How To Plan A Rehabilitation Program

Project Plan to

Rehabilitation Service

Connecting and Collaborating in the

Continuity of Care

in Rehabilitation

Presented By:

Arlene Whitehead,

May 31, 2011

Rehabilitation Collaborative Overview

OUTLINE

• WGH Rehab Planning Team

Rehab Facilities

Rehab Foundation: Our Mission/Vision/Values
Planning Update

• Patient Referral Processes

Intensive Rehabilitation Outpatient Program

• Outcomes

Rehab Team Foundation

MISSION

VISION

VALUES

Inpatient Integrated Rehabilitation

Right person, right place, right time

:

Clear, defined referral/admission criteria, includes patient assessment

Interprofessional Collaborative Processes:

Integrated Assessment/Discharge Planning,

Daily/Weekly Rounds, Patient/Family Meetings

Patient-Focused Care:

Individualized (SMART) Goal Setting and Treatment Plans, Clear Team Roles to ensure communication with patient/family, Rounds/Patient/Family Meetings

Inpatient Integrated Rehabilitation

Best Practice:

2010 Stroke Best Practice

Bone and Joint Health Network Benchmarking LOS & efficiency

External Collaboration:

To ensure the Rehab Programs reflect the County, London Rehab needs and that the processes are user-friendly.

WGH New Rehabilitation Programs

Inpatient Rehab Planning Update:

• Medical Director of Rehabilitation

• Care Team: full scope rehab professionals

• Referral, Admission, D/C: Criteria, forms, processes,

roles

• Patient/family Orientation Booklet

• Process Standards of Care:

• Discharge Planning: LOA, TLU, evaluation survey

• CIHI NRS: software selection, direct input, roles

WGH New Rehabilitation Programs

Inpatient Rehab Planning In Development:

• Integrated Initial Assessment: includes goal setting

• Weekly Rounds: benchmarking, monitoring, documentation, roles, technology

• Equipment Purchasing

• Hire Director of Patient Care • Patient/Family Meetings

Rehab Planning Future Development:

• Inpatient Discharge Processes

• Outpatient Program Development: staffing & #s directs service, group therapy

• Recreational Therapy: equipment, programming with documentation, volunteers

Inpatient Rehabilitation Program

Primary program streams offered at WGH are:

•

Orthopaedic / MSK

•

Stroke

•

Other Neurological Conditions (Exceptions:

ABI, Spinal Cord)

Rehabilitation Referral Process

Rehabilitation Candidate Includes:

• 18 years of age or over. Patients less than 18 years of age will be assessed for admission on an individual basis.

• The patient resides in Oxford County. Residents from other areas will be considered based on bed availability when an appropriate rehabilitation service is not available/accessible locally. There will be an expectation of repatriation once the inpatient rehabilitation process is completed.

• The patient has demonstrated improvement in function over time.

• There are clearly identified goals for rehabilitation that are specific, measurable, achievable, realistic and timely that require an inpatient rehabilitation stay and involvement of an interdisciplinary team to achieve.

Rehabilitation Candidate Includes:

• The patient’s needs cannot be adequately met with outpatient or community-based services.

• The patient is able to minimally follow one-step commands. • The patient/substitute decision maker has consented to the

assessment/treatment in the rehabilitation program.

• The patient is willing and motivated to participate in the rehabilitation program. (Exception: patients with reduced motivation/initiation secondary to a diagnosis, i.e.:

depression, stroke)

• The Rehabilitation Candidacy Tool is completed • Stroke – Part I and II

Exclusion Criteria

Patients that do not meet WGH eligibility requirements

for rehab include:

• Patients requiring 5-point restraint or seclusion for aggressive behavior that can place other patients at risk

• Patients with significant assault behavior that could be harmful to self or others.

• Patients demonstrating active exit-seeking who require a locked area for their safety.

• Patients with severe cognitive impairment not amenable to treatment.

Rehabilitation Referral Process

Rehab Readiness Includes:

The patient is ready for rehabilitation if:

• The patient meets the criteria for rehabilitation candidacy. • All medical investigations have been completed or a

follow-up plan is in place at the time of referral and follow-follow-up appointments made at the time of discharge.

• Patient has the tolerance to minimally sit for 1 hour, twice a day and tolerate 2 therapies per day.

• Discharge options following rehabilitation have been discussed.

Determining Medical Stability

Guidelines for determining medical stability:

• The Most Responsible Physician (MRP) in acute care

determines that the patient no longer requires acute care, i.e.: all acute medical issues have been resolved or reached a

plateau.

• A clear diagnosis and co-morbidities have been established. • Co-morbid medical conditions are managed/stable and

would not preclude participation in a rehabilitation program, i.e.: dialysis or active cancer treatment resulting in excessive fatigue or frequent absences from the unit during rehab treatment sessions.

Determining Medical Stability continued:

Guidelines for determining medical stability:

• Patient’s vital signs are stable.

• No undetermined medical issues (i.e.

excessive shortness of breath, congestive

heart failure).

Rehabilitation Referral Process

REHABILITATION READY?

REHABILITATION

READY? NONO CONTINUE TO _MONITOR CONTINUE TO MONITOR INPATIENT STAY REQUIRED? INPATIENT STAY REQUIRED? NO NO REFER TO OUTPATIENT/COMMUNITY SERVICE REFER TO OUTPATIENT/COMMUNITY SERVICE YES YES YES YES

Inpatient Rehabilitation Criteria

Inpatient admission is the most appropriate

setting if:

• Patient needs 24 hour nursing care/assistance • Patient cannot be safely managed at home

• Patient requires a frequent and intense interdisciplinary rehabilitation program

• Patient rehabilitation needs cannot be provided by an outpatient/community program

• Patient has a diagnosis of stroke. Patients with an early FIM < 80 and Motor FIM < 62

Rehabilitation Referral Process

BED AVAILABLE?

BED

AVAILABLE? NONO PUT ON WAITLIST

AND MONITOR PUT ON WAITLIST AND MONITOR YES YES ADMIT ADMIT

Discharge Criteria

Patients are discharged when:

• The patient has completed the rehabilitation plan and/or has achieved most mutually agreed upon goals to allow safe

community living.

• The patient has progressed such that community/outpatient resources can meet continuing needs.

• The patient has not demonstrated adequate improvement as determined by program standards, i.e., has reached a plateau. • A suitable discharge destination has been identified.

• A competent patient or legal guardian wishes discharge regardless of the team’s opinion.

Discharge Criteria Continued:

Patients are discharged when:

• The patient is physically/emotionally unable to participate in the Rehabilitation Program.

• The patient is non-compliant with the mutually identified goals and/or policies of the program.

• The patient is non-compliant with the rules of the hospital, i.e. alcohol, drug abuse.

• The patient requires further investigation, surgery, and treatment, becomes medically unstable, or requires

Intensive Rehab Outpatient Program

Program Purpose:

The Intensive Rehabilitation Outpatient Program

provides interdisciplinary rehabilitation and healthcare

services that promote independence and function. The

program allows early discharge from acute and

rehabilitation hospital beds for clients who are well

enough to go home, have transportation, but would

still benefit from further intensive rehabilitation. It

also prevents hospitalization for those who require

intensive rehabilitation but are still living at home and

have transportation.

Intensive Rehab Outpatient Program

Program Intensity:

•

typically 2-3 days per week for 3 hours each day,

• length of program is based on each individual rehab

plan which is developed in collaboration with the

client during admission process

Health Care Team:

Physiatrist, Physiotherapist, Occupational Therapist,

Therapeutic Recreation Specialist, RN, Speech

Language Pathologist, Dietitian, PT/OT Assistant,

Pharmacy consult.

Intensive Rehab Outpatient Program

Most Common Reasons for referral/streams

include:

• Neurological

• Geriatric

Referral Process

Intensive Rehab Outpatient

•

All referrals require a physician signature.

•

New Rehabilitation Referrals:

Additional client information to further

evaluate the potential client.

An interdisciplinary assessment to determine

rehabilitation candidacy and readiness.

•

Referrals from Inpatient Rehabilitation

Programs:

Fast track WH Inpatient Rehabilitation Program

and Parkwood referrals.

Rehabilitation Candidate Includes:

The client is a rehabilitation candidate if:

•

The client’s needs can be met by outpatient

rehabilitation services.

•

The client has appropriate transportation to and

The client is ready for rehabilitation if:

The client has sufficient tolerance for

transportation plus participation in the Intensive

Rehabilitation Outpatient Program, i.e.: travel time

plus 3 hours therapy per day. Exceptions will be

assessed on an individual basis.

Discharge Criteria

• The client has been educated regarding a continued

home program and can achieve/maintain progress

without further therapeutic input.

• If there is a duplication of service identified, and

another provider is meeting the client’s needs.

Expected Outcomes

•

Clear admission and discharge criteria, assessment

tools and protocols

• Strengthening the appropriate use of Rehab

resources (reducing ALC days)

• Improved uptake and adherence to evidence-base

best practices

• A clear and strong vision as well as conceptual

framework for Rehab

Thank You

Contact Information:

Arlene Whitehead

Director, Ambulatory Rehabilitation

Email: [email protected]