REHAB DEFINITIONS INITIATIVE FINAL REPORT MARCH 2010

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1 REHAB DEFINITIONS INITIATIVE FINAL REPORT MARCH 2010 Submitted by: GTA Rehab Netwrk Submitted t: TORONTO CENTRAL LHIN March 31, 2010

2 TABLE OF CONTENTS Acknwledgements i 1.0 Executive Summary Backgrund Apprach Phase 1: Rehab Cnceptual Framewrk Phase 2: Ppulatin-Specific Framewrks Phase 3: Self-Assessment Key Findings frm the Ppulatin-Specific Rehab Definitins Framewrks Geriatric/Medically Cmplex Rehab Strke Rehab Spinal Crd Injury Rehab Onclgy Rehab ABI/Neur Rehab Cardiac Rehab Amputee Rehab Pulmnary Rehab Burns Rehab MSK/Trauma Rehab Key Messages Challenges in develping the definitin framewrks What can we d better Next Steps 16 Appendices.. 17 Appendix A: Rehab Definitins Advisry Cmmittee and Task Grup Membership. 17 Appendix B: Rehab Cnceptual Framewrk. 20

3 ACKNOWLEDGMENTS The Rehab Definitins Initiative was supprted by funding received frm the Trnt Central LHIN. The GTA Rehab Netwrk wuld like t thank Dr. Mark Bayley (Medical Directr, Neur Rehab Prgram, Trnt Rehab) wh has tirelessly led this initiative. Thrugh his effrts and the effrts f thse invlved in the advisry cmmittee and task grups, the rehab definitin framewrks prvide the rehab sectr with a structure fr prviding qualitative and quantitative standards, against which prgrams can be measured t supprt system imprvement and planning. Authrs: Sue Balgh, B.Sc., MSW, RSW Prject Crdinatr/Planner GTA Rehab Netwrk balgh.sue@trntrehab.n.ca x3923 Charissa Levy, MHSc, BSc OT, OT (Reg) Ont. Executive Directr GTA Rehab Netwrk levy.charissa@trntrehab.n.ca x3616 Judy Mir Prject Crdinatr/Planner GTA Rehab Netwrk mir.judy@trntrehab.n.ca , x3688 Hannah Se, MSc OT, OT (Reg) Ont. Prject Crdinatr/Planner GTA Rehab Netwrk se.hannah@trntrehab.n.ca x 5277 Rehab Definitins Initiative Final Reprt / March 2010 i

4 1.0 Executive Summary Since 2006, the GTA Rehab Netwrk has been leading a large-scale initiative t develp standardized rehabilitatin prgram definitins fr publicly-funded rehabilitatin services acrss the care cntinuum. This initiative has translated evidence-based best practices int ppulatin-specific rehab framewrks t define the gld standard fr what shuld ccur as leading practices within rehab prgrams acrss the cntinuum. In the absence f evidence-based literature, definitins have been derived thrugh cnsensus n ptimal clinical practices. In additin t the rehabilitatin framewrks, self-assessment tls have been develped t supprt rganizatins in the evaluatin f their rehab prgrams against the definitins in each framewrk. Thrugh this prcess, the Netwrk has engaged a large number f representatives frm a variety f clinical backgrunds including physicians, nurses, ccupatinal therapists, physitherapists, speech language pathlgists and thers frm acrss the cntinuum and acrss the Greater Trnt Area (and prvincially in sme cases) (See Appendix A fr list f cmmittee members). A cnsistent and deliberate prcess has been used t reference existing best practice guidelines where available and engage with ther netwrks/rganizatins t leverage cllabratins and avid duplicatin f effrt. As evidence and mdels f practice cntinue t evlve, maintaining the definitins framewrks fr each ppulatin will be an nging, iterative prcess. Rehab framewrks and self-assessment surveys have been cmpleted fr the fllwing ppulatins: Geriatric, Strke, ABI/Neur, Spinal Crd Injury, Onclgy, Amputee and Pulmnary rehab. Findings frm these self-assessment surveys indicate that many f the prgrams acrss rehab ppulatin grups were unable t meet designated key criteria. Rehab definitin framewrks have been cmpleted fr Cardiac, Burns and MSK/Trauma rehab and the self-assessment surveys were disseminated in March The Rehab Definitins Initiative has the endrsement f the Netwrk s Crdinating Cuncil as an imprtant step twards: Defining and prmting cnsistency in rehab care acrss different care settings thrugh the translatin f evidence int ppulatin-specific rehab definitin framewrks Enhancing transparency in rehab prgramming acrss rganizatins and ptimizing the apprpriate matching f rehab needs Evaluating rehab perfrmance against the definitins in the framewrks and using the self-assessment findings t identify pprtunities fr quality imprvement and infrm planning An imprtant next step, fllwing the cmpletin f all f the ppulatin-specific rehab definitins, will be the develpment f a set f perfrmance indicatrs and benchmarks fr use by rehab prgrams 1. The identificatin f perfrmance indicatrs and benchmarks will be based n their (1) relevance t rehabilitatin, clinical utcmes and administrative prcesses (e.g. wait times); and (2) their alignment with the rehab definitin framewrks acrss rehabilitatin sectrs (e.g. inpatient rehab, utpatient rehabilitatin). The Netwrk has submitted preliminary cnsideratins fr the develpment f such indicatrs and benchmarks t the Trnt Central LHIN in its December 2009 reprt, System Perfrmance Indicatrs fr Rehabilitatin and Cmplex Cntinuing Care. Next steps include reviewing and updating the rehab framewrks t ensure they are cnsistent with emerging evidence and current mdels f practice; investigating the requirements fr mdifying Rehab Finder t enable it t incrprate self-assessment findings as a basis fr streamlining and rganizing its listing f rehab prgrams; sharing key learnings frm the initiative with stakehlders 1 The develpment f perfrmance indicatrs fr rehabilitatin was recmmended and strngly endrsed by members at the GTA Rehab Netwrk s Strategic Planning Sessin, held n June 1, Rehab Definitins Initiative Final Reprt / March

5 using the evidence and learnings frm this initiative as a basis t infrm system-wide discussins n the rganizatin and delivery f rehabilitatin services t supprt imprvements in patient flw and clinical utcmes. The Netwrk s definitins initiative has generated interest frm acrss the prvince. The Netwrk has been asked t present n this initiative twice t the OHA Rehab/CCC Leadership Cuncil and as rehabilitatin netwrks evlve in ther regins acrss the prvince, cmparable initiatives t define rehabilitatin prgrams have been utlined in their wrk plans. In additin t receiving funding frm the Trnt Central LHIN in 2009 t supprt the Netwrk s Definitin initiative, this wrk has als been referenced by reprts fr the LHINs including the Rehabilitatin Task Grup f the Central East LHIN (March 2009 reprt); and the Rehabilitatin / Alternate Level f Care Capacity Assessment cnducted by the Central LHIN in March The Netwrk has als been part f LHIN cnsultatins n related initiatives and was cnsulted in 2009 by the Mississauga Haltn LHIN in their review f pst acute prgrams and mst recently, the Netwrk has been asked t participate in the develpment f a rehabilitatin framewrk t be cmpleted by the Central West LHIN. In additin t the learnings frm engaging in a review f rehabilitatin prgrams fr each ppulatin, a unique and added value f this initiative stems frm the Netwrk s cllective review acrss ppulatins, which has illustrated gaps in service acrss ppulatin specific prgrams and highlighted differences in flw and use f alternate mdels. The Rehab Definitins initiative serves as nt nly a quality imprvement tl fr rganizatins t cmpare perfrmance f their prgrams against evidence-based framewrks, but it is expected that the GTA Rehab Netwrk and thers will use the wrk f the rehab definitins initiative as a basis t infrm discussins n capacity planning including review f access and flw f individuals acrss health services. Rehab Definitins Initiative Final Reprt / March

6 2.0 Backgrund The GTA Rehab Netwrk s Rehab Definitins Initiative was prmpted by the need t address the cnfusin abut the variatins in service scpe amng rehab prgrams, including thse that serve the same client ppulatins. The Netwrk recgnized that standards in rehabilitatin prgramming, including clear definitins abut the services prvided, wuld prmte cnsistency in rehab care and prvide clarity fr patients, families and referrers. Althugh sme related wrk was dne previusly by the Ontari Hspital Assciatin t classify rehab ppulatin grups, the definitins were brad and prvided little directin t guide rehab prgramming. As a result, rehab prgrams have varied in terms f what they prvide making it difficult t cmpare ptential rehab ptins at the pint f referral. Such differences amng rehab prgrams have als reduced the capacity fr effective system planning and perfrmance measurement. 3.0 Apprach 3.1 Phase 1: Rehab Cnceptual Framewrk The first phase f the initiative was cnducted in the spring f The Netwrk brught tgether representatives frm acrss the cntinuum including stakehlders frm acute care and rehab hspitals, the University f Trnt, Cmmunity Care Access Centres and lng-term care t develp a cnceptual rehab framewrk utlining the cre elements f rehabilitatin in institutinal and cmmunity-based settings. Guiding principles t infrm the initiative were identified such that the rehab framewrks: Utilize the Wrld Health Organizatin s definitin f rehabilitatin Refer t publicly-funded cgnitive & physical frms f rehab fr clients with rehab ptential and defined gals Prvide definitins fr each rehab sectr based n the ideal r gld standard f practice using evidence where available Describe categries based n rehab needs and typical services prvided nt length f stay r type f rehab bed Are validated thrugh input frm stakehlders and cntent experts The cnceptual rehab framewrk addresses rehab services that are prvided in the acute care setting, the inpatient setting and in the cmmunity setting and fr each f these settings, the services, differential criteria, degree f specializatin and key activities f rehabilitatin were delineated. [See Appendix B] Fllwing its develpment, the cnceptual framewrk was presented t and apprved by a large cnstituency f health prviders invlved in rehabilitatin in June Phase 2: Ppulatin-Specific Framewrks The secnd phase f the initiative began in the fall f 2006 and fcused n the develpment f ppulatin-specific rehab framewrks. The rehab cnceptual framewrk prvided the fundatin frm which the individual rehab ppulatin framewrks were develped. Using evidence-based best practices r, in the absence f evidence in the literature, cnsensus n ptimal clinical practices, the gal f the initiative was t develp the ideal r gld standard f practice. Ppulatin-specific task grups, cmprised f clinical/cntent experts frm acute care and rehab hspitals within the GTA and in sme cases frm acrss the prvince, were cnvened as framewrks were develped. Task grup members reviewed best practices, current research and clinical practices. In additin, a number f trigger questins generated further pints fr discussin. These included the fllwing: a. Is it apprpriate fr the rehab ppulatin t be mixed with ther rehab grups n a unit and if s, which nes? b. What criteria can be used t assist in identifying the patient s primary rehab needs fr triage t the mst apprpriate rehab prgram? c. What level f specializatin is needed at each phase f the cntinuum? What services shuld be reginal and mre specialized versus thse that can be prvided within lcal cmmunities clser t hme? d. What patient vlume is required t sustain an adequate critical mass t supprt the develpment and maintenance f clinical expertise? Rehab Definitins Initiative Final Reprt / March

7 Ppulatin-specific rehab framewrks are nw available fr 12 rehab ppulatin grups: Strke, Geriatric, ABI/Neur, Spinal Crd Injury, Onclgy, Cardiac, Burns, Amputee, Pulmnary Rehab and MSK/Trauma Rehab. 3.3 Phase 3: Self-Assessment Once the first set f rehab framewrks were develped, it became clear that a resurce tl was needed t help member rganizatins make practical use f the framewrks by assessing hw well their prgrams met the rehab definitins and criteria. Self-assessment tls fr acute care, inpatient rehab, utpatient/ambulatry rehab and cmmunity-based rehab have been develped t accmpany the rehab framewrks fr each ppulatin. Organizatins use the self-assessment tl t determine if their prgrams fully meet the criteria (i.e. meet the criteria 80% f the time); partially meet the criteria (i.e % f the time); r d nt meet the criteria (i.e. criteria are met < 40% f the time). While individual prgrams make use f the survey findings t imprve the delivery f rehab services within their wn rganizatin, the GTA Rehab Netwrk analyzes the survey findings t determine hw well, n a systems-wide level, prgrams meet all f the criteria and hw well individual prgrams are able t meet designated key criteria 2 frm the ppulatin-specific framewrk. The self-assessment tls, as new resurces, prvide a mechanism thrugh which the GTA Rehab Netwrk and individual member rganizatins can assess what is currently prvided in rehabilitatin prgrams/services against the evidence-based definitins in the rehab framewrks. The self-assessment findings prvide the basis fr identifying pprtunities fr quality imprvement initiatives t supprt patient flw and quality rehab care. They als prvide the Netwrk with infrmatin t help target its initiatives and assist member rganizatins in wrking twards the gld standards utlined in the rehab prgram definitins. Frm a system-planning perspective, the Netwrk can use the aggregated findings t cnduct a system-wide analysis f rehab prgramming, rehab resurces, and issues related t access t supprt capacity planning acrss the rehabilitatin sectr. Finally, the self-assessment findings will als be used in future t describe the rehab prgrams ffered by member rganizatins n the Netwrk s Rehab Finder, its web-based, searchable listing f rehab prgrams, t prvide increased transparency abut the quality f prgrams ffered and further clarity fr referrers and patients and families abut available rehab ptins. 4.0 Key Findings frm the Ppulatin-Specific Rehab Definitins Framewrks 4.1 Geriatric/Medically Cmplex Rehab Geriatric rehab was identified as an initial area f fcus fr the Rehab Definitins Initiative in respnse t the Netwrk s 2006 ALC survey findings and feedback frm its 2006 cnsultatin sessin. The ALC survey fund that 43% f ALC patients awaiting rehab had been referred fr geriatric rehab and accunted fr the largest ttal number f ALC days (365 days). In additin, stakehlder feedback indicated that referrers experienced much cnfusin abut where t refer elderly patients fr rehab since many rehab prgrams include senirs in their admissin criteria. T address the cmplexities invlved in prviding clear rehab definitins fr senirs requiring rehabilitatin, an extensive literature review and key infrmant interviews with geriatricians frm arund the prvince were cnducted t btain cnsensus n the terms geriatric, frail and medically cmplex within the senir ppulatin in the fall f Findings frm these activities 3 were used by the Geriatric Rehab Definitins Task Grup t develp standardized definitins t describe the staffing, services ffered and differential criteria fr geriatric rehab using evidence-based best practices. A new triage 2 Key criteria, representing apprximately half f all the criteria in a ppulatin-specific framewrk, are selected by the task grup that develped the rehab framewrk fllwing the self-assessment phase. An expectatin has been set that rehab prgrams meet, at a minimum, all f the key criteria. 3 A summary f these discussins and findings can be fund in the GTA Rehab Netwrk reprt, Clarifying the Cmplexities f Inpatient Geriatric Rehab (February 2007). The reprt can be dwnladed frm the GTA Rehab Netwrk website at Rehab Definitins Initiative Final Reprt / March

8 guideline fr inpatient geriatric rehab was als develped and pilted in the winter f 2007 t assist referrers in referral decisin-making. The tl triages senir rehab patients based n rehab ptential and rehab readiness; the primary fcus f rehab (e.g. impaired premrbid functining and current multisystem needs vs. functinal impairment arising frm recent acute event); and the patient s rehab tlerance level. Self-assessments were cnducted by acute care, rehab hspitals and cmmunity care access centres in the winter f A ttal f 40 surveys were received frm rehab prgrams spanning acute care, inpatient and utpatient/ambulatry, and cmmunity settings. An analysis f the surveys highlighted the fllwing key findings: Acute Care: All specialized geriatric units in acute care met all f the key criteria; hwever, greater expertise amng staff in the care f the elderly n nn-specialized geriatric units with high number f senirs is recmmended (i.e. General Internal Medicine) with increased access t geriatric cnsult teams n medical units. Inpatient Rehab: While the dedicated geriatric rehab prgrams were able t meet mst f the key criteria, all prgrams needed t imprve their prvisin f wellness educatin t patients. (Of nte, sme rganizatins indicated that the self-assessment survey prmpted them t implement wellness fcussed educatin int their prgrams.) Mixed ppulatin rehab prgrams, where many elderly patients are seen, need t increase their specializatin in multi-system issues and principles f senir-fcused care. This wuld include maintaining a critical mass f 8 beds with clustered beds/teams t supprt the develpment f expertise in senir-fcused care. The Lw Tlerance Lng Duratin (LTLD) prgrams perfrmed quite well with respect t meeting the key criteria and prviding access t the recmmended cre team members, including a physician with expertise in medical cmplexity and senir-fcused care principles. Outpatient and Cmmunity-Based Rehab: Outpatient/ambulatry rehab prgrams perfrmed well with respect t the criteria fr services prvided and specializatin; hwever, increased access t the recmmended cre team members n a dedicated basis is needed (i.e. access t a clinical dietician, pharmacist, therapeutic recreatin therapists, chaplain, and speech-language pathlgist). The develpment f the Geriatric Rehab Definitins Framewrk, undertaken within a brader cntext f btaining an enhanced understanding f the diverse patient prfiles and rehab needs amng the senir rehab ppulatin, presented many challenges. Data frm 2005 indicates that senirs ver the age f 65 represent apprximately 71% f all inpatient rehabilitatin patients and f these, almst half (47%) are ver 74 years f age. 4 These senirs d nt represent a hmgenus grup with respect t their rehab needs and therefre they are referred t a variety f inpatient rehab prgrams. Develping a triage tl t help determine which elderly rehab patients require a specialized geriatric rehab prgram versus a rehab prgram dedicated t a particular diagnstic rehab grup (e.g. ABI, Strke, MSK) versus a mixed ppulatin rehab prgram required much discussin and multiple revisins t the triage tl, particularly as task grup members struggled t understand which services are currently prvided and which ught t be prvided in each f these types f prgrams. 4.2 Strke Rehab The Strke Rehab Definitins Framewrk was develped in the winter f 2007 with input frm acute care and rehabilitatin hspitals and cmmunity care access centres. Other task grup participants included the fur rehab/educatin crdinatrs frm the Trnt area reginal strke netwrks as well as the 4 Canadian Institute fr Health Infrmatin. Inpatient Rehabilitatin in Canada, Special Tpic: A Lk at the Older Ppulatin. (2005) Rehab Definitins Initiative Final Reprt / March

9 cnsultant/prject lead frm the Heart and Strke Fundatin f Ontari (HSFO) invlved in the develpment f the Ontari Strke System s Rehab Cnsensus Panel Standards. In an effrt t reduce duplicatin f effrts and reduce the burden n strke rehab prviders invlved in the cmpletin f self-assessment surveys, the GTA Rehab Netwrk subsequently cllabrated with the Trnt area reginal strke managers and rehab crdinatrs t develp a self-assessment survey that wuld serve a dual purpse: t assess strke prgrams against the newly develped Ontari Strke System s Rehab Cnsensus Panel standards and assess them against the GTA Rehab Netwrk s Strke Rehab Definitins Framewrk. The self-assessment surveys were disseminated by the Reginal Strke Managers f the West GTA, Trnt West, Suth East and Nrth and East regins in January The reginal strke netwrks shared their data with the Netwrk fr an analysis f the findings accrding t its requirements based n the definitins in the Strke Rehab Definitins Framewrk. The self-assessment surveys were analyzed in the spring f Self-assessment findings frm a ttal f 57 strke prgrams spanning acute care, inpatient and utpatient/ambulatry rehab and cmmunitybased rehab were reviewed. An analysis f the surveys highlighted the fllwing key findings: Acute Care: Of 14 prgrams, 5 acute care strke prgrams met all 4 f the key criteria. Almst all f the prgrams (93%) met the criterin t reassess strke patients wh are nt initially eligible fr inpatient rehab fr their rehab needs. Only half f the prgrams fully met the criterin t prvide access t an interprfessinal rehabilitatin team with expertise in strke care when the patient is rehab ready. N prgrams prvided all f the recmmended cre team members althugh all teams had nursing, physitherapy, speech-language pathlgy and pharmacy and all but ne prgram had access t a primary care physician, scial wrk, ccupatinal therapy and chaplaincy. The availability f a physiatrist, rehab nurse and recreatinal therapists was nt available in mst prgrams. Inpatient High Tlerance Rehab: Of 12 prgrams, nly ne prgram met all 9 key criteria. Only half f the prgrams met the benchmark fr a 2 day r less wait time fr accessing inpatient rehabilitatin fllwing referral. Mst prgrams (83%) met the hur benchmark t prvide an early initial rehab assessment fllwing admissin. Only 25% f the prgrams prvided the recmmended amunt f therapy by ccupatinal therapy, physitherapy and speech-language pathlgy. Althugh all prgrams prvided the traditinal rehab therapies, nt all interprfessinal teams included a rehab nurse, recreatinal therapist and physiatrist. Mst prgrams screened fr the presence f cgnitive deficits, falls, depressin, behaviural issues and swallwing prblems. All prgrams prvided infrmatin and educatin in the recmmended areas (e.g. the nature f strke, signs and symptms, risk factrs, resurces and cmmunity supprt). Inpatient Lw Tlerance Rehab: Of 5 prgrams, n prgrams met all f the 9 key criteria. 80% f the LTLD strke rehab prgrams are prvided n a strke unit as recmmended. 5 Analysis f the data was held up fr the fllwing reasns: (1) there were delays in receiving the data and; (2) the quality f the data frm ne f the strke reginal netwrks was questinable. As a result f these issues, the self-assessment findings were nly analyzed relative t prgrams meeting the designated key criteria frm the Strke Rehab Definitins Framewrk. Rehab Definitins Initiative Final Reprt / March

10 Apprximately 60% f the prgrams prvided the recmmended amunt f therapy; hwever, less than half f the prgrams initiated the first rehab assessment within hurs fllwing admissin. The prgrams perfrmed well with respect t meeting the criteria fr the cre team. That is, all prgrams prvided a primary care physician, ccupatinal therapy, pharmacy, geriatrician and psychiatry and mst prgrams (80%) prvided physitherapy, speechlanguage pathlgy, scial wrk and recreatinal therapy. Only 1 prgram had access t a physiatrist. All prgrams screened fr cgnitive deficits, falls, depressin, behaviural issues and swallwing prblems and all prgrams prvided educatin and infrmatin in the recmmended areas (e.g. the nature f strke, signs and symptms, risk factrs, resurces and cmmunity supprt). Outpatient/Ambulatry Rehab: Of 13 prgrams ffering an interprfessinal strke team apprach and 10 prgrams prviding utpatient single services, n prgrams met all key criteria. In the 13 prgrams that prvide an interprfessinal team, nly 4 prgrams prvided mst f the cre team members recmmended. Nt all teams included a primary care physician r physiatrist, nurse, scial wrker, clinical dietician, pharmacist r recreatinal therapist. Almst all interprfessinal teams screen fr cgnitive deficits, falls, depressin, behaviural issues and swallwing prblems and all prgrams prvided educatin and infrmatin in the recmmended areas (e.g. the nature f strke, signs and symptms, risk factrs, resurces and cmmunity supprt). There is a need t increase the use f a crdinated apprach with frmal team meetings and t accept referrals frm lng-term care. N prgrams met the benchmark fr the 5 day r less wait time fr accessing utpatient/ambulatry rehabilitatin fllwing referral. Cmmunity-Based Rehab: Of 3 prgrams, ne prgram, a cmmunity care access centre, met all 4 key criteria. The ther prgrams did nt fully meet any f the key criteria. In ttal, nly 12% f the prgrams spanning acute care, inpatient and utpatient/ambulatry rehabilitatin and cmmunity-based rehab met all f the key criteria fr their sectr. With the exceptin f LTLD rehab, mst prgrams were unable t prvide the recmmended cre team members. Mst prgrams screened fr cgnitive deficits, falls, depressin, behaviural issues and swallwing prblems and prvided educatin and infrmatin in the recmmended areas (e.g. the nature f strke, signs and symptms, risk factrs, resurces and cmmunity supprt). 4.3 Spinal Crd Injury Rehab The Spinal Crd Injury Rehab Definitins Framewrk was cmpleted by the summer f A key differentiating feature f the Spinal Crd Injury Rehab Definitins Framewrk is its statement that a mixed rehab unit is nt an apprpriate setting fr patients with spinal crd injury. The framewrk recmmends that patients with a spinal crd injury require the expertise f rehab prfessinals in either a dedicated neur rehab unit r a dedicated spinal crd injury unit. The framewrk prvides differentiating criteria t distinguish which patients are apprpriate fr each f these settings. Self-assessment surveys were disseminated in January A ttal f 17 surveys were received spanning acute care, inpatient, utpatient and cmmunity-based rehab prgrams. An analysis f the surveys highlighted the fllwing key findings: Acute Care: Only ne f the three acute care units met all f the key criteria. Rehab Definitins Initiative Final Reprt / March

11 All 3 acute care specialized neurlgical/neursurgical units have dedicated cre teams with expertise in spinal crd injury. Althugh these teams include the traditinal rehab health prviders (e.g. physician, nurse, physitherapist, ccupatinal therapist, speechlanguage pathlgist, scial wrk and pharmacist), there is a need fr increased access t psychlgy acrss all prgrams. Increased access t peer supprt, respiratry therapy, nutritin and rthtist, chirpdy and physiatry is needed in sme prgrams as well. Educatin t patients/families is prvided acrss all prgrams regarding changes in functin and identificatin f rehab gals. Inpatient Rehab: The ne dedicated SCI rehab prgram participating in the survey met all criteria. In the dedicated neur rehab units, almst all f the recmmended cre team members are actively invlved in assessment and treatment and participate in runds regularly. Teams utilize a patient-centred, gal-riented apprach with established mechanisms f cmmunicatin f gals and treatment plans with the patient/family; hwever, the intensity f treatment des nt always meet the recmmended level due t caselad demands. There is a need fr increased cnsultatin between SCI rehab prgrams and neur rehab prgrams fr thse SCI patients in neur rehab wh have cmplex needs and are awaiting admissin t an SCI rehab prgram. In LTLD rehab, there is a need fr increased expertise in the treatment f neurlgical disrders and cmpetence in skin, nutritinal, bwel and bladder and seating management. There is als a need fr increased access t specialized SCI services, pain services and SCI educatin. Outpatient/Ambulatry Rehab: The dedicated SCI utpatient/ambulatry prgrams met all f the criteria The dedicated interprfessinal neur teams have the required cre team members and expertise in neurlgical disease; hwever, nt all recmmended cnsultative services are available (e.g. pharmacy, dietician, recreatinal therapy). Cmmunity-Based Rehab: The 3 prgrams met the criteria fr recmmended cre team members and services; hwever, specializatin in spinal crd injury is lacking. In ttal, f 17 prgrams surveyed, nly 18% f the prgrams met all f the criteria in the SCI Rehab Definitins Framewrk and nly 29% f the prgrams met all f the key criteria. 4.4 Onclgy Rehab The Onclgy Rehab Definitins Framewrk was cmpleted in the fall f 2008 and the self-assessment surveys were disseminated in March Self-assessment surveys were nt distributed t acute care as there is n single nclgy unit n which patients are seen; nclgy patients are admitted t many different prgrams in acute care. In ttal, 21 surveys were received spanning inpatient and utpatient/ambulatry rehabilitatin and cmmunity-based CCAC rehab prgrams. An analysis f the surveys highlighted the fllwing key findings: Inpatient Rehab: Neither f the tw nclgy rehab prgrams with a dedicated interprfessinal nclgy team met all f the criteria. Hwever, ne prgrams met all f the key criteria. Of the six mixed rehab units that see nclgy rehab patients, ne prgram met all f the criteria and a third f the prgrams met all key criteria. In general, the inpatient prgrams perfrmed well with mst prgrams meeting ver 85% f all criteria. Rehab Definitins Initiative Final Reprt / March

12 The inpatient rehab prgrams were generally able t prvide the recmmended cre team members and the recmmended amunt f therapy. One prgram with a dedicated nclgy rehab team, hwever, stated that it makes use f therapy assistants fr mre than the recmmended amunt f time. Areas fr imprvement include prvisin f recreatinal therapy, chaplaincy and wellness educatin. Sme prgrams are unable t accmmdate patients wh need TPN, cntinuus infusin and/r ral chemtherapy. One prgram with a dedicated nclgy rehab team des nt accept patients wh are underging chemtherapy treatment. Outpatient/Ambulatry Rehab Nne f the dedicated r mixed ppulatin utpatient teams met all f the key criteria. Three f five single services met all f the key criteria. The utpatient/ambulatry interprfessinal rehab teams perfrmed well with respect t the prvisin f the recmmended services pertaining t the amunt f therapy, access t a dedicated interprfessinal team and the prgram s respnsiveness t individual patient needs and gals. Hwever, nne f the teams met all f the key criteria. Only half f the interprfessinal teams included all f the recmmended cre team members and the required level f expertise in nclgy diagnsis, prgnsis, recvery and ptential deficits. Three f fur team prgrams have a mechanism in place t supprt the re-entry f patients t be served. N prgrams fully met the criterin regarding the participatin f patient families in team meetings althugh families d prvide input t individual team members. Cmmunity-Based Rehab Tw f three CCAC prgrams met all f the criteria and all f the key criteria; all prgrams met the criteria regarding the recmmended team members, the services prvided and the duratin f invlvement. One prgram stated that althugh the CCAC service prviders typically have the recmmended skills and knwledge in nclgy rehab, in the case f an urgent referral, a prvider withut the equivalent skill set may be sent in instead. In ttal, f 21 prgrams surveyed, 29% f the prgrams met all f the criteria in the Onclgy Rehab Definitins Framewrk and 38% f the prgrams met all f the key criteria. 4.5 ABI/Neur Rehab The ABI/Neur Rehab Definitins Framewrk was cmpleted in the winter f A key differentiating feature f the ABI/Neur Rehab Definitins Framewrk is its statement that a mixed rehab unit is nt an apprpriate setting fr all patients with an acquired brain injury. Specifically, thse with mderate t severe cgnitive/behaviural impairment shuld be referred t a unit with Dedicated Inpatient ABI Rehab beds. In additin, this framewrk includes criteria fr a rehab service that is unique t brain injury (i.e., Transitinal Behaviural Rehab in a Specialized Unit). Self-assessment surveys were disseminated in the fall f A ttal f 22 surveys were received spanning acute care, inpatient, utpatient and cmmunity-based rehab prgrams. The prcess f cnducting the self-assessments prmpted the cmmittee t make three adjustments t the Framewrk, requiring subsequent fllw-up t ensure rganizatins met the additinal/mdified criteria. An analysis f the surveys highlighted the fllwing key findings: Acute Care: Only ne respnse was received frm acute care. That respndent met all criteria fully; hwever, the limited respnses make it difficult t cmment n system level perfrmance. Rehab Definitins Initiative Final Reprt / March

13 Inpatient Rehab: Only 1 f the 3 prgrams ffering ABI rehab n a dedicated inpatient rehab prgram met ALL f the key criteria. 2 f the 3 dedicated ABI rehab prgrams reprted having access t all cre team members. Fr the rganizatin that did nt meet this criterin, neurpsychiatry and behaviural therapy were nt part f the cre team. 100% f the dedicated ABI rehab prgrams reprted having the recmmended critical mass f beds and clustered the ABI beds gegraphically, facilitating the develpment and maintenance f expertise. Only ne f the dedicated rehab prgrams reprted having a self-cntained unit with apprpriately secured access. Intensity f treatment did nt cnsistently meet the recmmended level acrss all prgrams due t caselad demands. Of the fur prgrams ffering ABI rehab in a mixed rehab unit, 50% have fully met the key criteria. 100% f the prgrams reprted have access t all cre team members. Hwever, nly 2 f the 4 reprted having access t medical staff with expertise in ABI. In LTLD ABI rehab, limited availability f medical staff with expertise in ABI is reprted. The need t increase expertise in the management f severe ABI (i.e., with a Ranch Ls Amig scre <4 r significant behaviural issues) and imprve referral practices/cnsultatin t link patients with specialized services and cmmunity supprt was als reprted. Althugh nt identified as a key criterin there was cnsistent lack f access t psychlgy/psychiatry with neurlgical expertise acrss nn-dedicated rehab prgrams. Outpatient/Ambulatry Rehab: 8 respnses were received fr utpatient/ambulatry rehab (mixed, dedicated, and single service). The utpatient rehab teams perfrmed well with respect t the cre team members required. One prgram reprted having access t a physician but nt t a physiatrist. A crdinated team apprach is cnsistently being used with regular team meetings fr the 6 Dedicated and Mixed Outpatient ABI Teams. Increased availability f within and between service case management r equivalent is needed t facilitate access t services thrugh the cntinuum f care. Althugh nt identified as a key criterin, wait times fr utpatient rehab are frequently exceeding the recmmended guidelines f access within 5 business days. Cmmunity-Based Rehab: Bth CCAC s respnding met the criteria fr recmmended cre team and crdinate activity thrugh regular team cnferences Only 1 f the 2 CCAC s reprted having cnsistent access t health prfessinals with expertise in ABI/Neur. Vcatinal rehab and anger management was nt cnsistently available. 4.6 Cardiac Rehab The Cardiac Rehab Definitins Framewrk was cmpleted in summer f The develpment f a Definitins Framewrk fr cardiac rehab was different fr a number f reasns. First, there is an abundance f evidence in cardiac rehabilitatin which shws its effectiveness. Thrugh the prcess f develping this evidence, cre cmpnents f rehabilitatin prgrams have already been established and Rehab Definitins Initiative Final Reprt / March

14 in many cases frmalized. In spite f this evidence, cardiac rehabilitatin prgrams are sparse; have nt had funding renewed t them; and cntinue t be underutilized. Given this cntext it was agreed that the Rehabilitatin Definitins Framewrk will be applied t cardiac rehabilitatin with a view t utilizing the resulting dcument t refresh the dialgue n the imprtance f cardiac rehabilitatin at bth the level f the system and the level f the patient. This wrk was supprted by the Cardiac Care Netwrk and the Cardiac Rehab Netwrk f Ontari bth thrugh reliance n wrk they had undertaken in develping standards f care fr cardiac rehab and thrugh their direct invlvement in the cmmittee s deliberatins. The majrity f the Framewrk was cmpleted in early 2009 but a decisin was made t defer finalizing the Framewrk and cnducting the self assessment surveys until after the release f the third editin f the Canadian Guidelines fr Cardiac Rehabilitatin and Cardivascular Disease Preventin. This prvided the pprtunity t ensure the definitins were as cmplete and up t date as pssible. The Framewrk has nw been mdified t reflect the mst recent Canadian Guidelines and the selfassessment surveys are in the prcess f being cmpleted. We anticipate having the survey results in the spring. Once the results are received the Cmmittee will recnvene t review the analysis, establish key criteria, and determine pprtunities fr next steps. 4.7 Amputee Rehab The Amputee Rehab Definitins cmmittee was frmed in February The framewrk was cmpleted in June Tw key differentiating features f the Amputee Rehab Definitins Framewrk were: (1) a recmmendatin that inpatient dedicated rehab prgrams have dialysis services n site; and (2) a recmmendatin that an amputee rehab prgram be cnsidered as an integrated system f care that includes inpatient care, utpatient care and an ADP Clinic. The task grup recgnized that a full prgram may nt be hused within ne facility, but recmmended that such partnerships wuld need t be frmed t ensure efficient patient flw and cmmunicatin acrss teams. Self assessment surveys were disseminated in July Seventeen self assessment surveys were received frm acute care, inpatient rehab, utpatient rehab and cmmunity rehab prgrams. An analysis f the surveys highlighted the fllwing key findings: Acute Care: Nne f the 3 prgrams met all f the key criteria. Althugh all 3 prgrams had % f the recmmended cre team members, all 3 were als missing 50-60% f the cnsultative team. There is a need fr increased access t a physiatrist, psychlgist, neurpsychlgist, trained peer visitr and prsthetist. Nne f the prgrams prvided the recmmended pre-perative activities. Inpatient Rehab: Dedicated Amputee Rehab Team n a Mixed Rehab Unit Nne f the 3 prgrams met all the key criteria (nte that 1 survey was incmplete and culd nt be fully analyzed). Althugh all prgrams were able t prvide the recmmended intensity and frequency f therapy, nne were able t meet all f the criteria fr specializatin (i.e. critical mass, gegraphical clustering, ADP clinic number). One f the prgrams was nt able t ffer a dedicated team within the mixed unit. Dedicated Amputee Rehab Unit Fr the purpse f analysis, the key criterin related t availability f n-site dialysis was excluded. As such, ne prgram f the tw met all f the key criteria fr a dedicated amputee rehab prgram. Bth prgrams ffered the recmmended intensity and frequency f therapy and nearly all f the recmmended interprfessinal team members. Areas f imprvement include cnsistently incrprating sexuality and end f life decisin making as part f the key activities. Rehab Definitins Initiative Final Reprt / March

15 Lw Tlerance Lng Duratin (LTLD) Rehab The sle prgram which respnded t this survey did nt meet all f the key criteria. Althugh this prgram was able t prvide all f the recmmended cre team members, a dedicated team was nt available fr the majrity (80% r mre) f the time. Areas f imprvement include matching the recmmended intensity and frequency f therapy recmmended, gegraphically clustering beds and cnsistently incrprating mre f the recmmended key activities. Outpatient/Ambulatry Rehab: Of the 5 prgrams which respnded t this survey, nne met all f the key criteria. Mst prgrams ffered the recmmended cre team members and had an ADP clinic number and rehab assessr. Only ne prgram was able t meet the recmmendatin fr access t utpatient rehab within 1 week f discharge frm inpatient rehab/acute care. Cmmunity-Based Rehab: Of the 3 prgrams which respnded t this survey, ne met all f the key criteria. Nte that ne survey was incmplete and culd nt be fully analyzed. Mst f the prgrams reprted that the cmmunity based rehab prviders have cntact with the amputee rehab team and that services are in place until identified gals have been met r are ther wise addressed. One prgram identified that althugh it met mst f the criteria, it des nt cnsider itself an amputee rehab prgram due t lw vlumes. In ttal, f the 17 prgrams surveyed, nne f the prgrams met all f the criteria in the Amputee Rehab Definitins Framewrk and nly 13% f the prgrams met all f the key criteria. 4.8 Pulmnary Rehab The Pulmnary Rehab Definitins cmmittee was frmed in February The framewrk was cmpleted in August A differentiating feature f the Pulmnary Rehab Definitins Framewrk is a statement that a mixed rehab unit is nt an apprpriate setting fr patients requiring pulmnary rehab. This framewrk specifies that either patients shuld receive services frm a dedicated pulmnary rehab team n a mixed rehab unit, r that patients shuld receive services frm a dedicated pulmnary rehab unit. The task grup als made specific recmmendatins regarding the cmpetencies expected and the intensity and frequency f therapy recmmended fr best practice in pulmnary rehab. Self assessment surveys were disseminated in August 2009 acrss the Greater Trnt Area. Twenty self assessment surveys were received frm inpatient rehab, utpatient rehab and cmmunity rehab prgrams. An analysis f the surveys highlighted the fllwing key findings (nte that nt all surveys were fully cmplete): Inpatient Rehab: Dedicated Pulmnary Rehab Team n a Mixed Rehab Unit 1 ut f the 4 prgrams met all f the key criteria 3 ut f the 4 prgrams prvided the intensity, frequency and duratin f rehab that were recmmended 3 f the prgrams did nt meet the dedicated space and/r vlume recmmendatins. Dedicated Pulmnary Rehab Unit The sle prgram which prvided this level f rehab met all f the key criteria Lw Tlerance Lng Duratin (LTLD) Rehab 1 f the 2 prgrams met all f the key criteria All prgrams were able t prvide the level f specializatin that was recmmended. 1 prgram did nt prvide the intensity and frequency f rehab recmmended r prvide the level f staffing needed t supprt the recmmended amunt f therapy. 1 prgram did nt prvide all cmpnents f self management that were recmmended Rehab Definitins Initiative Final Reprt / March

16 Outpatient/Ambulatry Rehab: Outpatient Mixed Rehab 1 prgram filled ut this survey and did nt meet all f the key criteria. This prgram was nt able t prvide the recmmended cre and cnsultative team members Sme cmpnents f the recmmended key activities and assessments were nt prvided. Outpatient Dedicated Rehab 9 prgrams filled ut this survey, f which 7 were sufficiently cmpleted t analyze the key criteria. Of the 7 surveys which culd be analyzed, 3 f them met all f the key criteria. 3 prgrams were nt able t prvide the frequency f supervised exercise sessins and/r the ttal number f supervised exercise sessins. 3 prgrams were nt able t prvide cnsultatin services by a scial wrker and a Respirlgist. Cmmunity-Based Rehab: Of the 3 prgrams which respnded t this survey, nne culd be fully analyzed. All f the prgrams prvided rehab based n the client s needs and gals 2 f the prgrams prvided the services that were recmmended fr cmmunity pulmnary rehab In ttal, f the 20 survey respnses, 33% met all f the criteria in the Pulmnary Rehab Definitins Framewrk (excluding thse which were incmplete) and 40% f the prgrams (excluding thse which culd nt have the key criteria analyzed) met all f the key criteria. 4.9 Burn Rehab The Burn Rehab Definitins cmmittee was frmed in February Unlike its predecessrs, the small size f the burn rehab cmmunity and the intercnnectedness f the prvincial Burn Centres with the utlying cmmunity partners acrss the prvince necessitated a prvincial cmmittee. In additin, this is the first cmmittee that has incrprated paediatrics int the framewrk. This was dne because f the intercnnected nature f the paediatric and adult burn rehab systems in Ontari. The cmmittee meetings have been cnducted using videcnferencing technlgy t bring prvincial partners tgether. The Burn Rehab Definitins Framewrk was cmpleted in February, This framewrk utlines specific cmpetencies and timelines fr burn rehab. In acute and inpatient rehab, fr example, the task grup recmmended that n mre than 24 hurs ccur between therapy sessins. The task grup als recmmended that access t utpatient rehab ccur within 72 hurs f referral frm fr burns t critical areas (defined as: face, hands, feet, genitalia, perineum r majr jints) and within 7 days fr all ther burns. Self assessment surveys were distributed t 33 rehab prgrams serving the burn ppulatin acrss the prvince in March, A final meeting is planned fr end f April/early May t review the results f the analysis and discuss next steps MSK/Trauma Rehab The MSK Rehab Definitins Framewrk was initiated in May, 2009 and is the last f the framewrks t be cmpleted. The MSK cmmittee has determined that mre than ne framewrk is required t fully capture the cmplexities f this ppulatin. The cmmittee cmpleted wrk n the Ttal Jint Replacement Rehab Definitins Framewrk as well as the Hip Fracture Rehab Definitins Framewrk in March, A key differentiating feature f the Ttal Jint Replacement Rehab Definitins Framewrk is the recmmendatin that the majrity f typical patients with primary, elective ttal hip r knee replacements, shuld nt g t inpatient rehab. Rather, the task grup has recmmended that these patients receive their pst-acute rehab thrugh utpatient r cmmunity services, given evidence that similar utcmes can be achieved. The framewrk als utlines circumstances where patients may require inpatient rehab. Rehab Definitins Initiative Final Reprt / March

17 Cnversely, a key differentiating feature f the Hip Fracture Rehab Definitins Framewrk is the recmmendatin that all patients be cnsidered fr inpatient (high tlerance, shrt duratin) rehab fr their pst-acute care, unless they are safe fr discharge hme. The task grup utlined several Guiding Principles fr hip fracture rehab, including: patients frm all types f pre-mrbid living situatins shuld be cnsidered equally with regard t decisin making fr inpatient rehab admissin and that all patients with mild t mderate cgnitive impairment shuld be cnsidered equally with thse wh are cgnitively intact with regard t decisin making fr inpatient rehab admissin. In additin, fr bth sub-ppulatin grups, the task grup recmmended that rehab shuld ccur either n a dedicated MSK/Orth unit/prgram, r that a dedicated MSK/Orth rehab team prvide rehab n a mixed ppulatin (general rehab) unit. Self assessment surveys were disseminated in March with a final meeting planned fr late April/early May t review the results f the analysis. 5.0 Key Messages 5.1 Challenges in develping the definitin framewrks A cmmn challenge experienced by each f the rehab definitin task grups invlved recnciling the tensin between what ught t be prvided in rehab (i.e. recmmending a gld standard f practice) and what can be prvided within current funding restraints. Task grup members ften struggled with setting high standards fr rehabilitatin knwing that in reality, sme f the definitins wuld nt be met by mst r all prgrams. Fr example, task grup members ften fund it initially difficult t supprt the inclusin f gld standard practices when they were acutely aware that there was a lack f resurces t prvide the recmmended staffing cmplement r t accmmdate a special need (e.g. TPN r dialysis). Task grup members als struggled with recmmendatins that at times ran cunter t the very real demands placed n rganizatins t meet the needs f patients within their catchment areas. As an example, the inability t adhere t the recmmendatins fr having the required critical mass f patients fr a particular rehab ppulatin (e.g. strke) t develp and maintain the recmmended level f expertise might mean that a rehab unit in an acute care cmmunity hspital wuld decide t n lnger prvide strke rehab t patients n its mixed unit, even thugh it wuld be clser t hme fr patients within their catchment area. Nevertheless, despite these challenges, task grup members accepted that it was imprtant t set high standards twards which rganizatins culd strive rather than develp definitins that reflected the status qu in rehab prgramming, where there are knwn gaps in the type and amunt f services prvided. 5.2 What can we d better? The discussins thrughut the develpment f the varius rehab definitin framewrks have led t a better understanding f current rehab services and areas fr imprvement. The initiative has highlighted that althugh rehab prgrams are rganized arund varius rehab ppulatin grups (e.g. strke, burns, spinal crd injury), the rehab needs f patients are ften nt rganized in the same way. Fr example, a patient with spinal crd injury might als have a brain injury. A patient wh has suffered a strke might als be a frail senir and present with a number f ther needs. In a similar vein, rehab prgrams d nt always prvide the flexibility that is needed t accmmdate patients wh, in additin t their rehab needs, may als require ther medical treatments at the same time. Fr example, a rehab patient may require dialysis at the same time as she/he is participating in an inpatient rehab prgram. The discussins that ccurred amng task grup members as the rehab definitin framewrks were develped have highlighted the fllwing issues: Rehab Definitins Initiative Final Reprt / March

18 1. There are significant gaps in the system s ability t address the needs f rehab patients with multiple diagnses and/r special needs. Specifically, Structured mechanisms are required t supprt crss-prgram cnsultatin regarding the treatment f patients with multiple diagnses. The tp special care needs f patients referred t inpatient rehab and CCC whse referrals are denied by all rganizatins are: skin cnditin; equipment needs and IV (High Tlerance Lng Duratin rehab); IV, skin cnditin and xygen (Lw Tlerance Lng Duratin rehab); and behaviural issues, enteral feeds, xygen, equipment needs and skin cnditin (CCC). 6 While each f these special care needs can be accmmdated by mst rganizatins, it is the cmbinatin f special care needs and cmrbid cnditins that tends t delay r prevent access t rehab and CCC. The tw tp reasns fr denial f referrals t inpatient rehab and CCC by all prgrams are that the patient is nt rehab ready and medical needs cannt be accmmdated. 7 On-site access t diagnstic services and ther resurces are needed t address the medical cmplexity f patients referred and their special needs/cmrbid cnditins (e.g. dialysis) 8 t supprt the delivery f rehab that is respnsive t patient needs and maximizes access t and the efficient use f rehab services. 2. There is a need t re-examine the philsphy f care by which rehab is prvided t build in prgram flexibility t meet patient need. Cnsideratins in this regard include the fllwing. There is a need fr increased cmpetencies in the areas f impaired cgnitin and senirfcused principles f care acrss all rehab prgrams 9 t better meet the needs f rehab patients, almst half f whm are ver 74 years f age 10. Enhanced expertise wuld increase access t timely and quality rehab care. The cmplexity f rehab patients tday due t the presence f cmrbidities and chrnic disease calls fr the re-examinatin f hw rehab prgrams are delivered and/r measured. Fr example, Lwer length f stay benchmarks tend t serve as a disincentive t admit mre cmplex patients wh culd benefit frm a rehab prgram but wh wuld likely t exceed the average length f stay target fr the prgram. Mnitring f length f stay alne in absence f understanding patient cmplexity and number f patients seen can drive perfrmance in a directin that is nt cnsistent with system gals f patient flw and reductin f ALC. The evidence utlined in the rehabilitatin framewrks culd be used as a basis t infrm a mre apprpriate cmbinatin f indicatrs fr perfrmance measurement t supprt better flw and quality f care. A review f rganizatinal prcesses invlved in the scheduling f treatment sessins, which is typically based n a regular 9:00 t 5:00 business day schedule, is warranted t determine if these prcesses adversely affect clinical utcmes and length f stay 3. The amunt f therapy that is recmmended fr high tlerance rehab in the rehab definitin framewrks calls fr a staffing rati f 1 rehab therapist fr every 6 rehab beds. A recent plling by the Netwrk f 6 These special needs are based n data frm the TC LHIN s Resurce Matching and Referral mnthly reprts frm August 2009 t February 28, Tp reasns fr denial are based n data frm the TC LHIN s Resurce Matching and Referral mnthly reprts frm August 2009 t January 31, The average number f cmrbid cnditins amng inpatient rehab patients at admissin increases with average client age. Hypertensin and Type I r Type II Diabetes Mellitus (ften assciated with chrnic renal failure) were amng the tp three c-mrbid cnditins amng lder rehab patients. Canadian Institute fr Health Infrmatin. Inpatient Rehabilitatin in Canada, Special Tpic: A Lk at the Older Ppulatin. (2005) 9 Integrating senir-fcused principles f care acrss all sectrs f the care cntinuum is recmmended t reduce the risk f adverse events, maximize health utcmes, independence and verall well-being. 10 Canadian Institute fr Health Infrmatin. Inpatient Rehabilitatin in Canada, Special Tpic: A Lk at the Older Ppulatin. (2005). In additin, findings frm the TC LHIN Resurce Matching and Referral System (RM&R) mnthly reprts indicates that n average, 62% f patients referred thrugh the electrnic RM&R system are 70 years f age r lder (YTD figures, April 2009 February 2010). Rehab Definitins Initiative Final Reprt / March

19 the staffing ratis acrss prgrams indicates that this gld standard fr the delivery f rehab services is rarely met. In dedicated rehab prgrams (i.e. dedicated t specific rehab ppulatin) n average, 1 physitherapist is available fr every 8 beds; 1 ccupatinal therapist is available fr every 10 beds and 1 speech-language pathlgist is available fr every 23 beds r n cnsult basis nly. In mixed rehab prgrams, n average, 1 physitherapist is available fr every 9 beds; 1 ccupatinal therapist is available fr every 10 beds and 1 speech-language pathlgist is available fr every 40 beds. 6.0 Next Steps i) The Netwrk will meet with the Rehab Definitins Advisry Cmmittee t discuss the fllwing prpsed plan fr reviewing and updating each f the rehab framewrks t ensure they are cnsistent with emerging evidence and current mdels f practice. The review will be cnducted in a 2-staged prcess ver this year t first address the framewrks cmpleted in the earlier phase f the initiative. The framewrks that were cmpleted earlier this year will be reviewed in the secnd stage f this prcess. ii) iii) iv) The Netwrk will explre the requirements (technical and cst-related) fr mdifying Rehab Finder t enable the inclusin f self-assessment findings as a basis fr streamlining and rganizing its listing f rehab prgrams. In June, 2009, the Netwrk held a strategic planning sessin with its members in which the Netwrk received clear endrsement t fcus n the develpment f perfrmance indicatrs fr rehabilitatin. In respnse t this feedback, the Netwrk will examine hw the Rehab Definitins initiative and its findings can infrm the identificatin f health system perfrmance indicatrs fr rehabilitatin. The identificatin f perfrmance indicatrs and benchmarks will be based n (1) their relevance t rehabilitatin, clinical utcmes and administrative prcesses (e.g. wait times); and (2) their alignment with the rehab definitin framewrks acrss rehabilitatin sectrs (e.g. inpatient rehab, utpatient rehabilitatin). This wrk may als include the identificatin f indicatrs specific t the measurement f structured mechanisms that facilitate crss-prgram cnsultatin. The Netwrk has submitted preliminary cnsideratins fr the develpment f such indicatrs and benchmarks t the TC LHIN in its December 2009 reprt, System Perfrmance Indicatrs fr Rehabilitatin/CCC. The Netwrk will cmmunicate a summary f the findings frm the self-assessment surveys t senir administratin at each member rganizatin and infrmatin abut the key learnings frm the initiative, including aggregate findings frm the self-assessment surveys. v) The GTA Rehab Netwrk will be wrking t use the results frm the self-assessment surveys alng with infrmatin frm ther data surces (e.g. NRS, TC LHIN RM&R system) t further investigate current rehab capacity, demand and gaps in services acrss the freestanding rehab/ccc hspitals as the Netwrk mves frward t supprt system imprvement and planning. Rehab Definitins Initiative Final Reprt / March

20 APPENDIX A: REHAB DEFINITIONS ADVISORY COMMITTEE & TASK GROUP MEMBERSHIP Rehab Definitins Advisry Cmmittee GTA Rehab Netwrk Staff Supprt: Charissa Levy, Executive Directr; Sue Balgh, Prject Planner/Crdinatr Dr. Mark Bayley, Medical Directr, Neurrehab Prgram, Trnt Rehab (Chair) Dnna Barker, University f Trnt Angela Chan, Baycrest James Fx, Prvidence Healthcare Kim Grtveld, St. Michael s Hspital Lynn Guerrier/Sandy Cx, Blrview Kids Rehab Mary Ann Neary, University Health Netwrk Linda Marabini, Castleview-Wychwd Twers Heather Brien/ Sharn McCarthy, TC CCAC Cathy Pierce, Markham Stuffville Hspital Heather Reid, Ruge Valley Health System Karyn Lumsden, Credit Valley Hspital ABI/Neur Rehab Definitins Task Grup GTA Rehab Netwrk Staff Supprt: Charissa Levy, Executive Directr; Judy Mir, Prject Planner/Crdinatr Dr. Mark Bayley, Medical Directr, Neurrehab Prgram, Trnt Rehab (Chair) Nancy Bar, Trnt Rehab Dr. Chris Bulias, West Park Healthcare Centre Sibhan Dnaghy, St. Jhn s Rehab Hspital Catherine Dyle, Central CCAC Dr. Gary Gerber, West Park Healthcare Centre Liz Inness, Trnt Rehab Dr. Carlyn Lemsky, Cmmunity Head Injury Resurce Services Cra Mncada, Trnt ABI Netwrk Mary Ann Neary, University Health Netwrk Dr. Peter Rumney, Blrview Kids Rehab Jan DeBruyn, Trillium Health Centre Sledad Silencieux, Bridgepint Health Estella Tse, Sunnybrk Health Sciences Centre Dr. Milan Unarket, Bridgepint Health Amputee Rehab Definitins Task Grup GTA Rehab Netwrk Staff Supprt: Charissa Levy, Executive Directr; Sarah Dimmck, Prject Planner/Crdinatr; Hannah Se, Prject Planner/Crdinatr Dr. Michael Devlin, Physiatrist, West Park Healthcare Centre (Chair) Sandy Beckett, Credit Valley Hspital Janet Bdy, West Park Healthcare Centre Shirlene Campbell, St. Jhn s Rehab Hspital Karen Fairley, SCIL Sunnybrk Health Sciences Centre Stefania Lehkyj, West Park Healthcare Centre Jane Turner, West Park Healthcare Centre Brad VanLenthe, Blrview/Private Practice Julia Filinski, Prvidence Health Judy Langfrd, Calmar Orthpaedics Burns Rehab Definitins Task Grup GTA Rehab Netwrk Staff Supprt: Charissa Levy, Executive Directr; Sarah Dimmck, Prject Planner/Crdinatr; Hannah Se, Prject Planner/Crdinatr Dr. Jel Fish, Chief Medical Officer, St. Jhn s Rehab Hspital (Chair) Nisha Umraw, Sunnybrk Health Sciences Centre Paula Gardner, St. Jhn s Rehab Hspital Vera Fung, St. Jhn s Rehab Hspital Barbara Panturescu, St. Jhn s Rehab Hspital Jennifer Fentn, SickKids Jamil Lati, SickKids Barbara Szelinski-Sctt, Children s Hspital f Eastern Ontari Hlly Pattersn, Hamiltn Health Sciences Gwen St. Jhn, Lndn Health Sciences Centre Nives McDnald, The Ottawa Hspital Denette Pacific, Thunder Bay Reginal Hspital Luisa Bellemare, Armstrng Physi, Timmins Rehab Definitins Initiative Final Reprt / March

21 Cardiac Rehab Definitins Task Grup GTA Rehab Netwrk Staff Supprt: Judy Mir, Prject Planner/Crdinatr; Tina Saryeddine, Prject Planner/Crdinatr Dr. Paul Oh, Medical Directr, Cardiac Rehabilitatin & Secndary Preventin, Trnt Rehab (Chair) Anne Tmpkins, Haltn Healthcare Carl Ois/Cllene Traille-Brwn, William Osler Health Centre Heather Haines, Credit Valley Hspital Janet Dmingues, Suthlake Reginal Health Centre Jim Pagiamtzis, Cardiac Care Netwrk f Ontari Linda Nasturzi, St. Jhn s Rehab Margaret Williams, St. Jseph s Health Centre Martha Strng, Trnt Rehab Nicle Smith, St. Jseph s Health Centre Paul Sawyer, Lakeridge Health Terry Fair, Trillium Health Centre Marc Davies, William Osler Health Centre Mnica Panetta, Credit Valley Hspital Pat Schley, Cardiac Care Netwrk Pulmnary Rehab Definitins Task Grup GTA Rehab Netwrk Staff Supprt: Charissa Levy, Executive Directr, Sarah Dimmck, Prject Crdinatr/Planner; Hannah Se, Prject Crdinatr/Planner Dr. Rger Gldstein, Respirlgist, West Park Health Care Centre (Chair) Dina Brks, West Park Health Care Centre Debbie Cutts, Credit Valley Hspital Kristine Weinacht, Trnt East General Hspital Raj Khli, West Park Health Care Centre Maria Lahey, Trillium Health Centre Carle Madeley, The Lung Assciatin Shirley Price, West Park Health Care Centre Geriatric Rehab Task Grup GTA Rehab Netwrk Staff Supprt: Charissa Levy, Executive Directr; Sue Balgh, Prject Planner/Crdinatr; Kathy Wheeler, Cnsultant Dr. Mark Bayley, Medical Directr, Neurrehab Prgram, Trnt Rehab (Chair) Carl Andersn, Lakeridge Health Judy Bnham, Bridgepint Health Tanya Diamnd, Yrk Central Hspital Alexis Dishaw, Trnt Grace Health Centre Dr. Jhn Flannery, Trnt Rehab James Fx/ Carl Jarman, Prvidence Healthcare Linda Jacksn, Baycrest Dr. Barbara Liu, Reginal Geriatric Prgram f Trnt Mary Lynne MacMaster/ Sandra Dickau, St. Jseph s Health Centre Paul Man-Sn-Hing, Trnt East General Hspital Kim Khlberger, Haltn Healthcare Services Dnna Renzetti, West Park Healthcare Centre Sandra Tully, UHN Trnt Western Hspital Laurence Wlfsn, William Osler Health Centre Charlie Yang, St. Michael's Hspital Dr. Shelly Veinish/ Angela Chan, Baycrest Anne Stephens, St. Michael's Hspital Onclgy Rehab Definitins Task Grup GTA Rehab Netwrk Staff Supprt: Charissa Levy, Executive Directr; Judy Mir,Executive Directr (Acting); Sue Balgh, Prject Crdinatr/Planner, Rhnda Galbraith, Vice-President, Patient Prgrams/Chief Nursing Officer, St. Jhn s Rehab Hspital (Chair) Gerry Beaudin, Sunnybrk Health Sciences Centre Susan Blacker, St. Michael s Hspital Rbin Frbes, Princess Margaret Hspital/University Health Netwrk Barbara Jacksn, Sunnybrk Health Sciences Centre Gina Lam, St. Jhn s Rehab Hspital Amber Oke, Mt. Sinai Hspital Lisa Rezler, Trnt CCAC James Fx, Prvidence Healthcare Cathy Lacmbe, Prvidence Healthcare Linda Nasturzi, St. Jhn s Rehab Hspital Heather Flett, Lyndhurst Centre/Trnt Rehab Barb Hper, St. Michael s Hspital Renay Benll, Hillcrest Centre/Trnt Rehab Mandy McGlynn, Hillcrest Centre/Trnt Rehab Rehab Definitins Initiative Final Reprt / March

22 MSK/Trauma Rehab Definitins Task Grup GTA Rehab Netwrk Staff Supprt: Charissa Levy, Executive Directr; Hannah Se, Prject Planner/Crdinatr; Judy Mir, Prject Planner/Crdinatr Dr. Susan Jaglal, University f Trnt/Trnt Rehab Institute (Chair) Angela Chan, Baycrest Hspital Sang Chi, Credit Valley Hspital Dr. Aileen Davis, University Health Netwrk Jan DeBruyn, Trillium Health Lri Edwards / Derek Glazier, Trnt East General Hspital Dr. Jhn Flannery, Trnt Rehabilitatin Institute Maureen Hunt, Ruge Valley Health System Gerry Hubble, Sunnybrk Health Sciences Centre Debbie Kennedy, Sunnybrk Health Sciences Centre Crystal MacKay, ACREU Dr. Kathy McGiltn, Trnt Rehabilitatin Institute Mandy McGlynn, Trnt Rehabilitatin Institute Janet Mulgrave, West Park Healthcare Centre Leeanne Smith / Julie Langtn, Lakeridge Health Leslie Sever, Mt. Sinai Hspital Ruth Ann Sullivan, Prvidence Health Dr. Sharn Switzer-McIntyre, University f Trnt Dr. Fina Webster, Sunnybrk Health Sciences Centre Riki Yamada, Suthlake Reginal Health Centre Bayla Zahler, Bridgepint Health Spinal Crd Injury Rehab Definitins Task Grup GTA Rehab Netwrk Staff Supprt: Judy Mir, Executive Directr (Acting); Sue Balgh, Prject Crdinatr/Planner Mary Ann Neary, Clinical Directr, Neurscience and Allied Health, University Health Netwrk (Chair) Tracy Anthny, Sunnybrk Health Sciences Centre Peter Athanaspuls, Canadian Paraplegic Assciatin Ontari Dr. Anthny Burns, Trnt Rehab Karen Davies, Trnt CCAC Andrea Dyrkacz, University Health Netwrk Heather Flett/Kristina Guy, Trnt Rehab Dr. Chantal Graveline, Trnt Rehab Jacqueline Hustn, St. Michael s Hspital Nick Iannidis/Bnnie Smith, Trnt Rehab Chantal Letang, Sunnybrk Health Sciences Centre Janet Mulgrave, West Park Healthcare Centre Linda Nasturzi, St. Jhn s Rehab Hspital Tracy Paulenk, Trnt Rehab Nijle Simnavicius, Trillium Health Centre Kevin White, University Health Netwrk Meredith Burley, Canadian Paraplegic Assciatin Ontari Strke Rehab Definitins Task Grup GTA Rehab Netwrk Staff Supprt: Charissa Levy, Executive Directr; Heather Brien, Acting Executive Directr; Sue Balgh, Prject Crdinatr/Planner Dr. Mark Bayley, Medical Directr, Neurrehab Prgram, Trnt Rehab Institute (Chair) Dr. Chris Bulias, West Park Healthcare Centre Shawn Brady, Prvidence Healthcare Dnna Cheung, Suth East Strke Netwrk Yvnne Cheung, Amputee and Neurlgical Rehabilitatin Services, West Park Healthcare Centre Catherine Chuang, St. Jhn s Rehab Hspital Jackie Eli, Prgram Bridgepint Health Anne McEwen, St. Jhn s Rehab Hspital Carline Gangji, Heart and Strke Fundatin f Ontari Janna Schechter, Baycrest Maria Huijbregts, Baycrest Anita Jacbsn, Scarbrugh CCAC Carl Jarman, Prvidence Healthcare Dr. Dmytr Rewilak, Psychiatry Prgram and Strke Clinic, Baycrest Shelley Santerre, Lakeridge Health Dr. Jn Ween, Strke Clinic, Brain Health Clinic, Baycrest Carmel Frrestal, West GTA Strke Netwrk Rehab Definitins Initiative Final Reprt / March

23 Outpatient & Cmmunity I n p a t I e n t APPENDIX B Rehab Definitin Cnceptual Framewrk Institutinal Setting Inpatient Rehab in Acute Care r Rehab Hspitals* Acute Care Integrated Specialized Units Transitinal Care in Acute Care, LTC r CCC Nt recmmended fr sme ppulatins Mixed Rehab Unit Dedicated Rehab Unit Hme / Residential Outpatient/Ambulatry Rehab in Acute Care Hspitals, Rehab Hspitals and Cmmunity Health Centres/Clinics* Lw Tlerance Lng Duratin (LTLD/slwstream) Rehab Prgram Cmmunity* (Rehab prvided in hme, schl r wrk envirnment) * Each Rehab sectr is defined by: Services Prvided Degree f Specializatin Differential Criteria Typical Duratin Key Activities / Nature f Services Names Typically Used Frequency f Therapy Single Service Dedicated Inter- Prfessinal Team** Mixed Ppulatin Inter- Prfessinal Team** Wellness Fcused Rehab Grups Single Service Dedicated Interprfessinal Team *Fr sme ppulatins, Dedicated and Single Service Rehab teams are nt differentiated. Rehab 2007 Definitins GTA Rehab Initiative Netwrk. Final Cntents Reprt f / this March publicatin 2010 may be reprduced either whle r in part prvided the intended use is fr nn-cmmercial purpses and 20 full acknwledgment is given t the GTA Rehab Netwrk.

24 OBJECTIVES: GUIDING PRINCIPLES I. Increase clarity and cnsistency in the frms f cgnitive and physical rehab acrss the cntinuum by: 1. Clarifying the distinctins between and acrss institutinal and cmmunity-based rehab prgrams. 2. Classifying prgrams with cnsistent terminlgy. 3. Describing the key features f institutinal and cmmunity-based rehabilitatin prgrams based n the services prvided, the degree f specializatin, differential/critical criteria, duratin, and the primary fcus f the rehab prgram/service. II. Infrm planning and perfrmance measurement thrugh the develpment f standards fr rehab prgram cmpnents against which rehab prgrams can be benchmarked. GUIDING PRINCIPLES: 1. The Rehab Definitins Cnceptual Framewrk presuppses the Wrld Health Organizatin s definitin f rehabilitatin as a prgressive, dynamic, gal-riented and ften time-limited prcess, which enables an individual with an impairment t identify and reach his/her ptimal mental, physical, cgnitive and/r scial functinal level. Rehabilitatin prvides pprtunities fr the individual, the family and the cmmunity t accmmdate a limitatin r lss f functin and aims t facilitate scial integratin and independence." 2. The Rehab Definitins Cnceptual Framewrk refers t cgnitive and physical frms f rehabilitatin acrss the cntinuum. The rehab cnceptual diagram refers t acute care, inpatient rehab prgrams within institutinal settings and utpatient and cmmunity-based rehab fr clients residing at hme r in a residential setting. The use f bi-directinal arrws in the schematic reflects the flw f patients and cntinuity f care acrss these settings. 3. The framewrk identifies key features f rehab prgrams based n evidence-based practices where available t define the gld standard f rehab care (e.g. rehab beds are clustered tgether). In mst instances these key features reflect current practices; hwever, sme rganizatins may be required t implement changes within their rganizatins t achieve cnsistency with the criteria set ut in the framewrk. 4. The term patient is used fr individuals receiving rehabilitatin in a hspital setting. The term client is used t refer t individuals receiving cmmunity rehab services. 5. The Rehab Definitins Cnceptual Framewrk uses categries that have been defined based n the rehab needs f the patient and the typical services prvided. Length f stay r the type f facility in which the rehab is prvided is nt cnsidered essential t defining rehab sectrs. 6. The Rehab Definitins Cnceptual Framewrk is based n the assumptin that clients participating in the prgrams described have rehab ptential and rehab gals. Fr criteria regarding rehab ptential, medical stability and rehab readiness fr inpatient rehab, refer t the GTA Rehab Netwrk s Inpatient Rehab Referral Guidelines ( 7. The framewrk uses terminlgy that is cnsistent with the MOHTLC guidelines fr inpatient rehabilitatin beds and can be applied t cmmunity and ambulatry service delivery. 8. While it is appreciated that much f rehabilitatin ccurs in third-party payer assessment centres r private clinics, the framewrk refers t publiclyfunded rehabilitatin. Hwever, it is hped that the framewrk will prmte cnsistency in standards f care and equitable access acrss all rehab prgrams. 9. Input frm healthcare prviders representing acute care, reginal rehab centres and cmmunity-based rganizatins that prvide adult (including geriatric) and paediatric rehab has been btained t validate the Rehab Definitins Cnceptual Framewrk. Rehab Definitins Initiative Final Reprt / March

25 GLOSSARY OF REHAB COMPONENT TERMS Cre Team: Cre team refers t the team members wh are essential, actively invlved in the assessment and treatment (if required) f rehab patients n the unit and wh participate regularly in team runds. Dedicated Interprfessinal Team (Cmmunity): Rehab prvided in the hme, schl r wrk envirnment by an interprfessinal team using a crdinated, integrated apprach fr specific rehab ppulatins r t reduce the impact f a particular disability. Dedicated Interprfessinal Team (Outpatient/Ambulatry Rehab): Outpatient rehab prvided by an interprfessinal team with expertise in the treatment and assessment f a particular patient ppulatin. Outpatient/Ambulatry dedicated interprfessinal teams are lcated in acute care hspitals, rehab hspitals and cmmunity health centres/clinics. They prvide rehab t patients wh require mre than ne rehab service and a crdinated rehab apprach. Dedicated Rehab Unit: An inpatient rehab unit lcated in acute care and rehab hspitals that serves a single patient ppulatin grup and prvides intensive rehabilitatin. Sme units may specialize in mre than ne diagnsis in related ppulatins (e.g. Cardi/Respiratry, Orthpaedic/Amputatin, etc.). A dedicated rehab unit is suitable fr individuals wh require 24-hur hspital care and wh are in need f an interprfessinal rehab prgram using a crdinated rehab apprach. Lw Tlerance Lng Duratin (LTLD/slwstream) Rehab Prgram: Suitable fr individuals in need f an interprfessinal rehab apprach t address specific rehab gals wh als have chrnic/cmplex cnditins requiring 24-hur hspital care and wh are expected t benefit frm a slwerpaced rehab prgram fr a lnger duratin than is ffered in dedicated r mixed rehab prgrams. LTLD rehab is mst cmmnly delivered in a cmplex cntinuing care bed but may als be prvided in a designated rehab bed. LTLD rehab prgrams may be lcated in acute care, rehab r cmplex cntinuing care hspitals. Mixed Ppulatin Interprfessinal Team (Outpatient/Ambulatry Rehab): Outpatient rehab that is prvided by an interprfessinal team, which typically assesses and treats patients frm a variety f patient ppulatin grups. Outpatient/Ambulatry mixed ppulatin interprfessinal teams are lcated in acute care hspitals, rehab hspitals and cmmunity health centres/clinics. They prvide rehab t patients wh require mre than ne rehab service and a crdinated rehab apprach. Mixed Rehab Unit: Frmerly referred t as a General inpatient rehab unit, this type f unit is lcated in acute care and rehab hspitals, prvides intensive rehabilitatin and serves a variety f patient ppulatin grups. The mixed rehab unit is suitable fr individuals wh require 24-hur hspital care and are in need f an interprfessinal rehab prgram using a crdinated apprach. Single Service (Cmmunity): Individual rehab services that are usually prvided thrugh Cmmunity Care Access Centres. Single rehab services are suitable fr individuals wh are in need f ne r mre rehabilitatin services in single specialty area(s)/prfessin(s) prvided in the hme, schl r wrk envirnment. Althugh clients may receive mre than ne service, a crdinated apprach is nt used as rehab prviders typically wrk as individual prviders. Hwever, sme cmmunicatin with ther health prviders may ccur n an as-needed basis. Single Service (Outpatient/Ambulatry Rehab): An utpatient rehab service lcated in acute care hspitals, rehab hspitals and cmmunity health centres/clinics that is suitable fr individuals wh are in need f an utpatient rehabilitatin service in a single specialty area/prfessin. Clients may receive mre than ne rehab service; hwever, the services are nt prvided by way f a crdinated rehab apprach. Services may include assessment nly r assessment and treatment. Services may be prvided during a ne-time visit r multiple visits. Wellness Fcused Rehab Grups: These grups are prvided in an utpatient/ambulatry setting and led by an individual rehab prvider r team r rehab specialists t enhance an individual s ability t cpe with a particular disability r impairment. These time-limited grups are publicly-funded althugh a small fee may be charged fr materials. Rehab Definitins Initiative Final Reprt / March

26

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