rehab Inpatient General). Note that typically only 1 application may be active per Patient at the same time with the exception of program transfers. Consult with Intake CC if 2 applications received for same Patient. Upload electronic application package to CHRIS documents tab. Add CHRIS note using Admin Support template (refer to PSM 12.4.1). Add CHRIS manual task to E_CCC_Rehab team: select CCC_Rehab Application template and medium priority enter type of application under Instructions change Status to Requires CC Action. Intake CC Monitor idle bed report and prioritize CCC_rehab applications. Search CHRIS manual tasks using custom search by E_CCC_Rehab team. Open CHRIS manual task for CCC_Rehab Application and edit status to in progress. Review CHRIS Patient note. Review electronic application package under CHRIS documents tab. Determine whether or not further information is required. If so: follow-up with referral source via phone edit manual task status to incomplete move to next application. Validate whether or not application meets program criteria. Add CHRIS eligibility screen (refer to Job Aid). Update Health Profile tab under Client Characteristics link. Update Referral Details tab under Referral Management link including: ALC designation (hospital) ALC date (ALC Discharge Destination Determination Date). Add CHRIS note using CCC_Rehab Eligibility Determination template. If Patient is ineligible or there is a wait list, print CHRIS note and forward to Intake TA to fax to referral source. Add CHRIS choices including infection status under Application Notes e.g., clear. Update status event log to Facility Accepts for CMH, GRH FHC and SJHC. Edit CHRIS manual task status to complete. Check idle bed report and notify Placement Coordinator if appropriate idle bed. Move to next application.
Senior Director, and Chief Nursing Executive Hospital Application Process Stroke Care Path Page 5 of 7 Intake TA Monitor electronic folder for inbound application packages. Open application package (refer to Complex Continuing Care and Rehabilitation Inpatient Admission Referral WW550). Search CHRIS for active or non-active CCAC record. Add/update CHRIS Patient record including: health profile tab [diagnoses, placement characteristics (infection status)] details/demographics Patient information, addresses, phone date of birth health card number (HCN) contacts (personal, medical) referral type (rehabilitation) method of consent (written) intake screen: Referral Date to CCAC (i.e., date fax received) Referral Contact Name, Referral Phone Number Referral Fax Number (i.e., enter under Presenting Problem field) Intake Team (E_CCC_Rehab) and Intake CC (if known) Assessing Team (E_CCC_Rehab) and Assessing CC (if known) referral coding tab (select 1 code from pick list): Rehab_IP_CVA_Hemorrhagic - Rehab Inpatient CVA Hemorrhagic Care Path Rehab_IP_CVA_Ischemic - Rehab Inpatient CVA Ischemic Care Path. Note that typically only 1 application may be active per Patient at the same time with the exception of program transfers. Consult with Intake CC if 2 applications received for same Patient. Upload electronic application package to CHRIS documents tab. Add CHRIS eligibility screen (refer to Job Aid) using Preplanned Carepath, Care Coordinator for Assessing CC. Update Referral Details tab under Referral Management link including: ALC designation (hospital) ALC date (ALC Discharge Destination Determination Date). Add CHRIS choices including the following under Application Notes: Care Path Rehab Ready Date (CPRD) Infection status e.g., CPRD May 6-13; clear. Update status event log to Facility Accepts for CMH, GRH FHC and SJHC. Check idle bed report and notify Placement Coordinator if appropriate idle bed. Add CHRIS note using Admin Support template (refer to PSM 12.4.1). Community Application Process General Rehabilitation Community CC E_CCC_ Rehab Team Complete Complex Continuing Care and Rehabilitation Inpatient Admission Referral WW550 as per above. Ensure that Letter of Understanding WW553E is completed. Coordinate completion of Confirmation of Medical Stability and Program Readiness WW551A upon request from Placement Coordinator at time of bed vacancy. Complete relevant steps as per hospital application process above. Collaborate with referral source re: application and bed vacancy process.
Senior Director, and Chief Nursing Executive Bed Vacancy Process Page 6 of 7 Placement Coordinator Monitor HPG for bed vacancy every 15-30 minutes (refer to Job Aid). Upload electronic bed vacancy to network folder (refer to Job Aid). Print copy for contingency purposes. Open CHRIS bed board management (BBM) tab. Add CHRIS Complex Care/Rehab bed (refer also to PSM 10.1.1). Review CHRIS BBM wait list. If there are no Patients listed based on bed vacancy type: Search CHRIS manual tasks for applications using custom search by team. Phone Intake Care Coordinator to expedite pending application if applicable. Complete idle bed process. Match Patient to CHRIS Complex Care/Rehab bed. Send application package to rehab facility via HPG (refer to Job Aid). Phone referral source up to 24 hours in advance to request status update. Indicate that referral source has 3 hours to complete status update and provide actual timeframe. Request that referral source fax status update to CCAC using Confirmation of Medical Stability and Program Readiness WW551A. Add CHRIS note using CCC_Rehab_Requested_Med Stability & Pgrm Readines template including date and time of request [DD/MM/YY-HR:MMam(or pm)]. Phone Intake CC to monitor for status update. Unmatch Patient and move to next Patient if notified by Intake CC. Intake TA Monitor electronic folder for inbound Confirmation of Medical Stability and Program Readiness WW551A from referral source. Upload electronic Confirmation of Medical Stability and Program Readiness WW551A to CHRIS documents tab. Add CHRIS note using CCC_Rehab_Received_Med Stability & Pgrm Readiness template including date and time of request [DD/MM/YY-HR:MMam(or pm)]. Add CHRIS manual task to E_CCC_Rehab team: select PC_CCC_Rehab_Medical Stability template select Urgent priority leave Status as Incomplete. Placement Coordinator Search CHRIS manual tasks using custom search by E_CCC_Rehab team: Open CHRIS manual task for PC_CCC_Rehab_Medical Stability. Check electronic Confirmation of Medical Stability and Program Readiness WW551A under CHRIS documents tab for completeness. Confirm that Patient is medically stable/appropriate for bed vacancy and clear or active for infection. Edit CHRIS manual task status to complete. Phone rehab facility to confirm bed details e.g., location, room number. Ask rehab facility to contact referral source to coordinate patient transfer and arrange transfer of accountability. Phone referral source to confirm bed offer. Send Confirmation of Medical Stability and Program Readiness WW551A to rehab facility via HPG (refer to Job Aid). Update CHRIS status event log and withdraw other rehab choices. Change CHRIS caseload to generic home care caseload based on rehab site. Add CHRIS note using template.
Senior Director, and Chief Nursing Executive Change in Status Page 7 of 7 Intake TA Monitor electronic folder for updates from referral source. Upload electronic Change in Status Form WW551B to CHRIS documents tab. Add CHRIS note using Admin Support template (refer to PSM 12.4.1). Add CHRIS manual task to E_CCC_Rehab team: select CC_Note template select Urgent priority change Status to Requires CC Action. Intake CC Placement Coordinator Search CHRIS manual tasks using custom search by E_CCC_Rehab team. Open CHRIS manual task for CC_Note. Review CHRIS Patient note. Review Change in Status Update WW551B under CHRIS documents tab. If Patient is not medically stable/appropriate for bed vacancy, add CHRIS note: select Health Care Team template specify Client On-Hold for 7 Days under Data section of structured note. Notify Placement Coordinator via phone. Enter the following under Choice Comment field for each rehab facility: enter onhold [start date] use lower case, no spaces before and 1 middle space note that this data populates to CCC/Rehab Application Status report. If application is no longer required following change in status update: Discharge CHRIS rehabilitation referral (refer to Job Aid). Discharge CHRIS record if there are no other active referrals. **** Monitor CHRIS BBM wait list for client on-hold for 7 days or more. If so: Discharge CHRIS rehabilitation referral (refer to Job Aid). Discharge CHRIS record if there are no other active referrals. Add CHRIS note using CCC_Rehab template. Print/fax CHRIS note to referral source following 7-day on-hold period. *Note Post-Admission Discharge Process Staff at the rehab site adds the facility discharge date via HPG Referral Management which triggers a CHRIS system-generated manual task based on hospital caseload. Follow-up with rehab site staff may be required if this step is not completed in a timely manner. Hospital CC Hospital TA Search CHRIS manual tasks using custom search by hospital caseload on a routine basis. Open CHRIS system-generated manual task for facility discharge date and mark status as complete. Follow-up on status of patient as part of discharge planning process. Add CHRIS manual task to hospital team for CCC_Rehab Referral Discharge. Complete the following steps in CHRIS: Search manual tasks using custom search by hospital team on a routine basis. Open manual task for CCC_Rehab Referral Discharge. Discharge rehabilitation referral (refer to Job Aid). Discharge Patient record if there are no other active referrals. Mark status as complete.