December 1, 2014 Webinar: Draft Definitions Framework for Community Based Levels of Rehabilitative Care Presenters: Charissa Levy, Executive Director

Transcription

1 December 1, 2014 Webinar: Draft Definitions Framework for Community Based Levels of Rehabilitative Care Presenters: Charissa Levy, Executive Director Sue Balogh, Project Manager

2 Webinar Overview 1. Welcome 2. Objectives of the Webinar 3. Background on: The Rehabilitative Care Alliance (RCA) The RCA s Definitions Task and Advisory Groups 4. In-Depth Look at the Draft Definitions Framework for Community-Based Rehabilitative Care 5. Discussion/Questions 2

3 Webinar Objectives 1. To provide information to healthcare professionals about: The Rehabilitative Care Alliance (RCA) The RCA s Definitions Task and Advisory Groups Purpose, objectives, structure and content of the Draft Definitions Framework for Community Based Levels of Rehabilitative Care 2. To provide an opportunity for feedback on the Draft Definitions Framework for Community Based Levels of Rehabilitative Care 3

4 What is the Rehabilitative Care Alliance? 4

5 Strategic Directive The Rehabilitative Care Alliance is a province-wide collaborative established by the LHINs for the purpose of effecting positive changes for rehabilitative care across Ontario. Through the development of standardized frameworks, toolkits, and processes, the Alliance is working to promote best practice to enhance outcomes for people receiving rehabilitative care. Priority Initiatives Rehabilitative Care Definitions Framework Frail Senior/ Medically Complex Outpatient/ Ambulatory Capacity Planning & System Evaluation Planning Considerations for Rehab/CCC Bed Re- Classification Term April 2013 March

6 LHIN CEOs Rehabilitative Care Alliance Steering Committee Co-Chairs Donna Cripps and Peter Nord MOHLTC GTA Rehab Network Secretariat Accountable to LHIN CEOs through Alliance Co-Chairs Definitions Task & Advisory Groups FS/MC Task & Advisory Groups CP & SE Task & Advisory Groups Outpatient / Ambulatory Task & Advisory Groups Planning Considerations for Rehab/CCC Beds LHIN & HSP Leads Advisory Group Dale Clement Halton Healthcare Dr. Jo-Anne Clarke North East SGS Marianne Walker Guelph General Hospital Marie Disotto-Monastero, Sunnybrook HSC Michael Gekas, Bridgepoint Dr. Peter Nord RCA Co-Chair & Providence Healthcare Mark Edmonds, CW LHIN & Andrea Lee Health Sciences North Membership Membership Membership Membership Membership Membership ENABLERS GTA Rehab Secretariat Support (Communication, Stakeholder Engagement, Coordination/Administration, Decision Support etc.) Contextual/Influencing Initiatives (PRS, CCAC Coordinated Access Role, Assess & Restore, PT Reform, etc.) Patient/Caregiver Advisory Group Charissa Levy, RCA Executive Director Membership

7 Definitions Task and Advisory Groups The mandate of the Definitions Task and Advisory Groups is to develop standardized definitions that describe rehabilitative care resources across the continuum The 1st phase of the Task and Advisory Groups work has focused on the development and completion of the Definitions Framework for Bedded Levels of Rehabilitative Care. This framework refers to rehabilitative care that is provided in hospital-based designated inpatient rehab beds and complex continuing care beds as well as convalescent care beds within Long Term Care Homes The 2 nd phase, currently underway, is focused on the drafting of a Definitions Framework for Community-Based Levels of Rehabilitative Care 7

8 What is the Draft Definitions Framework for Community-Based Levels of Rehabilitative Care? 8

9 Definitions Framework for Community-Based Levels of Rehabilitative Care Refers to rehabilitative care that is: Publicly-funded (i.e. LHIN or MOHLTC funded) Provided by or under the supervision of regulated health professionals Of a primary rehabilitative care focus to improve function or maintain / prevent functional decline.* *Note: While wellness focused health promotion/prevention programs that are not provided by or supervised under regulated health professionals are beyond the scope of the Definitions Framework for Community Levels of Rehabilitative Care, it is acknowledged that such programs play an important role in the system by promoting overall health and supporting patients /clients reintegration into the community. 9

10 Definitions Framework for Community- Based Levels of Rehabilitative Care Objectives To provide clarity for clients, families and referring professionals on the community-based levels of rehabilitative care through definitions for each level that describe: goals for levels of care target populations medical and healthcare professional resources overall focus and underlying principles for therapy services provided in the community. To support appropriate/efficient use of rehabilitative care system resources through the description of resources within each level of community based rehabilitative care To provide an understanding of current state resources to inform capacity planning 10

11 Eligibility Criteria for Communitybased Rehabilitative Care The patient/client has restorative potential* or s/he requires rehabilitative care to prevent functional decline and The patient/client is medically stable enough such that s/he is able to participate in and benefit from rehabilitative care (i.e., carry-over for learning) within the context of his/her specific functional goals; and The patient/client has identified goals that are specific, measurable, realistic and timely. *See next slide for definition of Restorative Potential 11

12 Restorative Potential Criteria for Community-based Rehabilitative Care Restorative Potential means that there is reason to believe (based on clinical assessment and expertise and evidence in the literature where available) that the patient's/client s condition is likely to undergo functional improvement and benefit from rehabilitative care. The degree of restorative potential and benefit from the rehabilitative care should take into consideration the patient s/client s: Premorbid level of functioning Medical diagnosis/prognosis and co-morbidities (i.e., is there a maximum level of functioning that can be expected owing to the medical diagnosis /prognosis?) Ability to participate in and benefit from rehabilitative care within the context of the patient s/client s specific functional goals and direction of care needs Note: Determination of whether a patient/client has restorative potential includes consideration of all three of the above factors. Cognitive impairment, depression and delirium should not be used in isolation to influence a determination of restorative potential. 12

13 What is the structure of the framework? The framework is divided into 2 parts: Step 1: Describes 2 levels of rehabilitative care (i.e. progression and maintenance) and for each level, the functional goals, patient characteristics and the medical and healthcare professional resources (e.g. allied health, nursing) that ideally should be provided. This part is used to determine which level of rehabilitative care would best meet the needs of a patient/client Step 2: Provides a flow chart for determining the location of community-based rehabilitative care Determination of where the client receives communitybased rehabilitative care is based on which environment would be best suited to achieve the client s rehabilitative care goals including consideration of resource/equipment needs, individual vs. group treatment modalities, and the capacity of clients to travel outside of the home. 13

14 Step 1: Determine which level of communitybased rehabilitative care would meet the needs of the patient/client CONCEPTUAL DEFINITIONS FRAMEWORK FOR COMMUNITY LEVELS OF REHABILITATIVE CARE (Draft) These definitions pertain to publicly-funded programs (i.e. LHIN or MOHLTC funded) with a primary rehabilitative care focus provided by or under the supervision of regulated health professionals. Patient Characteristics Medical / Healthcare Professionals Functional Trajectory Progression Maintenance Level of Care - Goal Target Population / Functional Characteristics Transition Indicator Medical Care Nursing/Therapy Care Wellness/Health Promotion Post-Rehabilitation Community Reintegration* Wellness/health promotion programs provided by non-regulated health professionals (see *Note) after illness/injury to halt/slow disease process, help individuals manage health problems and to support community reintegration These programs should be considered by providers within the defined levels of rehabilitative care when discharge planning and transitioning clients to self-management activities. Reporting Tools Step 2: Determine location of communitybased rehabilitative care Can the patient s/ client s functional goal(s) be met in an outpatient/ community setting? YES NO *Refer to Definitions Framework for Rehabilitative Care Is the overall functional trajectory of rehabilitative care progression (i.e. to restore or maximize functional abilities)? * NO Is the overall functional trajectory of rehabilitative care maintenance (i.e. to prevent functional decline/injury or maintain functional performance)? * If client lives: at home -- Refer for In-home rehabilitative care services** in a LTCH -- Contact the LTCH to discuss referral to rehabilitative care services. NO YES YES Consider other care plans Based on patient/client complexity, if a single or specialized rehabilitative care service or interdisciplinary team approach is needed that is not otherwise available in a community-based clinic, refer to a program/service delivered by a hospital-based team. 1 Refer patient/client to community clinics/ resources/services (e.g. Falls prevention classes; seating clinics etc.) 1 1 Determination of location is based on which environment would be best suited to achieve the client s rehabilitative care goals including consideration of resource/ equipment needs, individual vs. group treatment modalities, and the capacity of clients to travel outside of the home. **In-Home Rehabilitative Care Eligibility Typically a valid OHIP card is required and services are provided by Community Care Access Centres. For eligibility, see Home Care and Community Services Act, 1994, Ontario Regulation 386/99, Section There may be other local publicly funded programs with their own requirements that are available *While wellness focused health promotion/prevention programs that are not provided by or supervised under regulated health professionals are beyond the scope of the Definitions Framework for Community Levels of Rehabilitative Care, it is acknowledged that such programs play an important role in the system by promoting overall health and supporting patients reintegration into the community. Examples of these programs include: Group exercise; wellness promotion classes; swimming; walk-fit; yoga; Tai-Chi; Pilates; peer support and friendly visiting programs. 14

15 CONCEPTUAL DEFINITIONS FRAMEWORK FOR COMMUNITY LEVELS OF REHABILITATIVE CARE (Draft) These definitions pertain to publicly-funded programs (i.e. LHIN or MOHLTC funded) with a primary rehabilitative care focus provided by or under the supervision of regulated health professionals. Functional Trajectory Progression Maintenance Level of Care - Goal Step 1: Determine which level of Target communitybased Functional Population / rehabilitative Characteristics care would Transition meet the Indicator needs of the Medical Care patient/client Nursing/Therapy Care Reporting Tools Patient Characteristics Medical / Healthcare Professionals *While wellness focused health promotion/prevention programs provided by non-regulated health professionals are not part of the Definitions Framework for Community Levels of Rehabilitative Care, it is acknowledged that such programs play an important role in the system by promoting overall health and supporting patients reintegration into the community. Examples of these programs include: Group exercise; wellness promotion classes; swimming; walk-fit; yoga; Tai-Chi; Pilates; peer support and friendly visiting programs. Wellness/Health Promotion Post-Rehabilitation Community Reintegration* Wellness/health promotion programs provided by nonregulated health professionals (see *Note) after illness/injury to halt/slow disease process, help individuals manage health problems and to support community reintegration These programs should be considered by providers within the defined levels of rehabilitative care when discharge planning and transitioning clients to self-management 15 activities.

16 Step 2: Determining location of community-based rehabilitative care. Can the patient s/ client s functional goal(s) be met in an outpatient/ community setting? YES NO NO Is the overall functional trajectory of rehabilitative care progression (i.e. to restore or maximize functional abilities)? * YES Is the overall functional trajectory of rehabilitative care maintenance (i.e. to prevent functional decline/injury or maintain functional performance)? * If client lives: at home -- Refer for In-home rehabilitative care services** in a LTCH -- Contact the LTCH to discuss referral to rehabilitative care services. *Refer to Definitions Framework for Rehabilitative Care Based on patient/client complexity, if a single or specialized rehabilitative care service or interdisciplinary team approach is needed that is not otherwise available in a community-based clinic, refer to a program/service delivered by a hospital-based team. 1 NO YES Refer patient/client to community clinics /resources/ services (e.g. Falls prevention classes; seating clinics etc.) 1 Consider other care plans 1 Determination of location is based on which environment would be best suited to achieve the client s rehabilitative care goals including consideration of resource/ equipment needs, individual vs. group treatment modalities, and the capacity of clients to travel outside of the home. **In-Home Rehabilitative Care Eligibility Typically a valid OHIP card is required and services are provided by Community Care Access Centres. For eligibility, see Home Care and Community Services Act, 1994, Ontario Regulation 386/99, Section elaws_regs_990386_e.htm There may be other local publicly funded programs available with their own requirements 16

17 How is the content within the framework organized? 17

18 Organization of Content in Framework 1. Functional Trajectories Rehabilitative Care Levels based on 2 functional trajectories Progression Maintenance 2. Level of Care Goals 3. Patient Characteristics 4. Medical / Healthcare Professionals Target Population/Functional Characteristics Transition Indicator Medical Care Healthcare Professionals (Therapy Care) 18

19 Functional Trajectories: Progression & Maintenance Progression - Goal To provide assessment and time limited treatment through a single service or coordinated, inter-professional approach to: Restore or maximize functional abilities (including cognitive capacities in all aspects of living) Promote adaptation of/to the home environment to support reintegration to community and overall quality of life Support timely transition from or prevent admission to acute care or a bedded level of rehabilitative care Provide the opportunity to learn and practice in a familiar, stimulating and supportive environment Maintenance - Goal To prevent functional decline/injury or maintain functional performance (e.g. strength, mobility, balance, falls prevention etc.) through: Individual assessment/treatment to address functional impairments, including chronic disease selfmanagement Periodic assessment and oversight of care plan by regulated health professional/team to determine the need for engagement of additional rehab professionals depending on client need and availability of family support or informal care networks 19

20 Target Populations Progression Individuals who following acute episodes or the worsening of symptoms due to a debilitating event or progressive condition including chronic disease, pain, injury or surgical procedure: Have functional impairments resulting in decreased function (e.g. reduced functioning in ADLs, mobility, communication, cognition, swallowing or mobility etc.) Require rehabilitation to achieve functional goals, increase selfmanagement skills and maximize community reintegration Do not require a bedded level of care. Maintenance Individuals with reduced physical/cognitive/speechlanguage functioning (e.g. neuromuscular, musculoskeletal and cardio-respiratory etc.) who require rehabilitative care to prevent a decline in functional status and/or to promote their capacity to remain at home. Individuals living in the community (home, retirement homes, LTCHs) who have functional goals that can be met by participating in group intervention, which could include falls prevention classes. Note: Some individuals (i.e. those aging with a chronic disability where a decline might be anticipated) may need to move between the levels of rehabilitative care to address a new functional goal/treatment plan (e.g. client with Multiple Sclerosis developing the need for an Ankle Foot Orthosis or an aging client with paraplegia who develops shoulder osteoarthritis from years of transfers). 20

21 Transition Indicators Progression Determined by the following considerations: When individuals have achieved their identified therapeutic objectives / functional goals as per the client s treatment plan or Reasonably equivalent gains can be achieved independently or with the assistance of a caregiver at home or through self-care or wellness/health promotions classes (e.g. exercise classes) or other appropriate resources in the community or No further gains are likely to be achieved (i.e. a plateau has been reached) Maintenance Determined by the following considerations: When individuals have achieved their identified therapeutic objectives / functional goals as per the client s treatment plan to prevent decline in function or Reasonably equivalent gains can be achieved independently or with the assistance of a caregiver at home or through self-management or wellness/health promotions classes (e.g. exercise classes) or other appropriate resources in the community Individuals have the opportunity to transition back into the Maintenance level if intermittent assessment and/or intervention are needed. Individuals may transition to the Progression level of community-based rehabilitative care or to a bedded level of rehabilitative care to address the onset of a new condition or change in treatment plan Note: At each transition point, mechanisms for the coordination and communication of the postdischarge rehabilitative care plan with the receiving provider(s) and patient and families/caregivers should be in place to support a successful transition. (Health Quality Ontario) 21

22 Who is involved in providing rehabilitative care? Medical Care: Medical care/management may be provided by a primary care practitioner (e.g. Family Physician, Nurse Practitioner) as well as by those focused on rehabilitative care (e.g. physiatrists, geriatricians, paediatricians and/or other specialists) Regulated health professionals: May include but are not limited to: Physiotherapists, Occupational Therapists, Speech-Language Pathologists, Social Workers, Registered Nurses, Dietitians, Psychologists, Chiropodists, and Kinesiologists 22

23 Core Features of Rehabilitative Care by Medical/Healthcare Professionals Rehabilitative care provided by medical, nursing and allied health providers Is client-centred and based on the client s assessed care needs and goals Includes a written plan of care for each person receiving the service Is coordinated and uses a collaborative model of care where there are mechanisms in place to support effective case coordination/management and communication among all members of the rehabilitative care team and the primary care practitioner Involves the client, family and/or informal caregivers in care planning, with the client s consent 23

24 Common features of therapy services for progression/maintenance Therapy services: Are provided by or under the supervision of a minimum of one regulated health professional (RHP) or by an integrated, inter-professional team with expertise in the client s condition(s) and an understanding of associated pre-morbid conditions. Some programs may use therapy assistants under the supervision of a RHP May include interventions to improve: ADL, communication; cognition; swallowing; balance; lower /upper extremity strength; mobility; ability to transfer/move in bed; functional transfers; seating and positioning; behaviours; safety, adaptive equipment; coping including emotional functioning and adjustment to disability; independence and return to vocational activities. May be primarily consultative or assessment-based for assistive devices needs (e.g. seating clinics & Assistive Devices Programs; Augmentative Communication Clinics) or to address other impairments or disability (e.g. Spasticity Clinic; Vocational Rehab; Geriatric Assessment; Follow-up appointments following discharge) 24

25 Common features of therapy services for progression/maintenance May be provided in individual or group format May include rehab groups that are led by a RHP or team to enhance an individual s ability to cope with impairments, activity limitations and participation restrictions. The number and frequency of services are based on the treating therapist s assessment, evidencebased best practices and the client s individual needs. 25

26 Therapy services specific to each level Progression Maintenance Therapy services: Are provided to improve, develop or restore function lost or impaired as a result of deconditioning, a health condition, pain, injury or surgical procedure May include intensive rehabilitation to support early discharge from hospital or to prevent admission to hospital Therapy services: Are provided to maintain and/or to prevent a decline in functional/clinical status as a result of de-conditioning, a health condition, pain or aging May involve intermittent reassessment/treatment and/or periodic oversight by RHP/team to determine need for engagement of additional rehab professionals depending on client need and availability of family support or informal care networks May include falls prevention group classes or other wellness/health promotion classes provided by a physiotherapist or other regulated health professional. 26

27 Questions/Discussion Does the structure of the framework for communitybased rehabilitative care make sense? Is there anything else that should be included? Does Step 2 to determine the location of communitybased rehabilitative care make sense? Is there anything that you would change? Other questions/comments? 27

28 Thank you Should you have questions/comments on the Draft Definitions Framework for Community-Based Rehabilitative Care, contact: Sue Balogh, Project Manager Ext