H.(i) Full implementation and on-going monitoring of rehabilitative care best practices and standards of care including:
Provision of 7-day-a-week acute and in-patient rehabilitative care services to patents with total joint arthroplasty, fractured hip and stroke and to limit deconditioning in the frail elderly
Mobilization within 24 hours of admission for patients with a stroke
ALPHA FIM assessment on the 3rd-5th day after their event for patients with a stroke Referral to in-patient rehabilitation on post-op day #3 for patients with a total joint
arthroplasty or a fractured hip if pathway goals are not being met
'HYHORSPHQWRIFOLQLFDOSDWKZD\VWRVXSSRUWWKH³SXOO´RISDWLHQWVZLWKIUDFWXUHGKLSVWR in-patient rehab on post-op day #5 and patients with a stroke to rehab on Day 5
(Ischemic Strokes) or Day 7 (Haemorrhagic Stroke)
Support improved access to in-patient rehabilitative care for patients with fractured hips and moderate to severe stroke by supporting a shift of patients with total joint
arthroplasties and mild-moderate stroke from in patient/CCAC to outpatient rehabilitative care settings
5HKDELOLWDWLYHFDUHV\VWHP¶SURYLGHUVDVVXPHDQDFWLYHUROHLQWKHLPSOHPHQWDWLRQRI Senior Friendly Hospital initiatives to support early and active prevention of
deconditioning across the entire continuum of care
Comprehensive Geriatric Assessment (CGA) should be provided to frail older persons with rehabilitation needs
Geriatric rehabilitation should be managed by a physician and interdisciplinary team trained in care of the elderly
Frail older rehabilitation candidates with mild to moderate dementia should be eligible for rehabilitative care.
K.(ii) WWCCAC work with its service providers to identify opportunities to develop efficient and patient centred models of community rehabilitative care in alignment with clinical care pathways and through integration with other enabling initiatives.
L.(viii) Development of partnerships with academic centres to leverage the full potential of knowledge translation and to explore research opportunities.
[51]
Trust and Capacity
A.(i) 'HVLJQDWLRQRID5HKDELOLWDWLYH&DUH6\VWHP³6SRQVRU2UJDQL]DWLRQ´ZLWK
DFFRXQWDELOLWLHVWRWKH/+,1WRSURYLGHVXSSRUWWRWKH³5HKDELOLWDWLYH&DUH&RXQFLO´LQLWV FRRUGLQDWLQJUROHDQGWRRYHUVHHWKHDFFRXQWDELOLWLHVRIWKH³6\VWHP&RRUGLQDWRU´
A.(ii) 'HYHORSPHQWRID³5HKDELOLWDWLYH&DUH&RXQFLO´WRSURYLGHRYHUVLJKWDQGOHDGHUVKLSWR the Rehabilitative Care System. The Council will act as a central coordinating body to ensure that the activities within the Rehabilitative Care System are coordinated and are FRQWULEXWLQJWRWKHV\VWHP¶VJRDOV7KLV&RXQFLOZLOODFWLQDQDGYLVRU\UROHDQGZLOO Be co-FKDLUHGE\D³5HKDELOLWDWLYH&DUH6\VWHP´&(2DQG3K\VLFLDQ
Include representation with decision-making authority from each Stream Lead Organization
Coordinate the implementation of the recommendations of the Rehabilitation Review and support the on-going goals and objectives of the Rehabilitative Care system. A.(iii) Development and implementation of an accountability framework (including indicators
measuring system performance, patient outcomes and patient satisfaction at each point of the continuum of care and from each stream of care).
A.(iv) Further exploration of the role of the amalgamated Waterloo Wellington Rehabilitation Leadership Network and the Complex Continuing Care Network to optimize the
opportunity for these clinical/operational experts to provide advice to the Rehabilitative Care Council.
B.(i) 'HYHORSPHQWRID³6\VWHPRI5HKDELOLWDWLYH&DUH´WKDWLVRUJDQL]HG around the following four condition-VSHFLILF³6WUHDPVRI&DUH´
Stroke/Neurology Musculoskeletal Cardio-pulmonary
Frail Elderly/Medically Complex
B.(ii) ,GHQWLILFDWLRQRID³/HDG2UJDQL]DWLRQ´IRUHDFKVWUHDPZKRZLOOEHDFFRXQWDEOHWRWKH LHIN and whose mandate it is to lead the implementation of standardized, evidence- based best practices, through the development of clinical care pathways and
standardized outcome measurement within their respective stream and across the FRQWLQXXPRIWKH::/+,1µ5HKDELOLWDWLYH&DUH6\VWHP¶
collaboratively from a system perspective.
B.(iv) :LWKLQWKHJHRJUDSK\RIWKH::/+,1LGHQWLILFDWLRQRID³5HKDELOLWDWLYH&DUH6\VWHP´ Physician to co-chair the Rehabilitative Care Council, to provide leadership to the system, to establish a standardized medical model across the continuum of in-patient rehabilitative care, and to support the development of a regional model for Physiatry services (including specialist recruitment and retention).
B.(v) Stream Steering Committees should include patient representation to inform the Rehabilitative Care System about the experiences and needs of the patients/clients who use the system
B.(vi) The Committee acknowledges and supports the planned and approved enhancements to the rehabilitative care system capacity. The Committee also supports additional opportunities for future growth in system capacity (Especially community-based services) as identified by the Rehabilitative Care Council during the next phase of the Rehabilitation Services Review.
B.(vii) In consultation with stakeholders, identification of a LHIN-ZLGHGHILQLWLRQRI³PHGLFDO VWDELOLW\´DVLWUHODWHVWRDGPLVVLRQWRLQ-patient rehabilitative care
B.(viii) Staff providing rehabilitative care services across the care continuum will be expected to develop knowledge and skills related to the principles of rehabilitative care (e.g. principles of chronic disease management, fostering self ±managePHQW³$VVHVVDQG 5HVWRUH´SKLORVRSK\DQG³DFWLYDWLRQWRWROHUDQFH´(GXFDWLRQDORSSRUWXQLWLHVZLOOEH available.
C.(i) A 2-year full-time Project Lead/Rehabilitative Care System Coordinator position be developed. The Coordinator will be accountable to the Sponsor Organization and will: Lead implementation of the recommendations from the Rehabilitation Services Review
as directed by the Rehabilitative Care Council via the Sponsor Organization
Support the Rehabilitative Care Council in its work to oversee/coordinate the activities within the Rehabilitative Care System
$VVLVWDQGPRQLWRU6WUHDP/HDG2UJDQL]DWLRQ¶VGHYHORSPHQWDQGLPSOHPHQWDWLRQRI
best practice clinical care pathways
Develop a process to raise trends of system performance concerns
Facilitate coordinated implementation of provincial directions (i.e. RM&R, CCAC
[53] System
Support the Rehabilitative Council physician co-chair in physician recruitment and rehabilitative care system medical model development
Develop and implement an evaluation framework to measure the effect of system changes.
Identify barriers in the implementation of the project and facilitate the development of solutions
Facilitate the relationship building required to integrate services across the continuum Develop and implement change management and communication strategies to support
the implementation of the Phase I recommendations.
D.(i) :LWKLQ&&$&VHPHUJLQJ³&OLHQW&DUH0RGHO´DVSHFLDOL]HG&DVH0DQDJHPHQWUROH be developed to provide support and navigation to high needs patients within the rehabilitative care system and to act as a resource to other case managers. The specialized Case Manager(s) will:
Possess extensive and specific knowledge of the WWLHIN Rehabilitative Care system
Establish a formal process to link patients with community rehabilitative care needs with available publically and privately funded rehabilitative care programs/services, community resources and transportation to be provided to patients, families, providers and physicians.
Partner with primary care and community service agencies to provide education and support in accessing and navigating the WWLHIN Rehabilitative Care system
E.(i) The Committee supports the implementation of a WWLHIN-wide stroke recovery
V\VWHPRIFDUHLH³6WUHDPRI&DUH´DOLJQHGZLWKWKHUHFRPPHQGDWLRQVRIWKH6WURNH Review.
F.(i) ,QDOLJQPHQWZLWKWKH3URYLQFLDO([SHUW3DQHO¶VSXEOLVKed and pending
recommendations, develop processes to measure/collect and report key measures of SDWLHQWRXWFRPHZLWKVWDQGDUGL]HGFROOHFWLRQWRROVWRLPSURYHWKH::/+,1¶VDELOLW\WR GHVFULEHWKHSDWLHQW¶VMRXUQH\DFURVVWKHUHKDELOLWDWLYHFDUHFRQWLQXXPDQd from each ³6WUHDPRI&DUH´5HVXOWVDQGDQ\DVVRFLDWHGDFWLRQSODQV will be reported to the Rehabilitative Care Council and be supported through accountability agreements with the WWLHIN.
including:
Enhanced interdisciplinary team discharge planning practices
Facilitation of 7-day-per-week admissions to in-patient rehabilitative care programs I.(ii) Re-alignment of system resources to facilitate the management of more complex
patients with higher functional needs and cognitive deficits in in-patient rehabilitative care (e.g. patients with a stroke, patients with a fractured hip).
I.(iii) Review the rehabilitative care needs of oncology patients and ensure the needs of this patient group are integrated into the system.
J.(i) Identification of out-patient rehabilitative care as a priority area for funding re- allocation/re-investment if future opportunities are identified.
J.(ii) Development of processes to re-establish trust and capacity in the out-patient sector of the rehabilitative care system through:
Development and implementation of standardized intake criteria
'HYHORSPHQWRIVWDQGDUGL]HGSURFHVVWR³SXOO´SDWLHQWVWRRXW-patient rehabilitative care.
J.(iii) Development of decentralized out-patient service models to enhance access to rural and under-VHUYLFHGDUHDVLH³KXEDQGVSRNH´RU³VDWHOOLWH´PRGHORIVHUYLFH
provision).
L.(i) Work with regional partners to establish clear referral and admission expectations for in-patient specialized care for WWLHIN patients with SCI and ABI to provide clarity regarding referral and access processes for out-of-LHIN specialized rehabilitation programs.
L.(ii) Work with the ABI Network/ABI System Coordinator to access/leverage local community agencies to provide interim management strategies and support for patients (and their health care providers) with Acquired Brain Injuries as these patients await admission to a specialized, out-of-LHIN rehabilitation program. L.(iii) Patients awaiting admission to a specialized in-patient rehabilitation program be
eligible for a local, general rehabilitation program to receive rehabilitative care as they await admission to the specialized program.
[55]
access to services and for operational efficiencies including consideration of: a regional program with shared regional services
options to enhance the roles of other disciplines (e.g. Occupational Therapists), within respective scopes of practice, to support the SLP program.
L.(v) A benchmarking evaluation of the current Modified Barium Swallow resources in WWLHIN and formal regionalization of the current Barium Swallow resources to ensure equitable access.
L.(vi) Development and implementation of a regional Aphasia program.
L.(vii) Develop the OTN clinical program to provide services for the regionalization of out- patient service provision, delivery of CCAC rehabilitative care, and access to
rehabilitative care specialists both internal and external to WWLHIN. Educational and administrative OTN services should be leveraged for system efficiency and access. Integrated Transitions
G.(i) As part of CCA&¶V([SDQGHG5ROHGHYHORSPHQWDQGLPSOHPHQWDWLRQRIDFHQWUDOL]HG in-patient rehabilitation intake process. This process should be developed to reflect WKH³)XWXUH6WDWH:RUNIORZVIRU$FXWHWR5HKDE&&&´GHYHORSHGE\VWDNHKROGHUVDV SDUWRIWKH³Alternate Level of Care Resource Matching and Referral Business
7UDQVIRUPDWLRQ,QLWLDWLYH´
G.(ii) As identified by stakeholders, the centralized intake process will be supported by a ³&OLQLFDO,QWDNH&RRUGLQDWRU´ZKRZLOO
Possess the clinical knowledge required to match the needs of patients with available resources within the rehabilitative care system
6XSSRUWWKHUHKDELOLWDWLYHFDUHV\VWHP¶VFHQWUDOL]HGLQWDNHSURFHVVHVDQGEH accountable for flow through the system and the clinical interests and outcomes of the patients it serves.
G.(iii) Under the auspices of the RM&R and Expert Panel directions, develop a
³5HKDELOLWDWLYH&DUH6\VWHP0LQLPXP'DWD6HW´WRUHSODFHWKHFXUUHQWDSSOLFDWLRQ form.
G.(iv) Consider options for a low cost interim solution for an electronic referral process ahead of the implementation of the Resource Matching and Referral process. G.(v) Explore opportunities to develop and implement a process for electronic access to
rehabilitative care patient demographic and medical information (e.g. Clinical Connect).
D.(i) :LWKLQ&&$&VHPHUJLQJ³&OLHQW&DUH0RGHO´DVSHFLDOL]HG&DVH0DQDJHPHQWUROH be developed to provide support and navigation to high needs patients within the rehabilitative care system and to act as a resource to other case managers. The specialized Case Manager(s) will:
Possess extensive and specific knowledge of the WWLHIN Rehabilitative Care system
Establish a formal process to link patients with community rehabilitative care needs with available publically and privately funded rehabilitative care programs/services, community resources and transportation to be provided to patients, families,
providers and physicians.
Partner with primary care and community service agencies to provide education and support in accessing and navigating the WWLHIN Rehabilitative Care system
K.(i) WWCCAC lead the development of an inventory of rehabilitative community services, completion of a gap analysis and development of recommendations that will inform the Stream Lead Organizations (through the Rehabilitative Care Council) as they develop clinical care pathways to support integrated and seamless transitions across the continuum of care.