OPTIMIZING THE ROLE OF COMPLEX CONTINUING CARE AND REHABILITATION

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PTIMIZING THE

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A Discussion Paper Developed by the Complex Continuing Care and Rehabilitation Provincial Leadership Council of the Ontario Hospital Association

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XECUTIVE

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UMMARY

The Ontario government’s health care transformation agenda aims to improve the delivery of health care services through better integrated services and a more systemic approach to service delivery. The province’s complex continuing care (CCC) and rehabilitation sectors, which have undergone dramatic change over the past decade, provide an excellent, but all too often overlooked, resource to achieve the

transformation agenda.

Along with the acute care sector, the long-term care sector and community programs, the CCC and rehabilitation sectors have a valuable role to play in enabling a

transformed health care system. However, the roles that CCC and rehabilitation can play in an optimized system can only be achieved if their current role and capacity become better understood and integrated in health policy and in decision-making at all levels of the health system.

This paper summarizes some of the dramatic changes which have taken place in both rehabilitation and complex continuing care over the past decade, explores their

differentiation as distinct sectors, illustrates their capacity to relieve system pressures (e.g., in relieving the alternative level of care challenges in acute care hospitals), and recommends better integration of these sectors in health policy planning.

The paper argues that a more optimal integration of the CCC and rehabilitation sectors in how we think about the delivery of health care services could dramatically enhance system effectiveness.

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I

NTRODUCTION

Over the past decade, Ontario’s complex continuing care (CCC) and rehabilitation sectors have undergone significant change. These changes have occurred in response to hospital restructuring efforts as well as to new demands that have arisen from

changing population needs, changing disease patterns, and increases in the burden of chronic disease (see Figure 1).

Ensuring more appropriate use of CCC and rehabilitation services alongthe care

continuum will meet the increasingly complex

needs of patients, help to relieve pressures on acute care resources, strengthen capacity of other services where increased demand is anticipated,1_{and provide specialized services} and expertise to support other providers along the care continuum in caring for medically complex2_{patients and individuals with} co-morbidities.

Promoting a better understanding of CCC and rehabilitation as essential parts of the care continuum will require a stronger focus on meeting the needs of specific patient

population groups in a manner that links CCC and rehabilitation more closely with other providers along the care continuum.

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For example, dialysis and care for ventilated patients (including children). 2

Includes cases with multiple medical and functional problems and complications prolonging the recuperation period. Medically complex cases require medical management of principal condition and monitoring of co-morbidities and potential complications.

Figure 1: Changing Disease Patterns/Burden of Chronic Disease

• Growing number of individuals living with chronic disease and disabilities.

• Growing health problems arising from increase in certain conditions (e.g., genetic disorders, obesity, respiratory problems, cardiovascular disease, end state renal disease, diabetes, and Alzheimer’s disease).

• Survival of children born with disabilities (e.g., muscular dystrophy, cerebral palsey, spina bifida) or acquired injuries in

childhood surviving into adulthood.

• Shift from acute to chronic illness (e.g., asthma, diabetes, arthritis) more of which can be managed at home with intermittent medical and therapeutic interventions to stabilize conditions if suitable housing and support is available.

• Increase in demand of some rehabilitation services arising from the overall burden of chronic disease and disability.

• Changing patterns of practice (e.g., rehabilitation for total joint replacement, increased use of life maintaining

techniques – ventilation, G-tube feeding in children and young adults).

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Current Reality

• According to WHO, chronic disease is the most pressing health care issue of the 21st century.

• Approximately 250,000 individuals in Ontario live with three or more advanced chronic conditions or disabilities

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The Ontario government’s transformation agenda is focused on improving the delivery of health care by making better use of the strengths and advantages of Ontario’s vast health care community and creating more integrated health systems at the local level to improve access to appropriate services and make it easier for patients to navigate the system. One of the objectives of the current transformation agenda is to promote a stronger focus on systems’ thinking and systems’ integration.3

As the provincial health care transformation agenda is advanced, the CCC and rehabilitation sectors provide a valuable resource to enable the transformation of care delivery across the care

continuum.

The refocusing of the Ministry of Health and Long-Term Care’s mandate on stewardship of the system,4

and the introduction of Local Health Integration Networks (LHINs) in Ontario provides a real opportunity to clarify the role and value of CCC and

rehabilitation, and recognize their role in enabling the transformation of care delivery across the care continuum.

THE IMPORTANCE OF CCC AND REHABILITATION TO THE TRANSFORMATION AGENDA

Current system pressures (including over-crowded emergency rooms and alternate level care (ALC) patients residing for long periods of time in acute care beds) are the result of capacity pressures within the health care system as well as the failure of the current system to fully understand and utilize the role

and expertise of CCC and rehabilitation as resources in supporting other parts of the care continuum.5_This situation has arisen in response to a combination of factors including:

• The lack of understanding of the specialized programs/services and expertise that exists within the CCC and rehabilitation sectors and the capabilities that distinguish their outcomes from other providers along the care continuum.

• The lack of capacity within CCC and rehabilitation in some regions.

• The need for greater appreciation of the specialized services offered by

CCC/rehabilitation facilities and their role in supporting the acute care, long-term care (LTC), home care and community-based sectors along the care continuum.

3

Health Results Team, First Annual Report, 2004-05, p.3.

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To support the transformation, the Deputy Minister of Health and Long-Term Care announced in January 2006 that Ministry functions would be refocused on providing “stewardship” for the healthsystem. The stewardship role was defined as follows: “the Ministry guiding and directing the health system through strategy development, planning and evaluation, and setting the directions and enablingthe choices needed to improve the health system and to ensure the system is driven by the needs of Ontarians.” 5

For example, CCC is not considered to the extent that it should be in discharge planning from acute care of patients that could benefit from CCC programs that target patients with complex multiple and disabling medical conditions.

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• The continued challenge for the CCC and rehabilitation sectors in being able to articulate their capabilities to receive, in a timely manner, patients who require specialized treatment programs and/or aggressive clinical and therapeutic interventions, and to work more closely with providers along the care continuum to stabilize patients and then transition them to required services, as appropriate. Current utilization of CCC and rehabilitation resources needs to be examined more closely. In some areas where there is a lack of LTC beds, CCC and rehabilitation beds are being used inappropriately. In other areas, an excess of LTC beds/capacity

together with high ALC numbers results in situations where patients who are eligible but not appropriate for LTC are being transitioned from acute to LTC, not appreciating the full potential the patient would have achieved in CCC or rehabilitation. If the CCC and rehabilitation sectors are to perform their roles successfully, a better understanding of their role in integrating care along the continuum is needed. This will, however, require assessment of the current capacity and resources within these sectors to ensure that they are sufficient to help them to optimize their role and contribute to realizing system goals.

In order to appreciate the insufficiently tapped capacity of the post-acute sector and better utilize the skill base, expertise and resources within it, some clarification of the rehabilitation and CCC sector is warranted.

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DEFINITION

The World Health Organization defined rehabilitation as: “A progressive, dynamic, goal-oriented and often time-limited process, which enables an individual with an impairment to identify and reach his/her optimal mental, physical, cognitive and/or social functional level.”6

CHANGING TRENDS

Rehabilitation care is being driven by changes in clinical practice arising from new knowledge and understanding of the role and importance of rehabilitation in improving functional outcomes and well being, as well as reducing mortality and morbidity.

Changing modalities of care and best practice trends have initiated significant change in service delivery (e.g., seven days/week rehabilitation; shift in focus from inpatient to outpatient services for total joint population).

Although there is a public sector base in rehabilitation activities in Ontario, the share of private sector activity has grown significantly with rehabilitation services shifting away from a largely publicly-funded inpatient environment to increasing involvement of private

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payers as partners in delivering ambulatory and outpatient services.7

While some see this as a benefit, this trend is contributing to difficulties in filling in gaps in continuity of care, especially for individuals who do not have access to private insurance.8

A growing body of research is validating the important role played by rehabilitation in contributing to improved functional outcomes, in successfully reintegrating patients into the community and the workforce, and in reducing mortality and morbidity.9_The

effective use of rehabilitation services as part of disease management/clinical practice protocols is also being seen as a way to contribute to shorter hospital lengths of stay, lower readmission rates, decreased visits to physician offices and emergency rooms, and reintegration into home and school. All of these trends offer enormous potential to enhance patient outcomes and efficiency within the health care system.

Today, rehabilitation is increasingly being seen as an essential part of the care pathway and as a sector that supports better integration with other parts of the care continuum (i.e., home care, LTC, CCC, mental health, community-based care). This change has been supported by marked changes in the utilization of rehabilitation beds arising from the following trends:

− Greater complexity in patient caseloads (i.e., treatment of more highly complex populations in rehabilitation programming including transplant, cancer and post-intensive care patients).

− A strengthening of targeted programs within the sector with a growing emphasis on program specialization accompanied by a “regrouping” of rehabilitation beds into key sub-specialty areas.10

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In Ontario, responsibility for policy development related to the rehabilitation sector is vested in a number of different Ontario Government ministries, including: the Ministry of Health and Long-Term Care; the Ministry for Children and Youth; Ministry of Education, Ministry of Finance (administers automobile casualty insurance legislation); the Ministry of Labour (primarily through its agency, the Workplace Safety and Insurance Board that has a defined rehabilitation policy); and other ministries of the Ontario Government whose policies impact on those who receive rehabilitation services (e.g., policies related to income support and transportation programs). MOHLTC policies impacting on the rehabilitation services sector are also “woven” into a number of program areas (i.e., long-term care, home care, complex continuing care, stroke strategy, etc.). (Source: Taking A Closer Look: A review of trends and activities reshaping Ontario’s rehabilitation sector, West Park Healthcare Centre, 2003).

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The Balanced Budget Plans put forth by hospitals in 2004 and the Hospital Annual Planning submissions in 2005 have shown that a number of hospitals have eliminated or are proposing to eliminate outpatient physiotherapy as a balancing strategy with the assumption that other providers, mostly private, will pick up the services.

9_{For example, eighty percent of MS (Multiple Sclerosis) clients represented in the NRS Canadian Institute for Health Information} (CIHI), National Rehabilitation Reporting System) returned to the community at the end of their inpatient stay, with a majority requiring some level of in-home health service. CIHI, August 2005.

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For Example, TPN, ventilator dependent units, specialty units for those with aggressive behaviours/behaviour management, oncology patients, palliative care.

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PATIENT PROFILE AND PROGRAM CHARACTERISTICS

Rehabilitation plays an essential role (with varying degrees of intensity) in each phase of the health care continuum ranging from primary, secondary and tertiary acute services through community, ambulatory, in-home, inpatient rehabilitation, and day hospital settings, to CCC and LTC.

Rehabilitation programs range in complexity and intensity depending on the needs of clients and the goals of the program. There are highly specialized adult and paediatric rehabilitation services that serve large regions or the entire province. The most prevalent rehabilitation client groups seeking services include those with orthopaedic conditions such as hip fractures, hip replacement or knee replacements and those requiring rehabilitation services after a stroke. The second most prevalent rehabilitation client groups include: medically complex, brain dysfunction, debility and amputation of limb.11 Smaller volumes of patients, including children, are those with multiple, complex fractures and trauma, Acquired Brain Injury (ABI) (e.g., stroke), neuro-muscular disorders, spinal cord injury and burns. A small but growing population includes adults who were born with disabilities, or who acquired them in childhood, adulthood, required ongoing extensive outpatient rehabilitation intervention. (Health conditions that describe the primary reasons for admission to a rehabilitation program are summarized in Figure 2).

Rehabilitation requires a team approach including physicians and physiatrists, and typically at least one of the self-regulated rehabilitation professionals who are regarded as unique to rehabilitation science: occupational therapists, physiotherapists, and speech-language pathologists. A multi-disciplinary rehabilitation team will often also include one or more of the following: physicians, nurses, audiologists, dietitians, orthotic and prosthetic professionals, rehabilitation assistants, social workers, pharmacists, psychologists, home care workers.

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Source: Quick Stats, Table 13: Distribution of Rehabilitation Client Groups by Type of Facility, 2003-2004, Canadian Institute for Health Information (CIHI), National Rehabilitation Reporting System.

Figure 2: Rehab Client Groups (RCGs)

CIHI, National Rehabilitation Reporting System (NRS) • Orthopaedic conditions − Hip Fracture − Hip Replacement − Knee Replacement • Stroke • Brain Dysfunction • Amputation of Limb

• Spinal Cord Dysfunction

• Medically Complex • Debility • Cardiac Disorders • Neurological Conditions • Pulmonary Disorders • Arthritis

• Major Multiple Trauma

• Pain Syndromes

• Burn

• Other RCGs (including congenital deformities, Developmental Disabilities, other disabling Impairments)

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Rehabilitation services and programs are arrayed across the continuum in three major groupings as described below:

Rehabilitation Along the Care Continuum Location

High Volume/High Intensity12

Targeted to clients who require high intensity of rehabilitation and/or highly specialized expertise

• Available in multiple sites across the province and in designated

rehabilitation hospitals and/or programs/units in acute care

hospitals, ambulatory or community settings.

Low Volume/High Intensity

Targeted to clients who require high intensity of rehabilitation and/or highly specialized expertise

• Concentration of these services on fewer, targeted sites

• Designated rehabilitation hospital and/or programs/units in acute hospitals ambulatory or community settings.

Along the Care Continuum

Spans the continuum and delivered outside of designated rehabilitation programs or units

• Delivered by rehabilitation providers and health professionals and targeted to clients who require services to facilitate their progression along the continuum (e.g., acute care to home or high intensity rehabilitation

programs; transition care in CCC prior to intense rehabilitation or discharge home).13

Source: Adapted from Partners in Transformation: GTA Rehab Network Strategic Plan 2005-08

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High intensity services refer to those that are targeted to clients who require highly specialized rehabilitation expertise/technologies.

13_{Examples: low intensity/long duration rehabilitation in CCC units; acute short duration rehabilitation in acute care; physiotherapy} services in the ICU; osteoporosis clinic; OT consultations for seating and ADL in acute programs; SLP assessments and consultations for swallowing in a variety of settings (acute, post acute, CCC, LTC, in-home); multidisciplinary secondary prevention clinics for stroke care.

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DEFINITION

Complex continuing care is a specialized program of care providing programs for medically complex patients whose condition requires a hospital stay, regular onsite physician care and assessment, and active care management by specialized staff.

CHANGING TRENDS

The CCC sector has been redefined in response to changes resulting from health care restructuring, expansion of the LTC sector, and the changing needs and characteristics of patients being admitted to CCC.

Complex Continuing Care is significantly different from the chronic care provided in the past (Figure 3). Today’s CCC provides specialized

care critical to achieving high levels of medical

recovery by ensuring patients obtain the services and supports required and are then “transitioned” home and/or to other appropriate levels of care along the care continuum, wherever possible.

Although there is some variation in the kinds of specialized services offered by different CCC

providers across the province, for the most part there has been a decided shift away from lighter care patients requiring a residential model of care to more medically complex patients many of whom require active rehabilitation.14_{This trend has resulted in} significantly shorter lengths of stay and a need for “intermediate stay” programs. In other words, CCC has evolved into being viewed as a “resource” rather than a final destination. Increasingly, CCC beds are being used to enhance the system’s capacity to transition people to lower levels of care or back to the community.

14_{Examination of the assessment RUG class distribution and case mix index over time suggests that the CCC population is} becoming more resource intensive. The mean assessment case mix index has increased from 0.9951 to 1.1167 between FYs 1996-97 and 2002-03. [OCCPS 1996-97 to 2002-03. Complex Continuing Care in Ontario: Resident Demographics and System Characteristics]. Examination of the assessment RUG class distribution and case mix index over time may also, however, reflect better coding and ongoing efforts to improve coding as it ties into the funding formula over time.

Figure 3: Changes in the CCC Sector

Over the Past Fifteen Years

• A 67% decrease in length of stay;

• A 44% decrease in beds;

• A 59% increase in separations;

• An increase in the proportions of new residents classified under RUGS in the special

rehabilitation group (38.9% to 45.4 %) followed by the extensive care group (9.9% to 13.8%).

• A move in CCC towards more active rehabilitation of more complex patients.

• Greater specialization and less-program mix within CCC facilities.

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Figure 4: Most Common Disease/Conditions Managed in CCC Facilities • Heart/Circulation • Hypertension • Neurological • Cerebrovascular Accident • Dementias (Alzheimers and Non- Alzheimers)

• Musculoskeletal • Arthritis • Endocrine/Metabolic/ Nutritional • Diabetes Mellitus • Cancer • Psychiatric/Mood • Depression • Pulmonary • Emphysema

As of the fiscal year 2002-03, at least 50% of admissions had a length of stay (LOS) of 29 days or less and only 21% of admissions had a LOS of 90 days or greater.15_The changing patient profile and program characteristics arising from this change has

contributed to a greater range of variability in the profile of patients served between and within CCC facilities (e.g., freestanding facilities versus designated beds/units in acute care hospitals).16

PATIENT PROFILE AND PROGRAM CHARACTERISTICS

The CCC sector has worked to transform itself dating back to 1990 with the release and recommendations from the Chronic Care Role Study, the Chronic Care Implementation

Task Force, the Health Services Restructuring Commission’s Directions to hospitals and

its Change and Transition report along with a host of reports released by District Health

Councils across the province and individual hospitals. In recent years, the CCC sector has responded in new and different ways to the needs of the health care system by caring for a more complex patient caseload and filling the gaps for patients whose needs cannot appropriately be met in LTC.

The sector has transitioned to placing a growing emphasis on strengthening programs related to managing and/or maintaining individuals with

multiple co-morbidities and functional impairments (through intensive rehabilitation or reactivation) and on palliative care and respite care programs (for patients requiring CCC). While greater specialization and less program mix within facilities is a growing trend,17_{it is important to acknowledge} that there is a continuum of care that exists within the CCC sector that provides care for individuals with a broad range of medical and care requirement needs. This continuum serves the needs of “intermediate stay” patients as well as long-term patients who require a higher level of specialized care and are too complex to be cared for in a LTC facility. Some of the most prevalent conditions being managed by CCC facilities in the province are summarized in Figure 418_.

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OCCPS 1996-97 to 2002-03. Complex Continuing Care in Ontario: Resident Demographics and System Characteristics. 16_{Growing distinction in the profile of patients being cared for in freestanding CCC facilities versus those served in CCC units that}

are part of acute hospital services. 17

OHA, December 2001. Managing Change: Implications of Current Health Reforms on the Hospital Sector. 18

CIHI, Most common disease categories/diagnoses reported on MDS Admission Assessments, Hospital-Based Continuing Care, CCRS 2004-2005, Facility –Based Continuing Care in Canada, 2004-2005.

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Today, patients enter CCC programs19

from different parts of the care continuum including the acute sector, emergency rooms, LTC facilities, and the community. The profile of patients being cared for in CCC programs has shifted primarily from those who would stabilize and remain patients for a long period of time to:

• Individuals with increased complexity of care requirements who receive more active rehabilitation as part of their care20_.

• Individuals who require periodic changes in their care plans and redefinition of their therapeutic goals.

• Individuals whose needs can best be served in CCC, as they require more intense care than delivered within long-term care.

• Individuals who have shorter lengths of stay compared to traditional lengths of stay in former chronic facilities.21

• Individuals who require greater medical presence (such as physicians and/or advanced practice nurses) than LTC facilities to deal with the increased acute medical problems associated with their patients.22

• Individuals who are non-weight bearing requiring some rehabilitation in CCC before being transitioned and integrated to a full rehabilitation program.

The CCC sector is often mistakenly confused with the LTC sector. While the LTC sector emphasizes residential care within a social model, today's CCC sector typically reflects goal-oriented inpatient services (that may or may not be time-limited) and emphasizes the regaining of functional levels and often a goal of discharging the individual to the community or to LTC (in 2004, over half of all patients discharged from CCC went either home or to LTC).23

Patients requiring complex continuing care services are “clinically complex”; that is, they require more specialized programs and staff, greater frequency in physician care, and more aggressive therapeutic and clinical interventions than is currently available within

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Patients admitted to CCC programs tend to fall into one of three groups:

• Those with shorter LOS who are frail and who have medical needs that are complex. These patients are coming to CCC directly from the acute care system, are sicker, and are often being discharged back and forth to acute facilities before dying.

• Those with longer LOS because of their state of advanced chronic disease (accompanied by other clinical complications) who could be served in the community but have “fallen between the cracks” and are unable to find “alternate” places of care. This group includes individuals with severe behavioral problems who suffer from other chronic conditions/illnesses.

• Those with longer lengths of stays but requiring medical supervision, nursing and services than available in long-term care facilities. (Source: West Park Healthcare Centre, The Changing Face of Complex Continuing Care. November 2003. p.5) 20

Examination of the assessment RUG class distribution and case mix index over time suggests that the CCC population is becoming more resource intensive. The mean assessment case mix index has increased from 0.9951 to 1.1167 between FYs 1996-97 and 2002/03. (Source: OCCPS 1996-97 to 2002-03, Complex continuing care in Ontario: resident demographics and system characteristics).

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“Trends over time included an increase in the proportion of admissions categorized as 0 to 13, 30 to 59, 60 to 89 and 90 to 179 days, and a decrease in the proportion of admissions categorized as 180 days or greater. This shift in the distribution was reflected by a decrease in the mean LOS from 224.2 to 138.5 days between FYs 1996-1997 and 2002-2003.” CIHI, Complex Continuing Care in Ontario, Resident Demographics and System Characteristics, p. 61-62.

22_{Under the Schedule of Benefits, for a CCC visit, physicians can bill for the initial assessment and a maximum of four subsequent} visits per month. For a LTC visit, physicians can bill for the initial visit and subsequent two visits per month (at a lesser rate than CCC).

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MDS RUGS 2004 Data. Number of patients discharged to either home or a long-term care facility accounted for 52% of all discharges – 30% went home – 22% went to LTC.

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LTC facilities. Patients receive about twice the level of care of a LTC resident. The specialized staff and services needed to provide the level of care characteristic of the CCC sector explains the differences in funding rates between CCC and LTC facilities. For example, LTC facilities provide residents with an average of approximately 2.5 hours of direct and personal care a day, approximately 80 per cent of which is delivered by an RPN or unregulated health care worker.24_{CCC patients typically require more} than four hours of direct care a day delivered primarily by RPNs and RNs.25_{Many CCC} patients also receive care from a multi-disciplinary team including physicians,

occupational therapists, speech language pathologists, physiotherapists and dieticians. The lack of clear policy direction in the CCC sector, and the creation of policies in other sectors (an issue that many consider to be more problematic) have been key issues that have had an adverse impact on CCC. The introduction of new programs in LTC (e.g., creation of two new bed categories including interim/LTC bed program and a new

convalescent care program)26

is an example of a policy that has contributed to greater confusion among providers and patients in determining appropriate care options. Further complicating the situation has been the fact that different CCC bed categories have been introduced to respond to a variety of regional issues (e.g., large volume of ALC beds, too few LTC beds, high resource-intensive patients, etc). Some hospitals have established “transitional CCC beds” to reduce pressures on acute facilities.27

For example, one specialty CCC hospital in Toronto created an “ALC Connect Program” in partnership with an acute hospital for individuals whose condition has not completely stabilized, who no longer need acute care, but who do require continued treatment and reactivation. All of these examples illustrate both the complexity created by the current policy landscape and also the growing complexities arising from a health care system that is struggling to respond to meeting the needs of more complex patients. The CCC sector is the sector that has the resources and expertise to meet this need.

24_{LTC homes are staffed by a mix of many part-time nurses, health care aids and personal support workers.}

25_{While there was formerly a standard of 2.25 hours of daily care per resident in a LTC facility, this standard was dropped in the late} 1990s. The Ontario Long-Term Care Association (OLTCA) estimates that increased operating funding since 2001 has raised care levels from the 2.04 hours per resident per day documented in the 2001 Level of Service (LOS) study to approximately 2.5-2.6 hours. Ministry officials suggest most homes now provide between 2.27 and 2.3 hours. For further information see the following reference: Commitment to Care: A Plan for Long-Term Care in Ontario (Spring 2004), A report prepared by Monique Smith, Parliamentary Assistant, Ministry of Health and Long-Term Care.

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In February 2005, the Ontario Government announced an investment in its “Alternate Levels of Care Strategy” to optimize the use of health care resources and reduce pressure on hospitals. This strategy included the introduction of an interim/LTC bed program creating up to 500 interim long-term care beds for people waiting in hospital for a permanent LTC bed in their community, and a new convalescent care program creating up to 340 convalescent care beds in LTC for people who are recuperating but no longer need intensive hospital care but are not yet ready to return home.

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These beds are geared to post-acute patients that are too medically complex to be discharged from a hospital and not ready for the community, or are waiting for LTC. Transitional care beds are part of the CCC unit and therefore require completion of an MDS assessment. Providence Healthcare in Toronto has implemented two units.

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An integrated system is one where different services and sectors function as a unified whole. An integrated system would link CCC and rehab across the continuum of care and across Ontario. These linkages will prevent duplication of services and optimize access to specialized programs and resources available within these sectors.

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Both the CCC and rehabilitation sectors have developed a high level of expertise in managing the care of individuals with complex medical problems and in moving them along the care continuum. In spite of the significant

changes that have taken place in these sectors, no formal policies have been developed to support their redefinition of roles. As discussed above, a further issue arising from the current policy void relates to the

emergence of policies that have been created in other sectors (e.g., LTC, automobile insurance industry) that have resulted in greater fragmentation along the care continuum and a higher level of confusion with respect to the roles of providers.

The lack of clarity with respect to definitions of CCC and rehabilitation, growing fragmentation of care delivery arising from the introduction of new types of programs (e.g., transition programs), ongoing challenges with respect to “managing” ALC

caseloads, and variations in the use of CCC and rehabilitation beds across the province are symptoms of a health care system in need of greater policy direction. The lack of policy direction in the CCC and rehabilitation sectors, in particular, have contributed to the lack of recognition of the role these sectors play in enhancing access to appropriate care and improving outcomes for specific population groups.

Finding ways to better integrate CCC and rehabilitation into current health planning, policy, and funding priorities is needed. Benefits of achieving this goal will:

• Help shift the health care system from its current paradigm focused on acute, episodic care to a more integrated approach that better addresses the needs of patient populations (e.g., stroke patients, medically complex patients).

• Foster a better understanding of CCC and rehabilitation and strengthen their collaboration with other providers along the care continuum.

• Promote better management and treatment of patients in the most appropriate setting supported by appropriate incentives.

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RECOMMENDATIONS AND PRIORITIES

A renewed focus on filling the policy void in the post-acute sector must be a priority if the role of CCC and rehabilitation in improving integration and ensuring appropriate care for patients along the care continuum is to be

realized. The current restructuring agenda

unfolding within the MOHLTC and the emergence of LHINs provides a real opportunity to strengthen policy leadership to support post-acute care services, and in doing so, to better position CCC and rehabilitation as critical resources along the care continuum. In some regions, this will require that CCC and rehabilitation services be realigned to realize the benefits of critical mass. In other areas, new programs may need to be established (or enhanced) to better meet the needs of specific population groups including:

• Enhancement of slow stream rehabilitation (SSR) and reactivation services for complex patients to ensure better outcomes for patients.

• Ventilator care programs to relieve pressure on ICU resources currently accommodating these individuals.

• Development of partnership programs with hospitals, CCACs and LTC to support seniors with chronic diseases in their home or LTC setting.

• Enhancement of CCC “outreach programming” to ensure more appropriate care delivery and avoid unnecessary use of acute and emergency resources28_(e.g., PACE program for seniors in Montreal).

• Expansion of “transitional care” units to provide a graduated change in support for individuals being discharged following significant stays in acute care as a result of catastrophic illness/events29

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• Programs for patients with mental health issues or behavioural issues that no longer require acute services to relieve pressure on acute programming.30

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Additionally, outreach programs are instrumental in repatriating clients from the regional inpatient rehabilitation program to their home hospital when the client is at the stage in the rehabilitation process that the community hospital can meet the needs of clients with support from the outreach program.

29_{These types of programs ensure appropriate reactivation and better outcomes (e.g., innovative and more flexible options for} younger people requiring care for complex/degenerative/catastrophic conditions over a longer period of time).

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There are a few private programs for patients with severe behavioral problems, specifically ANAGRAM in Niagara. However, these programs must be privately funded by the families or by insurance settlements.

Stewardship – planning for and making wise use of our resources – is the solution… We need to focus on where we’re going with the health system. We need, for instance, to refocus on what we need to do today to guarantee health care that works for people, five, ten, 15 years down the road.

Ron Sapsford, Deputy Minister, MOHLTC

New Directions Newsletter, January 2006

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An initial priority to be addressed by both the Ministry and LHINs is to work with the post-acute sector to develop a systemic approach to managing and planning CCC

and rehabilitation services at the local, regional and provincial level. Work in this

area can be supported by development of clear policy directions with respect to the following:

• Clarification of the terminology and standardization of programming for the general (and hospital-specific) roles, programs, referral processes and admission criteria in CCC and rehabilitation facilities/units at the local, regional and

provincial level.

• Further articulation of the understanding of differences in care among programs (e.g., CCC, rehabilitation, LTC, convalescent, interim ALC beds, etc.) and the appropriate use of these programs in meeting the care needs of specific patient population groups.

• Development of a systemic approach to discharge planning from acute

care.

• Assessment of capacity and funding issues to correlate with system needs

and intensity of care provided in CCC and rehabilitation beds/facilities.

• The development of consistent clinical practice patterns that reflect best practice protocols (by patient population) in the use of CCC and

rehabilitation services.

Another important priority will be for the MOHLTC and LHINs to work with providers in

developing a better definition of the patient profile with respect to the ALC patient population requiring access to CCC and rehabilitation, to reduce the pressure on

acute care beds and ensure appropriate placement of patients. Policy priorities to

support this goal include:

• Ensuring ALC patients requiring CCC or rehabilitation are so designated.

• Addressing the shortfall in reliable/comparable/consistent data to describe this population.

• Refining data to show patient movement from one sector to another. The post-acute sectors (e.g., CCC, rehabilitation) provide an immense resource to achieve greater system integration. In particular, the CCC and rehabilitation sectors have an integral role to play in supporting the changing needs of a growing population living with chronic disease. Recognizing and optimizing CCC and rehabilitation’s full potential will help to resolve pressure points31_{in the system, reduce lengths of stay,} readmission rates, physician visits and emergency room visits in acute care, as well as improve the participation of young and old with disabilities in society.

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For example, wait list issues for total joint replacement and wait lists for responding to increases in demand for slow stream rehabilitation.

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EMARKS

Much of the success of the Ministry in carrying out its new “stewardship” mandate and the success of LHINs in working with local communities to develop local health

integrated systems plans will depend on their success in building relationships with providers along the care continuum. For integration to succeed, recognition of the role played by all members along the continuum is needed to shift the existing system from its current focus on providing acute hospital care to one that better meets the needs of specific patient populations through more effective use of post-acute services.